254LEFT SUBCLAVIAN ARTERY REVASCULARIZATION AS PART OF THORACIC ENDOVASCULAR AORTIC REPAIR

Objectives: Intentionally covering the left subclavian artery (LSA) as part of thoracic endovascular aortic repair (TEVAR) can cause (posterior) strokes or left arm malperfusion. LSA revascularization can be done prophylactically for, or as treatment of, these complications. We report our experience with the surgical technique, indications, and the results of LSA revascularization. Methods: Between 2000 and 2013, 53 patients out of 444 treated by TEVAR, had LSA revascularization. All elective patients had a preoperative work-up with magnetic resonance angiogram to evaluate the circle of Willis. In all, surgical access was through a left supraclavicular incision only. Results: The majority (87%) had prophylactic LSA revascularization because of incomplete circle of Willis and/or left dominant vertebral artery (LVA) (n = 40), patent left internal mammary artery (n = 2), prevention of myelum ischaemia (n = 2), prevention of left arm ischaemia due to small LVA (n = 2) and LVA origin in arch (n = 1). Thirteen per cent had secondary revascularization, either immediate because of malperfusion of the left arm (n = 2), or late after TEVAR because of persisting left arm claudication (n = 4). In nine patients, the following early complications were observed: re-exploration for bleeding, n = 1; left recurrent nerve paralysis, n = 2; left phrenic nerve paralysis, n = 2; left sympathetic chain neuropraxia, resulting in Horner's syndrome, n = 3; chyle duct lesions, resulting in persistent chyle leakage, n = 3. No strokes were observed. One patient experienced occlusion of the bypass at six months. Conclusions: The present study shows that the procedure of LSA revascularization as part of TEVAR is feasible and safe with low morbidity and negligible risk of strokes.