Results of Great Vessel Revascularization Techniques to Facilitate Endovascular Repair of Thoracic Aortic Lesions

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Paul J. Riesenman, MD MS, Mark A. Farber, MD, Robert R. Mendes, MD, William A. Marston, MD, Joseph J. Fulton, MD, Dianne L. Glover, RN, CVN, Blair A. Keagy, MD.
University of North Carolina, Chapel Hill, NC, USA.

Background: Endovascular stent-grafts require proximal and distal landing zones of adequate distance to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery (SCA) and other aortic arch branch vessels often impose limitations on the proximal landing zone thereby disallowing endovascular repair of more proximal thoracic lesions.
Methods: Between October 2000 and September 2005, 96 patients received stent-grafts to treat aortic lesions involving the thoracic territory. The proximal aspect of the covered portion of the stent-graft partially or totally occluded the ostium of at least one great vessel in 22 patients (23%). The proximal attachment site was in Zone 0 in one patient (5%), Zone 1 in three patients (14%) and Zone 2 in 18 patients (82%). Patients with proximal implantation in Zones 0 or 1 underwent prior revascularization with either ascending arch to innominate bypass (1) or carotid-carotid bypass with or without subclavian revascularization (3). Among those patients (18) requiring implantation across the left SCA (Zone 2) for endovascular repair, none underwent prior revascularization. Patients were assessed post-operatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia.
Results: Mean follow-up was 6.7 months. None of the 22 patients who experienced partial or complete coverage of their aortic arch branch vessels developed neurological deficits or symptoms postoperatively. Among the 18 patients with Zone 2 implantations, six patients (33%) had partial left SCA coverage. All of these patients maintained antegrade flow after stent-graft insertion and were asymptomatic. Of the 14 patients who had intentional complete cessation of flow through the origin of the left SCA without revascularization, 1 (7%) developed symptoms of claudication that did not warrant intervention, and 1 (7%) developed rest pain which was treated 1 month later with the deployment of a left SCA stent. Two primary endoleaks (9%) were observed (Type IB and Type III). The Type III endoleak was treated with the deployment of an additional component. The Type IB endoleak was observed to have resolved on repeat imaging at 1 month. One secondary Type IA endoleak (5%) developed in a patient who had partial coverage of their left SCA for a ruptured aortic dissection. Despite proximal extension with an additional component, the endoleak persisted but did not communicate with the region of rupture and is being observed.
Conclusion: Intentional coverage of the origin of the left subclavian artery during endovascular repair of the thoracic aorta is well tolerated and may be managed expectantly with some exceptions. Great vessel debranching of the aortic arch is a viable option for optimization of the proximal landing zone for endovascular repair of thoracic aortic lesions.

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