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This retrospective study compared in situ reconstruction versus extra-anatomic aorto-axillary bypass for left subclavian artery (LSCA) revascularization during total aortic arch replacement in 436 patients. The study found that while perioperative outcomes were similar, extra-anatomic bypass demonstrated superior long-term LSCA patency at 5 years compared to in situ reconstruction (97.7% vs 87.8%). A small subgroup analysis suggested 100% patency in both LSCA and LITA grafts when LITA-LAD bypass was performed concomitantly.
Extra-anatomic aorto-axillary bypass offers superior long-term patency compared to in situ reconstruction for LSCA revascularization during total aortic arch replacement.
OBJECTIVES Revascularization of the left subclavian artery (LSCA) is routinely required during total aortic arch replacement. In situ reconstruction may be technically difficult in cases with large aneurysms or posterior vessel displacement. Extra-anatomic aorto-axillary bypass has been proposed as an alternative, but its long-term patency relative to in situ repair remains uncertain. This study compared LSCA patency between the two techniques. METHODS We retrospectively analyzed 436 consecutive patients (median age 69.0 years [interquartile range (IQR) 62.0-75.0]; 347 men) who underwent total arch replacement with LSCA revascularization: 240 in situ and 196 extra-anatomic. Postoperative CT imaging (1,853 scans; median 3 [IQR 1-6] per patient) was reviewed to determine immediate and long-term patency. Kaplan-Meier analysis was used for time-to-event comparison. A small descriptive subgroup of 18 patients undergoing concomitant left internal thoracic artery (LITA) to left anterior descending artery (LAD) bypass was also reviewed. RESULTS Perioperative outcomes, including mortality and major complications, were similar between groups. Subclavian wound infection occurred in three extra-anatomic cases (1.5%), all managed successfully with local care. Immediate LSCA patency was higher after extra-anatomic bypass (100% vs 92.9%, pā<ā0.001). At five years, patency remained superior with extra-anatomic bypass (97.7% vs 87.8%; log-rank pā=ā0.0002).In the descriptive LITA-LAD subgroup, CT follow-up demonstrated 100% LSCA and LITA graft patency; however, interpretation is limited by the small sample size. CONCLUSIONS Compared with in situ reconstruction, extra-anatomic LSCA bypass provides equivalent perioperative safety and superior long-term patency. These findings support extra-anatomic bypass as a reliable and technically straightforward option for LSCA revascularization during total arch replacement.
