Concomitant left subclavian artery revascularization with carotid-subclavian transposition during zone 2 thoracic endovascular aortic repair.

BACKGROUND: Left subclavian revascularization has become an integral part of thoracic endovascular aortic repair to extend the proximal landing zone. This is most commonly achieved via carotid-subclavian bypass; however, this can be achieved via vessel transposition. METHODS: All patients who had zone 2 thoracic endovascular aortic repairs without branched grafts from 2007 to 2018 were included in the study. The primary outcomes were adverse events, including operative mortality, paraplegia, left arm ischemia, and stroke. Multivariable regression analysis was performed for baseline characteristics associated with adverse events. RESULTS: A total of 58 patients underwent left subclavian artery transposition for zone 2 thoracic endovascular aortic repair coverage. Operative (30-day) mortality occurred in 3 patients (5.2%). The majority of patients were operated on under urgent (N = 25; 43.1%) or emergency (N = 12; 20.7%) status. Indications for thoracic endovascular aortic repair included aneurysmal disease (34.5%) and type B aortic dissection (chronic [13.8%]; acute [51.7%]). Major adverse events included paraplegia (N = 1; 1.7%), transient paraparesis (N = 3; 5.2%), and stroke (N = 2; 3.4%). Over a mean follow-up of 2.8 years, there were 5 deaths (8.6%). On multivariable analysis, prior stroke (odds ratio, 31.4; 1.95-506.72; P = .02) was an independent predictor of adverse events. CONCLUSIONS: Carotid-subclavian transposition offers patients a safe and effective method for left subclavian artery revascularization during thoracic endovascular aortic repair with zone 2 coverage with no increased operative risk and a low complication rate.

Bypass carótido-subclavio con vena safena como alternativa de tratamiento en la oclusión de la arteria subclavia izquierda / Carotid-subclavian bypass with saphenous vein as a choice in treating occlusion of the left subclavian artery

La oclusión de la arteria subclavia izquierda es un cuadro poco frecuente y que cursa de forma asintomática generalmente. La presencia de síntomas y posibles complicaciones indican el tratamiento quirúrgico. El bypass carótido-subclavio es la técnica quirúrgica más utilizada gracias a su baja morbilidad, mortalidad y elevados índices de permeabilidad a largo plazo. El propósito de este trabajo es presentar un procedimiento alternativo para el tratamiento quirúrgico de esta oclusión, en este caso, el bypass carótido-subclavio con injerto de vena safena interna. Se describe el caso de una paciente de 56 años, fumadora inveterada que acudió al Servicio de Cirugía Cardíaca y Vascular del Cardiocentro "Ernesto Guevara", Villa Clara en diciembre de 2014 por presentar dolor frecuente en el miembro superior izquierdo que limitaba la actividad física. Se diagnosticó oclusión de la primera porción de la arteria subclavia izquierda. Se realizó bypass carótido-subclavio con injerto de vena safena interna que solucionó su cuadro clínico. La paciente evolucionó satisfactoriamente con bypass permeable con ultrasonido y angio-tomografía computarizada a los dos años de operada. El bypass carótido-subclavio con injerto de vena safena interna representa una alternativa efectiva y segura en el tratamiento de la oclusión sintomática de la arteria subclavia izquierda(AU)

The occlusion of the left subclavian artery is an uncommon situation and mostly asymptomatic. The presence of symptoms and possible complications indicate the surgical treatment. The carotid-subclavian bypass is the classical surgical technique, due to its low morbidity and mortality rates, and long term permeability indexes. The objective of this paper was to present an alternative procedure for surgical treatment of this type of occlusion, that is, the carotid-subclavian bypass with internal saphenous vein graft. Here is a 56 year-old female , heavy smoker patient who went to the heart and vascular surgery of "Ernesto Guevara" cardiological center in Villa Clara province on December 2014. She presented with frequent pain in the left upper limb that restricted her daily physical activity; the diagnosis was occlusion of the first portion of the left subclavian artery. The patient underwent left carotid-subclavian bypass surgery using a greater saphenous vein graft that eliminated the clinical picture. The patient recovered satisfactorily with a permeable bypass and she was performed ultrasound and angiographic computer tomography after two years of operation. Carotid-subclavian bypass with greater saphenous vein graft represents an effective and safe alternative in the treatment of the symptomatic occlusion of the left subclavian artery(AU)