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Ann Thorac Surg 2009;88:504-505. doi:10.1016/j.athoracsur.2009.05.005
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Invited Commentary

Irving L. Kron, MD, Gorav Ailawadi, MD

Department of Surgery, University of Virginia Health System, PO Box 800679, 1215 Lee St, Charlottesville, VA 22908

(Email: ilk{at}virginia.edu).

We very much appreciate the opportunity to analyze the manuscript by Zipfel and colleagues [1]. They have stated that prophylactic subclavian artery revascularization may reduce significant neurologic complications. They concluded that prophylactic reconstruction of subclavian artery is safer than later elective reconstruction after stent graft repair of thoracic aorta disease. However, the authors demonstrated no statistical difference in neurologic complications between the patients in the protected and unprotected series.

When one reviews the major neurologic complications in the unprotected series, they all occurred in patients undergoing urgent procedures for type B dissections or traumatic injuries. Moreover, because many of these events occurred in patients with traumatic brain injury, it is difficult to conclude that preoperative subclavian artery revascularization would have altered the incidence of neurologic events.

We agree entirely with the concept that left arm ischemia is not the main indication for doing such prophylactic revascularization. In our series, approximately 40% of the patients undergoing stent graft coverage of the subclavian artery required subclavian artery revascularization [2], similar to the present study.

We believe that preoperative subclavian artery reconstruction should be performed in high-risk patients, including those with dominant left vertebral artery, an incomplete circle of Willis, or a patent left internal thoracic artery graft. In addition, based on the experience presented by Zipfel and colleagues [1], it may be appropriate to consider revascularization in urgent cases and patients with traumatic aortic injury or dissection.

Although the authors suggest that prophylactic subclavian revascularization should be done when long areas of the thoracic aorta are covered, they have no data to support this. The paraplegia rate was low in both groups. With this approach, the need for postoperative subclavian artery revascularization has been less than 15% in our experience [2]. We also agree that carotid subclavian bypass is a safe and simple procedure to perform either before or concomitant with stent graft repair of aneurysms, although we note that the authors had a 2.6% stroke rate with this procedure [1].

In summary, we do not agree that left subclavian artery revascularization needs to be performed in all cases of stent graft repair of thoracic aneurysms, even when long areas needed to covered. We believe in a selective approach based on a preoperative anatomic assessment.


   References
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 References
 

  1. Zipfel B, Buz S, Hammerschmidt R, Hetzer R. Occlusion of the left subclavian artery with stent grafts is safer with protective reconstruction Ann Thorac Surg 2009;88:498-505.[Abstract/Free Full Text]
  2. Reece TB, Gazoni LM, Cherry KJ, et al. Reevaluating the need for left subclavian artery revascularization with thoracic endovascular aortic repair Ann Thorac Surg 2007;84:1201-1205.[Abstract/Free Full Text]

Related Article

Occlusion of the Left Subclavian Artery With Stent Grafts Is Safer With Protective Reconstruction
Burkhart Zipfel, Semih Buz, Robert Hammerschmidt, and Roland Hetzer
Ann. Thorac. Surg. 2009 88: 498-504. [Abstract] [Full Text] [PDF]




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Gorav Ailawadi
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