Endovascular versus surgical left subclavian artery revascularization with thoracic endovascular aortic repair involving the aortic arch

Objective: Left subclavian artery (LSA) revascularization has been recommended for thoracic endovascular aortic repair (TEVAR) that require LSA coverage to achieve adequate seal. The aim of this study is to evaluate the comparative effectiveness of endovascular techniques vs surgical methods for LSA revascularization. Methods: The Vascular Quality Initiative was queried for patients undergoing TEVAR involving the arch from August 2014 to November 2023. Procedures for descending thoracic aortic aneurysms (DTAAs) and type B aortic dissections (TBADs) were included. Endovascular LSA revascularization techniques (stents, stent grafts, chimneys, fenestrations, stented fenestrations, fenestrated branch, side-arm branched device) and surgical LSA revascularization were compared with respect to 30-day mortality, stroke, stroke or death, spinal cord ischemia, perioperative and 1-year reinterventions, and 1-year survival using both univariate analysis and multivariable analysis controlling for potential confounders. Results: In a total of 2455 TEVAR procedures done for DTAA and TBAD, LSA revascularization was achieved surgically in 68.8% (n = 1689) and by endovascular techniques in 31.1%. Comparing surgical with endovascular LSA revascularization, there were no differences in 30-day mortality (4.4% vs 4.1%; odds ratio [OR], 1.10; 95% confidence interval [CI], 0.71-1.71; P = .677), perioperative stroke (4.2% vs 4.6%; OR, 0.88; 95% CI, 0.58-1.34; P = .557), stroke or death (7.6% vs 6.5%; OR, 1.16; 95% CI, 0.82-1.64; P = .391), spinal cord ischemia (3.6% vs 2.9%; OR, 1.26; 95% CI, 0.76-2.07; P = .365), and arm ischemia (1.1% vs 0.5%, P = .614). Overall perioperative reinterventions related to the thoracic aorta or branches or direct procedureal complications were higher in the surgical group compared with the endovascular group (10.7% vs 6.1%; OR, 1.75; 95% CI, 1.75-2.45; P < .001). However, reinterventions done specifically for type III endoleaks were notably higher in the endovascular group (16.7% vs 3.2%; P = .008). Predictors of perioperative reinterventions were Black race (OR, 1.36; P = .016), symptomatic presentation (OR, 1.66; P = .001), prior coronary revascularization (OR, 1.56; P = .041), and prior aneurysm repair (OR, 1.58; P = .004). One-year reintervention rates (13.5% vs 13.9%; P = 1.00) and 8-year survival (79.5% vs 78.0%; P = .478) were similar between the surgical and endovascular groups. Conclusions: In this study of over 2400 patients with DTAA or TBAD undergoing TEVAR that required LSA revascularization, endovascular techniques and surgical procedures were similar with regards to perioperative mortality, stroke, spinal cord ischemia, arm ischemia, and 8-year survival. Perioperative aorta-related and branch-related reinterventions were higher among the surgical group, with Black race, prior aneurysm repair, and coronary artery disease being predictors. This suggests that although endovascular techniques have been less often employed for LSA revascularization, they have similar outcomes compared with surgical LSA revascularization with lower rates of overall perioperative reinterventions.