Zone 2 TEVAR with the Reconstruction of the Isolated Left Vertebral Artery

Abstract

Spinal cord ischemia (SCI) is one of the serious complications in patients undergoing TEVAR (thoracic endovascular aortic repair). Although the left subclavian artery (LSA) reconstruction in patients with zone 1 and zone 2 TEVAR is controversial, LSA reconstruction has been reported to prevent peri-operative SCI. The isolated left vertebral artery (ILVA) is a common anomaly in which the left vertebral artery originates directly from the aortic arch. We report the ILVA reconstruction in addition to the left common carotid artery (LCCA)–LSA bypass in zone 2 TEVAR performed in two patients with thoracic aortic aneurysm and aortic dissection. Case 1: A 79-year-old female with hoarseness had a distal aortic arch aneurysm 50 mm in diameter with ILVA. Since the length between ILVA and the aneurysm was 19 mm, we performed ILVA end-to-side anastomosis in addition to LCCA–LSA bypass using PROPATEN graft prior TEVAR. Zone 2 TEVAR was then performed using conformable TAG. Case 2: A 70-year-old female undergoing the partial aortic arch replacement (innominate and left common carotid artery reconstruction) for type A aortic dissection had a new entry at the distal anastomosis. She had the ILVA between LCCA and LSA, we performed zone 2 TEVAR with LCCA–LSA bypass and the reconstruction of ILVA. The post-operative courses were uneventful. The ILVA reconstruction could prevent peri-operative stroke and SCI.