Left Subclavian Artery Management Strategies During TEVAR for Blunt Thoracic Aortic Injury: Do Branched Endografts Offer a Clinical Advantage?

Abstract

To compare outcomes of left subclavian artery (LSA) management strategies during thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) using a national registry. The Society for Vascular Surgery Vascular Quality Initiative TEVAR registry was queried for patients undergoing zone 2 TEVAR for BTAI from 2013 through April 2026. Patients were stratified into LSA coverage without revascularization, TEVAR with branched endograft (TBE), or staged carotid-subclavian bypass with TEVAR (CSB+TEVAR). Primary outcomes were 30-day mortality and arm ischemia. Secondary outcomes included stroke, spinal cord ischemia (SCI), and reintervention. Kaplan-Meier survival analysis and adjusted TBE-versus-coverage sensitivity analyses were performed. A total of 416 patients were included (LSA coverage n=327, TBE n=74, CSB+TEVAR n=15). Patients undergoing LSA coverage were younger and more frequently presented with rupture. Thirty-day mortality was 11.6%, 5.4%, and 0%, respectively (P=.113). Stroke (5.2% vs 5.4% vs 6.7%) and arm ischemia (2.4% vs 1.4% vs 6.7%) were not significantly different across groups. SCI was rare (1.8%, 0%, and 6.7%). Aortic- or arm ischemia-related reintervention was more frequent after CSB+TEVAR (13.3% vs 2.7% vs 1.5%; P=.044). Overall reintervention and survival did not differ significantly among groups. In patients undergoing zone 2 TEVAR for BTAI, no statistically significant differences were detected in major neurologic or ischemic complications among LSA management strategies. These findings suggest a pragmatic, damage-control approach favoring rapid TEVAR with selective delayed revascularization rather than routine prophylactic LSA intervention.