ZONE 2 COVERAGE DURING THORACIC ENDOVASCULAR AORTIC REPAIR: A SINGLE-CENTER EXPERIENCE

OBJECTIVES:
To determine the results of left subclavian artery(LSA) coverage during thoracic endovascular aortic repair(TEVAR).
METHODS:
We retrospectively reviewed the results of 308 patients who underwent TEVAR from 1999-2007. Seventy patients (ages41-89, mean67; 53male, 17female) had complete coverage of the LSA. Elective revascularization of the LSA was performed in 42 cases. LSA revascularization was comprised of transposition(5), bypass and ligation(3), or bypass and coil embolization(34). Follow-up ranged from 1-48 months(mean 11). Statistics were performed with chi square analysis.
RESULTS:
Indications for treatment included aneurysm (47), dissection(16), transection(4), pseuodoaneurysm(2), right subclavian aneurysm(1) with 47 elective and 23 emergent operations. Aortic coverage extended from the left common carotid artery(LCCA) to the distal arch(29), mid thoracic aorta(9), or celiac artery(32). Technical success was 99%. 30-day mortality was 4%(intraoperative MI-1; traumatic injuries-1; visceral infarction-1). No patients developed paraplegia. The stroke rate was 8.6% of which none were related to LSA coverage. Stroke rates between the revascularization(7%) and non-revascularization(11%) groups were not significantly different(p=0.6). All but one patient fully recovered by 6 months. No patients with LSA revascularization developed left arm symptoms and all bypasses remained patent throughout follow-up. One complication(2%) resulted in an asymptomatic persistently elevated left hemidiaphragm. Five(18%) patients without LSA revascularization developed symptoms in their left upper extremity. Two required LSA revascularization. No patients developed permanent left upper extremity dysfunction or ischemia.
CONCLUSIONS:
In summary, Zone 2 TEVAR with LSA coverage can be accomplished safely in both elective and emergent settings and with and without revascularization(with the exception of a patent LIMA-LAD bypass). Nevertheless, overall stroke rates are higher when compared to all zone TEVAR. Staged LSA revascularization may be necessary but can be performed without detriment to the left arm.