Routine revascularization is unnecessary in the majority of patients requiring zone II coverage during thoracic endovascular aortic repair: A longitudinal outcomes study using United States Medicare population data
Restricted accessResearch articleFirst published online August, 2014
Routine revascularization is unnecessary in the majority of patients requiring zone II coverage during thoracic endovascular aortic repair: A longitudinal outcomes study using United States Medicare population data
We aimed to evaluate outcomes of thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage without bypass (TEVAR + SUB) to TEVAR with coverage of the LSA with a bypass at the time of the initial procedure or later at a separate procedure (TEVAR + SUB + BYPASS).
Methods
The Centers for Medicare & Medicaid Services inpatient claims for 2006–2007 were queried using Current Procedural Terminology codes for TEVAR, TEVAR + SUB, TEVAR + SUB + BYPASS or later as a separate procedure.
Results
A total of 2676 patients underwent TEVAR; 869 (32.5%) underwent TEVAR + SUB and 49 (5.6%) TEVAR + SUB + BYPASS. At the time of the initial procedure, TEVAR + SUB + BYPASS was associated with a higher incidence of stroke compared to TEVAR + SUB (12.8% vs. 3.8 %; p = 0.0033). Among TEVAR + SUB, only 1.93% (50 patients) had a subsequent bypass performed during a one-year follow-up. Overall rates of morbidity (p = 0.004) and mortality (p = 0.011) trended towards significance in favor of TEVAR + SUB.
Conclusions
TEVAR + SUB were associated with lower rates of mortality and complications. Only a small percentage of TEVAR + SUB required a bypass at one year after procedure. Our data suggest that routine LSA bypass during TEVAR is unnecessary and associated with increase morbidity and mortality.
LambrechtsDCasselmanFSchroeyersP. Endovascular treatment of the descending thoracic aorta. Eur J Vasc Endovasc Surg2003; 26: 437–444.
2.
RehdersTCPetzschMInceH. Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance. J Endovasc Ther2004; 11: 659–666.
3.
GorichJAsquanYSeifarthH. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs. J Endovasc Ther2002; 9(Suppl 2): II39–II43.
4.
TiesenhausenKHauseggerKAOberwalderP. Left subclavian artery management in endovascular repair of thoracic aortic aneurysms and aortic dissections. J Card Surg2003; 18: 429–435.
5.
BavariaJEAppooJJMakarounMS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial. J Thorac Cardiovasc Surg2007; 133: 369–377.
6.
DexterDMaldonadoTS. Left subclavian artery coverage during TEVAR: is revascularization necessary?J Cardiovasc Surg (Torino)2012; 53: 135–141.
7.
FeezorRJLeeWA. Management of the left subclavian artery during TEVAR. Semin Vasc Surg2009; 22: 159–164.
8.
PetersonBGEskandariMKGleasonTG. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg2006; 43: 433–439.
9.
WeigangEParkerJACzernyM. Should intentional endovascular stent-graft coverage of the left subclavian artery be preceded by prophylactic revascularisation?Eur J Cardiothorac Surg2011; 40: 858–868.
10.
MatsumuraJSLeeWAMitchellRS. The Society for Vascular Surgery Practice Guidelines: management of the left subclavian artery with thoracic endovascular aortic repair. J Vasc Surg2009; 50: 1155–1158.
11.
RehmanSMVechtJAPereraR. How to manage the left subclavian artery during endovascular stenting of the thoracic aorta. Eur J Cardiothorac Surg2011; 39: 507–518.
12.
MoraschMDPetersonB. Subclavian artery transposition and bypass techniques for use with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg2006; 43(Suppl A): 73A–77A.
13.
FeezorRJMartinTDHessPJ. Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR). J Endovasc Ther2007; 14: 568–573.
14.
ButhJHarrisPLHoboR. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on stent/graft techniques for aortic aneurysm repair (EUROSTAR) registry. J Vasc Surg2007; 46: 1103–1110. discussion 1110–1101.
15.
RizviAZMuradMHFairmanRM. The effect of left subclavian artery coverage on morbidity and mortality in patients undergoing endovascular thoracic aortic interventions: a systematic review and meta-analysis. J Vasc Surg2009; 50: 1159–1169.
16.
ChungJKasirajanKVeeraswamyRK. Left subclavian artery coverage during thoracic endovascular aortic repair and risk of perioperative stroke or death. J Vasc Surg2011; 54: 979–984.
17.
MadenciALOzakiCKBelkinM. Carotid-subclavian bypass and subclavian-carotid transposition in the thoracic endovascular aortic repair era. J Vasc Surg2013; 57: 1275–1282.
18.
LeeMLeeDYKimMD. Selective coverage of the left subclavian artery without revascularization in patients with bilateral patent vertebrobasilar junctions during thoracic endovascular aortic repair. J Vasc Surg2013; 57: 1311–1316.
19.
GutscheJTCheungATMcGarveyML. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg2007; 84: 1195–1200. discussion 1200.
20.
UlleryBWMcGarveyMCheungAT. Vascular distribution of stroke and its relationship to perioperative mortality and neurologic outcome after thoracic endovascular aortic repair. J Vasc Surg2012; 56: 1510–1517.
21.
MaldonadoTSDexterDRockmanCB. Left subclavian artery coverage during thoracic endovascular aortic aneurysm repair does not mandate revascularization. J Vasc Surg2013; 57: 116–124.
22.
MaedaTYoshitaniKSatoS. Spinal cord ischemia after endovascular aortic repair versus open surgical repair for descending thoracic and thoracoabdominal aortic aneurism. J Anesth2012; 26: 805–811.
23.
CzernyMEggebrechtHSodeckG. Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC). J Endovasc Ther2012; 19: 37–43.
24.
UlleryBWCheungATFairmanRM. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg2011; 54: 677–684.
25.
KeithCJJrPassmanMACarignanMJ. Protocol implementation of selective postoperative lumbar spinal drainage after thoracic aortic endograft. J Vasc Surg2012; 55: 1–8. discussion 8.
26.
TakachTJDuncanJMLivesayJJ. Contemporary relevancy of carotid-subclavian bypass defined by an experience spanning five decades. Ann Vasc Surg2011; 25: 895–901.
27.
ReeceTBGazoniLMCherryKJ. Reevaluating the need for left subclavian artery revascularization with thoracic endovascular aortic repair. Ann Thorac Surg2007; 84: 1201–1205. discussion 1205.
28.
LeeTCAndersenNDWilliamsJB. Results with a selective revascularization strategy for left subclavian artery coverage during thoracic endovascular aortic repair. Ann Thorac Surg2011; 92: 97–102. discussion 102–103.
29.
MartinGSManninoDMEatonS. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med2003; 348: 1546–1554.
30.
KrumholzHMWangYMatteraJA. An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with an acute myocardial infarction. Circulation2006; 113: 1683–1692.
