Selective left subclavian ligation in total aortic arch replacement.

Abstract

The left subclavian artery (LSA) is usually difficult to manipulate in total aortic arch replacement procedures if it is displaced by huge false lumens in the ascending aorta or right hemiarch. We summarize our experience of selectively ligating the deeply located LSA in total aortic arch replacement and stented "elephant trunk" implantation procedures for Stanford type A aortic dissection. Data of 29 patients with deep LSA undergoing total arch replacement and stented "elephant trunk" implantation from January 2008 to June 2010 were reviewed. The LSA was ligated because of the difficult exposure (21 males, 8 females, age 19 to 55). Collateral circulation of the circle of Willis and bilateral vertebral arteries were assessed thoroughly by preoperative imaging and intraoperative observations. If collateral circulation was sufficient, LSA was ligated; if insufficient, an additional bypass graft was created from the ascending aorta to the left axillary artery. Twenty-eight patients survived the operation with 1 early death. Postoperative blood pressures were lower in the left arm than in the right (78±17.3 vs 126±3.7 mm Hg, p<0.01), but oxygen saturation, skin temperature, and strength of the left hand were normal. The surviving patients have been followed for 16.6±9.0 months (6 to 36) and none had symptoms of LSA steal syndrome or arm ischemia. Ligation of the LSA after strict evaluation of collateral circulation could be safe for type A dissection patients if the exposure is insufficient, and this method can simplify the operation significantly.