Nicholas D. Andersen, MD, Michael E. Barfield, MD, Jennifer M

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Presentation transcript:

Intrathoracic subclavian artery aneurysm repair in the thoracic endovascular aortic repair era Nicholas D. Andersen, MD, Michael E. Barfield, MD, Jennifer M. Hanna, MD, MBA, Asad A. Shah, MD, Cynthia K. Shortell, MD, Richard L. McCann, MD, G. Chad Hughes, MD Journal of Vascular Surgery Volume 57, Issue 4, Pages 915-925 (April 2013) DOI: 10.1016/j.jvs.2012.09.074 Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 1 Native left subclavian artery aneurysm (SAA) endovascular repair. A, Preoperative appearance of the aneurysmal left subclavian artery (LSCA) with a concomitant descending thoracic aortic aneurysm. B, Repair is accomplished by endovascular coverage of the LSCA orifice and distal vascular plug occlusion proximal to the origin of the left vertebral artery. In the case shown, the thoracic endograft was used to treat a concomitant descending thoracic aortic aneurysm. C, The LSCA was revascularized selectively via a left carotid–subclavian bypass for previously reported indications.20 Journal of Vascular Surgery 2013 57, 915-925DOI: (10.1016/j.jvs.2012.09.074) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 2 Native left subclavian artery aneurysm (SAA) open repair. For patients with a native left SAA and extensive thoracic aortic disease, total arch replacement (stage I elephant trunk procedure) was first performed using a modified Mt. Sinai technique.25,30 A, For patients in whom the left subclavian artery (LSCA) was accessible via a median sternotomy approach, the LSCA was ligated and bypassed at the time of total arch replacement. B and C, For patients in whom the LSCA was not accessible via median sternotomy, the LSCA was bypassed from the new Dacron descending aorta at the time of open stage II thoracoabdominal aortic aneurysm (TAAA) repair. Journal of Vascular Surgery 2013 57, 915-925DOI: (10.1016/j.jvs.2012.09.074) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 3 Aberrant left subclavian artery aneurysm (SAA; Kommerell’s diverticulum) repair. A, Preoperative appearance of an aberrant left SAA in a patient with a right-sided aortic arch and a right descending thoracic aorta. B, Repair is accomplished by endovascular coverage of the left subclavian artery (LSCA) orifice and vascular plug occlusion distal to the aneurysm. In the case shown, coverage of the right subclavian artery (RSCA) or more proximal arch vessels was not required, although this may be necessary in some cases. Journal of Vascular Surgery 2013 57, 915-925DOI: (10.1016/j.jvs.2012.09.074) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 4 Native right subclavian artery aneurysm (SAA) repair. A, Preoperative appearance of a proximal native right SAA. B, In the case shown, repair was accomplished by right subclavian artery (RSCA) interposition grafting with aneurysm exclusion (endoaneurysmorrhaphy). Journal of Vascular Surgery 2013 57, 915-925DOI: (10.1016/j.jvs.2012.09.074) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 5 Aberrant right subclavian artery aneurysm (SAA; Kommerell's diverticulum) repair. A, Preoperative appearance of an aberrant right SAA with a concomitant descending thoracic aortic aneurysm. B, In the first scenario, repair was achieved via zone 2 endograft placement with bilateral subclavian artery (SCA) coverage and vascular plug occlusion of the aneurysm outflow. A left carotid–subclavian bypass was performed to revascularize at least one subclavian artery. C, In the second scenario, zone 1 endograft placement was required to achieve adequate proximal seal, necessitating carotid–carotid bypass for left common carotid artery (LCCA) revascularization in addition to left subclavian artery (LSCA) revascularization. Journal of Vascular Surgery 2013 57, 915-925DOI: (10.1016/j.jvs.2012.09.074) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 6 Kaplan-Meier estimates of freedom from reintervention (A), primary subclavian artery bypass graft patency (B), and survival (C), stratified by operative approach. Asterisk denotes the time point at which standard error exceeds 10%. N, Number at risk; SE, standard error; TEVAR, thoracic endovascular aortic repair. Journal of Vascular Surgery 2013 57, 915-925DOI: (10.1016/j.jvs.2012.09.074) Copyright © 2013 Society for Vascular Surgery Terms and Conditions

Fig 7 Treatment of mega aorta syndrome with an aberrant right subclavian artery aneurysm (SAA). A, The patient (no. 19) underwent stented elephant trunk with visceral debranching hybrid thoracoabdominal aortic aneurysm (TAAA) repair 5 years after total arch replacement (stage I elephant trunk procedure) at an outside hospital. B, The aberrant right SAA arising from the proximal descending thoracic aorta was excluded by proximal endografting and distal occlusion with an Amplatzer Vascular Plug II (AVP II; arrow). Journal of Vascular Surgery 2013 57, 915-925DOI: (10.1016/j.jvs.2012.09.074) Copyright © 2013 Society for Vascular Surgery Terms and Conditions