Mid-term outcomes of the fenestration, branched stent-graft, and hybrid techniques in the treatment of thoracic aortic pathologies involving the left subclavian artery

Objective To compare the midterm outcomes of fenestration, branched stent-graft thoracic endovascular aortic repair, and hybrid procedures in treating aortic arch pathologies involving the left subclavian artery. Methods We collected the clinical data from 144 patients with aortic arch pathologies involving and only involving the left subclavian artery (LSA) who underwent fenestration, branched stent-graft thoracic endovascular aortic repair, and hybrid procedures from November 2015 and December 2022 at a single center. Among the patients, 68 were treated by fenestration, 61 by branched stent-grafts, and 15 by hybrid surgery. The clinical data was retrospectively analyzed and compared. The primary outcome indicators included technical success and in-hospital mortality; others included the incidence of endoleaks, spinal cord ischemia, LSA patency, stent-related entry tear, aortic-related reintervention, operative time, blood loss, and aortic remodeling. Results The technical success rate was 83.8%, 95.1%, and 100% (p = .046), and the in-hospital mortality rate was 1.5% (n = 1), 0%, and 0% (p = 1.000) in the fenestration, branched stent-graft, and hybrid surgery groups. Type I or III endoleaks occurred in 16.2% (n = 11), 4.9% (n = 3), and 0% of patients, respectively (p = .046). The operative time, blood loss, and hospitalization duration of the hybrid surgery group was significantly higher than those of the other two groups (p < .05). However, the surgery-related costs and total costs in the hybrid surgery group were lower than the other two groups (p < .001). The rate of LSA patency was 100% in the fenestration group and 98.3% in the branched stent-graft group (p = .475). The all-cause mortality rates were 10.9% (n = 7), 6.9% (n = 4), and 0%, respectively (p = .359). Spinal cord ischemia and other complications were not significantly different in each group, both in the perioperative and postoperative periods. In the subgroup analysis of patients with AD, the incidence of endoleaks was 28.9% (n = 13), 7.0% (n = 3), and 0%, respectively (p = .011), and stent-related new entry tears in each group were 2.2% (n = 1), 18.6% (n = 8), and 14.3% (n = 1), respectively, p = .032. The overall cumulative survival rate at 2 years was 90.0%, 92.4%, and 100%, respectively (p = .508). The true lumen area of the aortic arch and descending thoracic aorta in the stent segment was significantly larger postoperatively compared to that preoperatively in both of these three groups. Conclusion The fenestration technique is sophisticated with long learning curve and is prone to complications such as endoleaks with inexperience. Branched grafts are at greater risk of stent-related entry tears, which result in a higher rate of re-intervention. The hybrid technique broadens the indications for patients with aortic arch vessel variation and generally costs less, but the operative time is longer. Surgeons should select the optimal solution based on each patient's condition to achieve satisfactory results.