InnovatIng for ClInICal PerformanCe

L eft subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) is often necessary due to anatomic factors and is performed in up to 40% of TEVAR procedures.1 Society for Vascular Surgery practice guidelines recommend that preoperative revascularization should be performed in patients who need elective TEVAR in which proximal seal necessitates coverage of the LSA. Furthermore, routine preoperative LSA revascularization is strongly recommended in selected patients who have anatomy that compromises perfusion to critical organs. However, in patients who need urgent TEVAR in which LSA coverage is necessary, revascularization should be individualized and addressed expectantly.2 Data to date are inconclusive as to the appropriate management of the LSA during TEVAR. LSA coverage is associated with an increased risk of arm ischemia, vertebrobasilar ischemia, and possibly spinal cord ischemia and anterior circulation stroke; left subclavian revascularization should be performed before coverage.3,4 However, others have found that the use of selective revascularization is safe and does not appear to increase the risk of neurologic events.5,6 The Valiant® Mona LSA Stent Graft (Medtronic, Inc., Minneapolis, MN), the clinical configuration of the new Thoracic Branch Stent Grafta program, was developed to solve these clinical challenges and extend the benefits of endovascular repair without surgery to more patients with thoracic aortic aneurysms. The intention was to design a technology leveraging the proven clinical effectiveness of the FDA-approved Medtronic Valiant Thoracic Stent Graft in the management of thoracic aortic disease while maintaining flow to the LSA without the need for surgical bypass. The Valiant Thoracic Stent Graft consists of a monofilament polyester fabric graft with nitinol springs. It is indicated for the treatment of isolated lesions (excluding dissections) of the descending thoracic aorta. The stent graft system incorporates an eight-peak proximal stent design that distributes radial force evenly across the aortic wall. There is no connecting bar between stents, which makes the graft highly conformable. Advantages of the delivery system include tip capture for enhanced control and precise deployment, as well as a hydrophilic coating that facilitates delivery through difficult access vessels. Multiple publications have addressed the use of the Valiant Stent Graft in the treatment of thoracic aortic pathology, including the TRAVIATA registry, the VIRTUE registry, the Valiant® Captivia® registry, and the pivotal From benchtop to bedside With the valiant mona lsa thoracic stent Graft