Background Evaluation of the optimal left subclavian artery (LSA) management during thoracic endovascular aortic repair (TEVAR) involving the distal aortic arch in an urgent setting.

Methods A total of 52 patients with acute aortic syndromes underwent TEVAR (March 2017 to May 2021) requiring proximal landing in the distal aortic arch. Decision for partial or complete LSA ostial endograft coverage, with or without additional bypassing, was made depending upon the aortic pathology and vascular anatomy. We focused on the patency of the circle of Willis and the unilateral dominance of one carotid or a vertebral artery: 35% underwent complete (complete LSA group) and 17% partial LSA coverage (partial LSA group), whereas in 48% the LSA was reached only by the bare springs of the endograft (control group). A total of 22% of the complete LSA group underwent LSA bypass before TEVAR, whereas 11% underwent cerebrospinal fluid drainage. Endpoints were 30-day and 1-year mortality, stroke, spinal cord ischemia (SCI), and malperfusion.

Results Technical success was achieved in 96%. The endograft length was 171 ± 34 (complete LSA group) versus 151 ± 22 (partial LSA group) versus 181 ± 52 mm (control group), covering 6 ± 2 versus 5 ± 1 versus 7 ± 2 intercostal arteries. The 30-day mortality, stroke and SCI rates did not differ. One patient with arm malperfusion underwent LSA bypass post-TEVAR. After 1 year, aortic interventions occurred in 6 (complete LSA group) versus 22 (partial LSA group) versus 13% (control group). One-year mortality (0 vs. 0 vs. 8%), stroke (6 vs. 0 vs. 4%), and SCI (0 vs. 0 vs. 4%) were similar between groups.

Conclusion With an adequate analysis of vascular anatomy, coverage of the LSA for TEVAR is safe and may offer results similar to TEVAR starting distal to the LSA.

背景 紧急情况下涉及远端主动脉弓的胸主动脉腔内修复术 (TEVAR) 期间最佳左锁骨下动脉 (LSA) 管理的评估。

方法 52 例急性主动脉综合征患者接受了 TEVAR（2017 年 3 月至 2021 年 5 月），需要在远端主动脉弓近端着陆。根据主动脉病理学和血管解剖学，决定部分或完全 LSA 口内移植物覆盖，有或没有额外的旁路。我们重点关注 Willis 环的通畅性以及单侧颈动脉或椎动脉的优势：35% 的患者接受了完整的 LSA 覆盖（完全 LSA 组），17% 的患者接受了部分 LSA 覆盖（部分 LSA 组），而 48% 的患者接受了部分 LSA 覆盖（部分 LSA 组）。仅通过内移植物的裸露弹簧到达（对照组）。共有 22% 的完整 LSA 组在 TEVAR 之前接受了 LSA 搭桥术，而 11% 的患者接受了脑脊液引流。终点为 30 天和 1 年死亡率、中风、脊髓缺血 (SCI) 和灌注不良。

结果 技术成功率为 96%。内移植物长度分别为171±34（完全LSA组）、151±22（部分LSA组）和181±52毫米（对照组），覆盖6±2、5±1、7±2条肋间动脉。30 天死亡率、中风和 SCI 发生率没有差异。一名手臂灌注不良的患者在 TEVAR 后接受了 LSA 搭桥术。1 年后，主动脉介入治疗发生率分别为 6%（完全 LSA 组）、22%（部分 LSA 组）和 13%（对照组）。各组之间的一年死亡率（0 vs. 0 vs. 8%）、卒中（6 vs. 0 vs. 4%）和 SCI（0 vs. 0 vs. 4%）相似。

结论 通过对血管解剖学进行充分分析，TEVAR 覆盖 LSA 是安全的，并且可能提供与从 LSA 远端开始进行 TEVAR 类似的结果。