Surgical options of left subclavian artery revascularization in the endovascular repair of the aortic arch.

BACKGROUND

Management of the left subclavian artery (LSA) is necessary to reduce the risk of stroke and spinal cord ischemia, when endovascular repair of thoracoabdominal and aortic arch pathologies requires proximal landing zone in the arch. This study presents the main surgical techniques and a single-center 10-year experience with LSA revascularization during thoracic endovascular aortic repair (TEVAR), contextualized within current literature.

METHODS

Described the main surgical techniques for LSA revascularization: left subclavian-to-carotid transposition, left carotid-subclavian bypass with prosthetic graft, right-to-left carotid-subclavian bypass with left carotid reimplantation, and right-to-left subclavian bypass. Detailed steps and 10-years single center experience (2014-2025), are outlined.

RESULTS

Overall 83 patients (median age 71 years; 81% male) underwent LSA revascularization during TEVAR procedures. Pathologies included acute aortic syndromes, degenerative and post-dissection thoracic and thoracoabdominal aneurysms. Proximal landing zones were zone 0 (6%), zone 1 (31%), and zone 2 (63%). A total of 88 LSA revascularizations were performed: left carotid-subclavian bypass (72%), right carotid-LSA with left carotid reimplantation (22%), and bilateral carotid-subclavian bypass (6%). Endovascular repair included standard TEVAR (63%) and branched/fenestrated devices (37%). Technical success was 100%, with early complication rate of 12% (7% surgical, 4% non-surgical). No major strokes occurred; paraplegia was 2%; 30-day mortality 8%, unrelated to debranching. Median follow-up was 22 months (IQR 12-39), with 100% primary patency. Overall 1- and 3-year survival rates were 77% and 73%, respectively.

CONCLUSIONS

Surgical LSA revascularization during TEVAR is safe and effective, with excellent technical success and patency rates. Individualized surgical strategies allow optimal protection of cerebral and spinal perfusion.