Ann Thorac Surg 2008;85:125-126. doi:10.1016/j.athoracsur.2007.09.043
© 2008 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
John Kern, MD
Department of Surgery, University of Virginia Health Sciences Center, Box 800679, Charlottesville, VA 22908
(Email: jak3r{at}virginia.edu).
Manninen and colleagues [1] present interesting anatomic data concerning the adequacy of the cerebral circulation after stent graft exclusion of the left subclavian artery. Since the Food and Drug Administration’s approval of a device for the endovascular repair of thoracic aortic aneurysms, the real world application of this technology has stretched our creativity and imagination. As surgeons we are not inherently used to thinking "destructively," but as we gain experience with the routine exclusion of major branch vessels without pre-emptive reconstruction, I am concerned that some may become complacent about the routine coverage of the left subclavian and perhaps even the celiac artery as well. Many of us are quick to report our favorable results, yet our less favorable outcomes often go unreported. As less experienced operators increase their individual experiences, they may find out the painful way that not everyone has suitable anatomy for left subclavian artery exclusion. When a patient presents for urgent or emergent endovascular aortic intervention, time and circumstance may not allow for in-depth evaluation of the carotid, vertebral, and intracranial circulation. The decision to proceed with endovascular repair and possible left subclavian artery exclusion will obviously depend on multiple factors.
This article serves as a reminder that not all patients will tolerate left subclavian artery exclusion. Although left arm claudication may be nothing more than a nuisance that can be safely treated after the endograft procedure, a significant posterior circulation stroke may be unrecoverable. Interestingly, as many of us know, the incidence of such devastating central neurologic events is actually quite rare. So the main issue is to determine exactly what the correlation of anatomy to physiology is when it comes to evaluating the cerebral circulation. Those of us who perform a significant amount of vascular surgery have wrestled with this concept for years when performing carotid surgery. Deciding whom to shunt based on preoperative imaging studies is basically impossible. Therefore, the safe approach would be to perform routine subclavian revascularization in every patient who requires left subclavian stent graft coverage. However, this would subject the patient to another procedure that is not without risk. I believe, as the authors point out, that all patients should be carefully and thoroughly evaluated prior to stent grafting, and based on identified anatomy and extent of pre-existing vascular disease, a reasonable decision can be made as to how to proceed.
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References
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- Manninen H, Tulla H, Vanninen R, Ronkainen A. Endangered cerebral blood supply after closure of left subclavian artery: postmortem and clinical imaging studies Ann Thorac Surg 2008;85:120-126.[Abstract/Free Full Text]
Related Article
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Endangered Cerebral Blood Supply After Closure of Left Subclavian Artery: Postmortem and Clinical Imaging Studies
- Hannu Manninen, Harri Tulla, Ritva Vanninen, and Antti Ronkainen
Ann. Thorac. Surg. 2008 85: 120-125.
[Abstract]
[Full Text]
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