Endovascular Versus Surgical Revascularization Of The Left Subclavian Artery In Zone 2 Tevar: Implications For Branched Aortic Stent-grafts
Corbin Muetterties1, Sahil Patel2, Alana Dutton2, Rohan Menon3, Grayson Wheatley, III4.
1UCLA Medical Center, Los Angeles, CA, USA, 2Drexel University College of Medicine, Philadelphia, PA, USA, 3Howard University College of Medicine, Washington, DC, USA, 4TriStar Centennial Medical Center, Nashville, TN, USA.
BACKGROUND: Left carotid-subclavin bypass or transposition in non-emergent Zone 2 thoracic endovascular aortic repair (TEVAR) is recommended by guidelines based on level C evidence. Nevertheless, several endovacular alternatives exist for addressing the left subclavian artery (LSCA) in these patients. We compared outcomes of endovascular versus surgical revascularization of the LSCA in Zone 2 TEVAR procedures. METHODS: A comprehensive review of PubMed was performed regarding endovascular LSCA revascularization in Zone 2 TEVAR and compared with literature controls for surgical revascularization. Studies in which LSCA revascularization was not the focus or there was incomplete data were excluded. Technique of LSCA revascularization, technical success, reinterventions, stroke and paraplegia risk and mortality rate were collected and analyzed using a chi-square test. RESULTS: A total of 341 patients in 34 publications were treated with 8 methods of endovascular LSCA revascularization/preservation. [Table 1] There were 10 (2.9%) strokes, 48 (14.1%) Type I endoleaks, 21 (6.2%) reinterventions, 1 (0.3%) spinal cord ischemia (SCI), and 13 (3.8%) deaths with a procedural success of 97.5% and a LSCA patency of 100% on follow-up between 0 days to 12 months. Chimney grafts (n=153, 45%) were the most frequently utilized endovascular approach and had the highest incidence of Type I endoleaks (18.3%). Surgical revascularization in 444 Zone 2 TEVAR patients had a higher rate of stroke (5.9% vs 2.9%, p=0.05), SCI (2.7% vs 0.3%, p=0.01, p=0.009) and death (6.5% vs 3.8%, p=0.09) compared to an endovascular approach. CONCLUSIONS: Endovascular revascularization of the LSCA in Zone 2 TEVAR can be successfully performed with low risk of stroke, SCI and death and compares favorably with surgical revascularization. The impending approval of a single-branched TEVAR device may necessitate a change in future guidelines regarding optimal method of LSCA revascularization in Zone 2 TEVAR. 
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