Is it safe to cover the subclavian artery during a Thoracic Endovascular Aortic Repair (TEVAR)?

From the Guidelines

Covering the subclavian artery during TEVAR can be safe in selected patients, but it is crucial to prioritize preoperative left subclavian revascularization in patients with specific risk factors, as outlined in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. When planning TEVAR that may involve subclavian coverage, physicians should first evaluate the patient's vertebrobasilar circulation and left arm perfusion through imaging studies.

• Patients with a patent left internal mammary artery to left anterior descending artery coronary artery bypass graft, or who are otherwise reliant on inflow from the left subclavian artery, should undergo left subclavian revascularization to preserve flow, as recommended by the 2022 ACC/AHA guideline 1.
• Preoperative left subclavian revascularization has been shown to decrease the rates of stroke and spinal cord ischemia (SCI) 1.
• However, patients undergoing TEVAR with left subclavian coverage may not be hemodynamically stable enough to undergo preemptive revascularization of the left subclavian artery, and in such cases, secondary revascularization of the left subclavian artery may be considered if SCI develops after TEVAR 1. The decision to cover the subclavian artery during TEVAR should be individualized based on patient anatomy, comorbidities, and the urgency of the procedure, with the goal of balancing the risk of stroke or arm ischemia against the benefits of achieving adequate proximal seal during TEVAR.
• Post-procedure monitoring for symptoms of vertebrobasilar insufficiency or arm ischemia is essential, and delayed revascularization may be necessary if symptoms develop. Ultimately, the safety of covering the subclavian artery during TEVAR depends on careful patient selection, preoperative planning, and post-procedure monitoring, as emphasized in the 2022 ACC/AHA guideline 1.

From the Research

Safety of Covering the Subclavian Artery during TEVAR

• The safety of covering the subclavian artery during thoracic endovascular aortic repair (TEVAR) is a topic of controversy, with some studies suggesting it may increase the risk of neurological complications such as stroke or ischemia of the left upper extremity 2, 3, 4, 5, 6.
• A study published in 2018 found that performing TEVAR without primary revascularization of the left subclavian artery (LSA) was justifiable in their cohort, with only one patient (2.5%) developing critical ischemia of the left arm immediately after aortic stent implantation 2.
• Another study published in 2012 reviewed the literature comparing routine and selective LSA revascularization after TEVAR, and found that intentional coverage of the LSA without revascularization was not associated with increased morbidity in some cases 3.
• A study published in 2015 reported outcomes of coverage of the LSA during TEVAR, and found that coverage of the LSA carried an increased risk of cerebrovascular accident (CVA), but that a selective LSA revascularization and embolization strategy was well tolerated 4.
• A study published in 2013 discussed the intentional left subclavian artery coverage without revascularization during TEVAR, and found that the quality of available evidence on necessity or superfluity to revascularize the LSA was very low, and that studies reported controversial outcomes after intentional LSA coverage 5.
• A recent study published in 2023 evaluated outcomes of TEVAR in patients with blunt thoracic aortic injury (BTAI) with and without LSA coverage, and found that late and all ischemic strokes were more common in patients with LSA coverage without revascularization compared to those with uncovered LSA 6.

Complications and Risks

• Neurological complications such as stroke or ischemia of the left upper extremity are potential risks of covering the subclavian artery during TEVAR 2, 3, 4, 5, 6.
• The risk of cerebrovascular accident (CVA) is increased in patients with coverage of the LSA during TEVAR 4, 6.
• The risk of paralysis or paraplegia is also a potential complication of TEVAR, although the evidence is less clear on the relationship between LSA coverage and this risk 5, 6.

Management Strategies

• Selective LSA revascularization and embolization strategies may be effective in managing patients with LSA coverage during TEVAR 3, 4.
• The decision to revascularize the LSA should be made on a case-by-case basis, taking into account individual patient factors and the specific anatomy of the aortic arch and subclavian artery 2, 3, 5.
• Further study is needed to determine the optimal management strategy for patients with LSA coverage during TEVAR 6.