Can the Left Subclavian Artery be Safely Covered During Endovascular Repair of the Descending Thoracic Aorta?

Objective: : Routine preoperative carotid-subclavian bypass or transposition is frequently recommended in patients undergoing endovascular repair of the descending thoracic aorta (DTA). We reviewed our comprehensive thoracic endografting experience with regards to coverage of the left subclavian artery (LSA) to assess whether mandatory preoperative carotid-subclavian bypass or transposition is necessary.

Methods: : Between February 2000 and November 2005, 255 patients were successfully treated with an endoluminal graft (ELG) to the DTA. Indications for intervention included atherosclerotic aneurysms (109/255, 42.7%), acute and chronic dissections (75/255, 29.4%), miscellaneous (41/255, 16.1%), and penetrating aortic ulcers (30/255, 11.8%). There were 151 males (151/255, 59.2%) and 104 females (104/255, 40.8%) with a mean age of 71 years (range, 23-91 years).

Results: : The LSA was completely covered with an ELG in 71 patients (71/255, 27.8%) and partially covered in 47 patients (47/255, 18.4%). In patients who had complete coverage of the LSA, 30 patients (30/71, 42.3%) had acute or chronic Type B dissections, 26 patients (26/71, 36.6%) had aneurysms, 11 patients (11/71, 15.5%) had miscellaneous aortic pathologies, and 4 patients (4/71, 5.6%) had pseudoaneurysms associated with prior coarctation repair. Fifteen patients (15/255, 5.9%) underwent preoperative carotid-subclavian bypass or transposition and subsequently underwent complete coverage of the LSA with an ELG. One patient (1/56, 1.8%) with complete coverage of the LSA required elective postoperative carotid-subclavian bypass secondary to left arm claudication.

Conclusions: : Routine preoperative carotid-subclavian bypass is not necessary, except in select patients with a patent left internal mammary artery to the left anterior descending artery bypass graft or contralateral vertebral artery disease.