Management of left subclavian artery in endovascular stent-grafting for distal aortic arch disease.

BACKGROUND Although the left subclavian artery (LSA) is simply covered to exclude distal aortic arch aneurysm during endovascular stent-grafting, this technique is potentially harmful. METHODS AND RESULTS Between January 2001 and April 2005, 40 cases of stent-grafting were performed for distal aortic arch diseases. For all 31 elective cases, the LSA occlusion test using a balloon catheter was preoperatively performed to predict critical complications secondary to LSA coverage by a stent graft and this revealed 2 cases in which the LSA was crucial for brain circulation (6.5%). The LSA was saved by using a hand-made fenestrated stent graft without bypass-grafting to the LSA in 22 cases. Bypass-grafting to LSA was performed in 5 cases. The LSA was simply occluded in 13 cases. Hospital mortality rates for the elective and emergency cases were 3.2% and 30.0%, respectively. One elective patient had a cerebral infarction (2.5%). LSA patency was successfully maintained in all 22 cases using a fenestrated stent graft. CONCLUSION The LSA plays an important role in brain circulation in some patients and so a preoperative LSA occlusion test is helpful when aortic stent-grafting is proposed. Fenestrated stent graft saved the LSA in more than 50% of the present cases.