Transposition of the left vertebral artery during endovascular stent-graft repair of the aortic arch

Abstract

Objectives: The aim of this study was to present our experience with the management of isolated left vertebral artery during hybrid aortic arch repairs with thoracic endovascular aortic repair completion.

Methods: This is a single-center, observational, cohort study. Between January 2007 and December 2018, 9 patients (4.5%) of 200 who underwent thoracic endovascular aortic repair were identified with isolated left vertebral artery. The isolated left vertebral artery was the dominant vertebral artery in 4 cases and entered the Circle of Willis to form the basilar artery in all cases. Isolated left vertebral artery transposition was performed in 2 patients during open ascending/arch repair before thoracic endovascular aortic repair completion. In 4 patients, isolated left vertebral artery transposition was performed concomitant with carotid-subclavian bypass during thoracic endovascular aortic repair completion ("zone 2" thoracic endovascular aortic repair). Primary outcomes were early (<30 days) and late survival, freedom from aortic-related mortality, and isolated left vertebral artery patency.

Results: Primary technical success was achieved in all cases. Isolated left vertebral artery-related complication occurred in 1 patient (Horner syndrome). Immediate thrombosis, vagus/recurrent laryngeal nerve palsy, lymphocele, and chylothorax were never observed. Postoperative cerebrovascular accident or spinal cord injury was not observed. Median follow-up was 15 months (range, 3-72). We did not observe aortic-related mortality during the follow-up. Aortic-related intervention was never required. Both isolated left vertebral artery and carotid-subclavian bypass are still patent in all patients with no sign of anastomotic pseudoaneurysm or stenosis.

Conclusions: Although isolated left vertebral artery is not a frequent occurrence, it is not so rare. It may pose additional difficulties during hybrid aortic arch surgical repairs, but isolated left vertebral artery transposition was feasible, safe, and a durable reconstruction.

Keywords: hybrid aortic arch repair; isolated left vertebral artery; vertebral artery transposition.