NESVS9. Chimney Stent Graft for Left Subclavian Artery Revascularization During Thoracic Endograft Placement

Carotid to subclavian artery bypass (CSB) has been the standard for revascularizing the left subclavian artery during coverage by thoracic endografts (thoracic endovascular aortic repair [TEVAR]). The purpose of this study was to determine whether a chimney stent graft (CSG) offers similar outcomes to an alternative to open bypass. A retrospective review of a single vascular surgery registry between February 2011 and September 2017 was performed of all left subclavian revascularization during elective TEVAR. Arch reconstructions involving more than just the left subclavian artery were excluded. Indications, demographics, procedural details, and outcomes were analyzed using standard statistical analysis. There were 81 patients with a mean age of 68 years (range, 32-87 years) who had left subclavian revascularization (64 [79%] CSB vs 17 [21%] CSG) during TEVAR. Median follow-up was 8 months (range, 0-52 months) for CSG and 18 months (range, 0-42 months) for CSB. Demographics between the groups were similar except for significantly more men in the CSB group (43 [67%] vs 10 [59%]; P = .52). The CSB group had significantly more aneurysms than dissections compared with the CSG group (45 [70%] vs 6 [35%]; P = .008). There were not any perioperative occlusions or ischemic issues for either group in the perioperative period. Postoperative hematoma rates trended higher in the CSB group (seven [11%] vs one [6%]; P = .53), with three (4.6%) of the CSB group requiring evacuation of hematoma. Left hemispheric strokes were 6% in the CSB group, with none occurring in the CSG group (P = .57). Perioperatively, the CSB group had one recurrent laryngeal nerve and one graft infection. Length of stay was similar in both groups (8.5 days for CSB vs 9.1 days for CSG). Perioperative mortality was not statistically significant between groups, with two deaths (3%) in the CSB group and none in the CSG group. No gutter leaks were identified on follow-up computed tomography scan during long-term follow-up. Patency rates were similar, with only one occlusion in the CSB group at 23 months. Left carotid to subclavian artery bypass has been the standard for revascularization of the left subclavian artery during coverage by TEVAR. Chimney stent grafting to perfuse the left arm appears to offer results equivalent to those of a minimally invasive alternative.