Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?

Weigang, Ernst; Parker, Jack A T C; Czerny, Martin; Lonn, Lars; Bonser, Robert S; Carrel, Thierry P; Mestres, Carlos A; Di Bartolomeo, Roberto; Schepens, Marc A A M; Bachet, Jean E; Vahl, Christian-Friedrich; Grabenwoger, Martin (2011). Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation? European journal of cardio-thoracic surgery, 40(4), pp. 858-68. Oxford: Elsevier Science B.V. 10.1016/j.ejcts.2011.01.046

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Thoracic endovascular aortic repair (TEVAR) has emerged as a promising therapeutic alternative to conventional open aortic replacement but it requires suitable proximal and distal landing zones for stent-graft anchoring. Many aortic pathologies affect in the immediate proximity of the left subclavian artery (LSA) limiting the proximal landing zone site without proximal vessel coverage. In patients in whom the distance between the LSA and aortic lesion is too short, extension of the landing zone can be obtained by covering the LSA's origin with the endovascular stent graft (ESG). This manoeuvre has the potential for immediate and delayed neurological and vascular symptoms. Some authors, therefore, propose prophylactic revascularisation of the LSA by transposition or bypass, while others suggest prophylactic revascularisation only under certain conditions, and still others see no requirement for prophylactic revascularisation in anticipation of LSA ostium coverage. In this review about LSA revascularisation in TEVAR patients with coverage of the LSA, we searched the electronic databases MEDLINE and EMBASE historically until the end date of May 2010 with the search terms left subclavian artery, covering, endovascular, revascularisation and thoracic aorta. We have gathered the most complete scientific evidence available used to support the various concepts to deal with this issue. After a review of the current available literature, 23 relevant articles were found, where we have identified and analysed three basic treatment concepts for LSA revascularisation in TEVAR patients (prophylactic, conditional prophylactic and no prophylactic LSA revascularisation). The available evidence supports prophylactic revascularisation of the LSA before ESG LSA coverage when preoperative imaging reveals abnormal supra-aortic vascular anatomy or pathology. We further conclude that elective patients undergoing planned coverage of the LSA during TEVAR should receive prophylactic LSA transposition or LSA-to-left-common-carotid-artery (LCCA) bypass surgery to prevent severe neurological complications, such as paraplegia or brain stem infarction.

Item Type:

Journal Article (Original Article)

Division/Institute:

04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiovascular Surgery

UniBE Contributor:

Czerny, Martin and Carrel, Thierry

ISSN:

1010-7940

Publisher:

Elsevier Science B.V.

Language:

English

Submitter:

Factscience Import

Date Deposited:

04 Oct 2013 14:20

Last Modified:

24 Oct 2019 22:55

Publisher DOI:

10.1016/j.ejcts.2011.01.046

PubMed ID:

21376612

Web of Science ID:

000295632900026

BORIS DOI:

10.7892/boris.6609

URI:

https://boris.unibe.ch/id/eprint/6609 (FactScience: 211605)

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