Perioperative Outcomes of Left Subclavian Artery Coverage and Revascularization in Thoracic Endovascular Aortic Repair

The left subclavian artery (LSA) is covered in one-third of all patients undergoing transthoracic endovascular aneurysm repair (TEVAR). The outcomes of this coverage with or without revascularization remain controversial due to lack of high-quality evidence. The aim of this study is to use a large, multi-center database to examine the effects of LSA coverage and revascularization on perioperative outcomes. Patients who had undergone TEVAR for any indication in the Vascular Quality Initiative TEVAR database between 2011 and 2021 were identified. Patients who had conversion to open repair, proximal disease > zone 5 and distal zone disease < zone 3 were excluded. We had three final groups: without coverage, with coverage and no revascularization, and with coverage and revascularization. Outcomes were perioperative stroke, arm ischemia (AI), spinal cord ischemia (SCI), and 30-day mortality. A total of 12,611 TEVAR patients met our inclusion criteria (without coverage = 8389 [66.5%], coverage and no revascularization = 1622 [12.8%], and with coverage and revascularization = 2600 [20.6%]). The results are summarized in the Table. When compared to no coverage, LSA coverage with no revascularization was associated with a significant increase in the risk of stroke (adjusted odds ratio [aOR], 1.6; 95% confidence interval [CI], 1.1-2.2; P = .010) and AI (aOR, 5.4; 95% CI, 2.9-10.2; P < .001), while there was no difference in SCI (aOR, 1.2; 95% CI, 0.8-1.8; P = .489) and 30-day mortality (aOR, 1.3; 95% CI, 0.98-1.7; P = .066). When compared to no coverage, LSA coverage with revascularization was also associated with a significant increase in the risk of stroke (aOR, 1.6; 95% CI, 1.2-2.1; P = .001) and AI (aOR, 3.1; 95% CI, 1.4-7.1; P = .007), while SCI (aOR, 0.9; 95% CI, 0.6-1.3; P = .592) and 30-day mortality (aOR, 1.0; 95% CI, 0.8-1.3; P = .911) were not different. When compared to coverage with no revascularization, LSA coverage with revascularization was associated with a decreased risk of AI (aOR, 0.4; 95% CI, 0.2-0.7; P = .003) but no difference in stroke (aOR, 0.9; 95% CI, 0.6-1.3; P = .535), SCI (aOR, 0.9; 95% CI, 0.6-1.2; P = .410), or 30-day mortality (aOR, 0.9; 95% CI, 0.7-1.2; P = .460). In this large, national, real-world data, TEVAR with LSA coverage was associated with increased risk of perioperative stroke and arm ischemia regardless of revascularization status. LSA revascularization was beneficial in only reducing the risk of arm ischemia. The decision to revascularize should be individualized based on patients' anatomy and risk factors for SCI.TablePostoperative outcomes of stroke, arm ischemia, spinal cord ischemia and 30-day mortality stratified by left subclavian artery (LSA) coverage and revascularization statusOutcomeLSA coverage with no revascularization vs no LSA coverageLSA coverage with revascularization vs no LSA coverageLSA coverage with revascularization vs LSA coverage with no revascularizationaOR (95% CI)(Reference = no LSA coverage)P valueaOR (95% CI)(Reference = no LSA coverage)P valueaOR (95% CI)(Reference = LSA coverage with No revascularization)P valuePostoperative stroke1.6 (1.1-2.2).0101.6 (1.2-2.1).0010.9 (0.6-1.3).535Postoperative AI5.4 (2.9-10.2)<.0013.1 (1.4-7.1).0070.4 (0.2-0.7).003Postoperative SCI1.2 (0.8-1.8).4890.9 (0.6-1.3).5920.9 (0.6-1.2).41030-Day mortality1.3 (0.98-1.7).0661.0 (0.8-1.3).9110.9 (0.7-1.2).460AI, Arm ischemia; aOR, adjusted odds ratio; CI, confidence interval; SCI, spinal cord ischemia.Multivariate regression analysis was used, adjusting for patient demographics, risk factors, and preoperative medications. Open table in a new tab