Carotid-subclavian bypass and subclavian-carotid transposition in the thoracic endovascular aortic repair era.

Abstract

Beyond traditional indications, subclavian revascularization is increasingly performed to allow for aortic arch debranching in the setting of thoracic endovascular aortic repair (TEVAR). Endovascular treatment options for subclavian disease have emerged, perhaps altering the patient population undergoing open revascularization. We leveraged prospectively collected American College of Surgeons (ACS)-National Surgical Quality Improvement Program (NSQIP) data to delineate evolving stroke and mortality rates after carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) in this dynamic context. The ACS-NSQIP database (2005 to 2010) was used to examine patients who underwent CSB or SCT. Patients admitted for emergency cases were excluded. Factors associated with 30-day postoperative cerebrovascular accident (CVA) or death (CVA/D) were defined using univariable and multivariable analyses. CSB comprised 41% of revascularizations associated with TEVAR and 89% of isolated revascularizations. A greater proportion of TEVARs were performed in the SCT group (37.4% vs 4.9%; P < .01). The groups were similar in demographic characteristics and prevalence of comorbidities. Overall stroke, mortality, and combined CVA/D rates were 3.5% (n = 31), 3.3% (n = 29), and 5.8% (n = 51), respectively. Surgical approach did not affect outcome. The CVA/D rate was 10.2% (n = 9) for revascularization in conjunction with TEVAR and 5.3% (n = 42) for isolated reconstruction (P = .06). For patients undergoing isolated revascularization, increasing age (adjusted odds ratio, 1.06; 95% confidence interval, 1.03-1.10; P < .01), and nonindependent functional status (odds ratio, 3.49; 95% confidence interval, 1.41-8.68; P < .01) were significantly associated with CVA/D. In this contemporary data set, there was no significant difference in CVA/D by surgical approach. TEVAR trended toward an association with CVA/D compared with isolated subclavian reconstruction. CVA/D continues to complicate contemporary CSB and SCT, especially among elderly and nonindependent patient subsets.