Comparative outcomes of open and endovascular left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair.

Abstract

To compare perioperative and follow-up outcomes of carotid-subclavian bypass (CSB)+thoracic endovascular aortic repair (TEVAR), branched TEVAR, and fenestrated TEVAR for left subclavian artery revascularization during zone 2 TEVAR. The Society for Vascular Surgery Vascular Quality Initiative TEVAR registry was queried from 2013 to 2026 to identify nontraumatic zone 2 TEVAR procedures with left subclavian artery revascularization. Outcomes were compared using omnibus testing and full-cohort multivariable-adjusted regression, with pairwise propensity-score matching performed as a sensitivity analysis. Among 723 patients from 113 centers, 406 (56.2%) underwent CSB+TEVAR, 205 (28.4%) underwent branched TEVAR, and 112 (15.5%) underwent fenestrated TEVAR. In-hospital mortality (3.2% vs. 1.0% vs. 3.6%; P=.212), cerebrovascular events (6.4% vs. 3.4% vs. 5.4%; P=.303), stroke (5.9% vs. 2.9% vs. 5.4%; P=.272), and spinal cord ischemia (3.0% vs. 4.9% vs. 0.9%; P=.143) did not differ significantly among groups. CSB+TEVAR was associated with greater blood loss, longer procedure duration, more frequent staged treatment, lower technical success, and longer postoperative length of stay. In full-cohort multivariable-adjusted analyses, mortality, cerebrovascular events, stroke, myocardial infarction, most access complications, and ICU stay did not differ significantly; however, side-arm branched TEVAR was associated with lower adjusted odds of aortic reintervention before discharge and shorter postoperative length of stay compared with CSB+TEVAR. Overall survival and freedom from aortic reintervention did not differ significantly by log-rank testing, whereas freedom from sac enlargement differed significantly. In pairwise propensity-matched analyses, no significant differences were identified for most perioperative outcomes, although matched sample sizes were limited. CSB+TEVAR, branched TEVAR, and fenestrated TEVAR demonstrated distinct procedural profiles during zone 2 TEVAR. After adjustment, most perioperative and follow-up outcomes did not differ significantly, supporting individualized selection of LSA revascularization strategies based on anatomy, device availability, and institutional expertise.