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Eur J Cardiothorac Surg 2007;31:628-636. doi:10.1016/j.ejcts.2006.12.026
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
a Department of Cardiovascular Surgery, University Medical Center Freiburg, Freiburg, Germany
b Department of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, Freiburg, Germany
c Department of Diagnostic Radiology, University Medical Center Freiburg, Freiburg, Germany
d Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, USA
e Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
Received 13 September 2006; received in revised form 27 November 2006; accepted 5 December 2006.
* Corresponding author. Address: Department of Cardiovascular Surgery, University Medical Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany. Tel.: +49 761 270 8888; fax: +49 761 270 2550. (Email: ernst.weigang{at}web.de).
Objective: Aortic endovascular stent-graft implantation is associated with low morbidity and mortality rates. Overstenting of the left subclavian artery may be necessary to create a satisfactory proximal ‘landing zone’ for the stent-graft. Few cases have been published reporting adverse neurological events after overstenting of the left subclavian artery. We thus evaluated whether this procedure is associated with a higher rate of neurological complications by focusing on the management of the supra-aortic vessels. Methods: Twenty patients suffering from aortic arch aneurysms (n = 3), descending aortic aneurysms (n = 7), acute (n = 6) and chronic (n = 4) type-B aortic dissections underwent stent-graft repair with complete (n = 14) or partial (n = 6) overstenting of the left subclavian artery. Three patients underwent overstenting of the entire aortic arch with ascending aortic-bi-carotid bypass grafting. One patient with right carotid and vertebral artery occlusion underwent initial carotid-to-subclavian bypass. All patients subsequently underwent neurological examination and Doppler ultrasound for detection of neurological and peripheral vascular complications. Results: Aortic stent-graft repair was successful in all patients without acute neurologic complications. Two patients developed late central adverse neurological events: right-sided vertebral artery occlusion with brainstem infarction (n = 1) and impaired binocular vision combined with dizziness (n = 1), necessitating secondary subclavian transposition in one patient. Peripheral symptoms related to occlusion of the left subclavian artery were observed in five patients as sensory and motoric deficits of the left hand and arm. Conclusions: Overstenting of the left subclavian artery as treatment of aortic pathologies in high-risk patients is feasible but associated with the risk of neurological complications and peripheral symptoms. Side effects were mild or transient in most of our patients. Detailed preoperative exploration of vascular anatomy and pathology via Doppler ultrasound, CT- or MRI scan is mandatory to avoid adverse neurological events. Prior surgical revascularization of the left subclavian artery is essential in patients with high-grade stenoses, occlusions, or anatomic variants of the supra-aortic branches. Delayed surgical revascularization is necessary only in patients with relevant subclavian steal syndrome or severe peripheral vascular symptoms.
Key Words: Endovascular stent-graft • Supra-aortic vessels • Aortic aneurysm • Aortic dissection • Neurological complication • Subclavian artery overstenting
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