Cervical Debranching in the Endovascular Era: A Single Centre Experience

Abstract

Objective/background: Debranching of the supra-aortic arteries is a common practice either as part of a hybrid treatment of aortic arch pathology or owing to arterial occlusive disease. Results of the debranching techniques have not been reported frequently.

Methods: This was a retrospective single centre study of all consecutive patients with cervical debranching procedures as part of hybrid aortic arch repair.

Results: Between 2010 and 2017, 201 patients underwent 211 cervical debranching procedures in a tertiary centre. Mean ± SD patient age was 67.7 ± 10.7 years (70.6% males; n = 142/201) and mean ± SD body mass index (BMI) was 26.3 ± 5. In 78.7% of the cases carotid-subclavian bypass was performed alone (n = 166/211) followed by transposition of the subclavian artery to the ipsilateral carotid (n = 17/211; 8.1%) and in 28 cases (13.3%) a combination of procedures was performed. Twenty-four cases (11.4%) were complicated with local bleeding and 21 cases required re-intervention (10.4%). Nineteen patients (9.5%) developed local peripheral neurological damage post-operatively. Eight patients (3.8%) developed a chylous fistula and five (2.4%) presented with a local wound infection. One patient (0.5%) developed a bypass graft infection. The thirty day mortality was 7.6% (n = 16/211): one death occurred after isolated debranching without thoracic endovascular aneurysm repair (TEVAR; 0.5%). Whether the hybrid procedures were undertaken in a single stage (simultaneous TEVAR and cervical debranching) or two stage fashion appeared to have a significant impact on 30 day mortality (single stage n = 9/60 [15%] vs. debranching alone or two stage hybrid procedures n = 7/144 [4.9%]; p = .018). The major stroke incidence was 4.3% (n = 9/211); no strokes occurred after isolated debranching. Stroke was correlated with longer operating times (odds ratio [OR] 1.006; 95% confidence interval [CI] 1.000-1.011; p = .045) and higher BMI (OR 1.195; 95% CI 1.009-1.415; p = .039). Mean ± SD follow up was 15 ± 17 months (range 0-89 months). Primary cumulative graft patency during follow up was 98.1% (n = 207/211) and secondary patency was 100%.

Conclusion: The results of cervical debranching procedures showed not only excellent patency rates, but also a significant rate of local complications. Carotid-subclavian bypass appeared to be safer with significantly fewer post-operative complications. Staged hybrid procedures also seemed to be safer.

Keywords: Aortic arch hybrid treatment; Carotid–subclavian bypass; Carotid–subclavian transposition; Cervical debranching; Stroke; TEVAR.