Supervisors info:
Γεώργιος Γερουλάκος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Ιωάννης Κακίσης, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αχιλλέας Χατζηϊωάννου, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Introduction
Minimal invasive approaches have recently risen as a field of significant importance in modern medicine .According to this trend Thoracic Endovascular Aortic Repair (TEVAR) is a rapidly evolving treatment strategy for numerous aortic pathologies, which replaces in many cases the conventional more invasive surgical approaches, in order to minimize the operation time, blood loss, postsurgical pain and improving the outcome in general.
However, TEVAR, as an endovascular intervention, demands a sufficient landing zone to achieve complete sealing. Unfortunately, in a substantial portion of cases, with short proximal landing zones, Left Subclavian Artery (LSA) coverage is required. This predisposes to potential severe complications such as stroke, spinal cord ischemia and left upper extremity ischemia.
Aim
The aim of this study is to examine the potential positive role of left subclavian artery revascularization in thoracic endovascular aortic repair with LSA coverage.
Methods
A systematic search was conducted to identify all studies providing comparative outcomes with or without LSA revascularization forLSA occlusion during TEVAR. All retrospective, prospective and observational studies were included with a limitation of at least 100 cases of TEVAR with LSA coverage.The primary outcome parameters were perioperative stroke, spinal cord ischemia (SCI), and mortality.
Results
The initial search included 33 trials. Upon exclusion of 27, six studies were finally selected with a total of 1,721 patients who had undergone TEVAR, to be included in the metanalysis. A total of 708 patients (41.1%) had LSA revascularization performed
Out of the 1,721 patients included in the metanalysis, 126 patients (7.3%) experienced stroke and 45 of them had LSA with revascularization performed. Overall pooled results showed that LSA revascularization was not significantly associated with the incidence of stroke even though the pooled odds ratio was lower than 1 (OR=0.70, 95% CI 0.47-1.03, p=0.07, I2=0%).(5.34%) experienced stroke and 36 of them had LSA with revascularization performed. Results of the pooled odds ratios showed that there was no statistically significant association of LSA revascularization with the incidence of SCI including all six studies (OR=0.66, 95% CI 0.42-1.02, p=0.06, I2=0%)
For Baba et. al it was not clear whether the three deaths were reported in the group of patients who had LSA revascularization or not and thus this study was not included in the metanalysis of mortality. Among the 1,600 patients in the five studies included in the metanalysis of mortality, 45 deaths were reported in the group of patients with LSA revascularization and 61 among patients who did not have revascularization performed. The pooled analysis did not find a significant association of mortality with LSA revascularization (OR=0.94, 95% CI 0.62-1.41, p=0.77, I2=0%)
Conclusions
Our analysis demonstrated that despite limited lower mortality and decreased incidence of stroke and spinal cord ischemia, these results were statistical insignificant, thus LSA revascularization does not significantly improve the outcomes of TEVAR with LSA coverage.We believe that individualized preoperational assessment in order to detect high risk patients with potential benefit of LSA revascularization is the optimal approach currently. High-quality RCTs are required to provide robust evidence on the role of LSA revascularization in patients with LSA coverage during TEVAR.
Keywords:
Thoracic, Endovascular, Aortic, Repair, Left, Subclavian, Artery, Revascularization
