Left Vertebral Artery Revascularization in Distal Aortic Arch Surgery: Comparative Study of Patients With and Without Aberrant Left Vertebral Anatomy

The aim of this study was to compare the outcomes of direct vertebral artery revascularization with indirect subclavian artery revascularization for treating aortic arch pathology, and to identify predictors of mortality. A retrospective cohort study was conducted at a single tertiary hospital, including patients who underwent vertebral artery revascularization between 2005 and 2022. The outcomes of interest were a composite outcome (death, stroke, nerve injury, thrombosis) and mortality. Univariate logistic regression models were fitted to quantify differences between direct and indirect revascularization cohorts. Cox regression was used to identify mortality predictors. Of 143 patients who underwent vertebral artery revascularization, 21 (14.7%) underwent direct vertebral revascularization. The median length of stay was 10 days (interquartile range, 6-20 days), and demographics were similar between cohorts. The incidence of composite outcome, bypass thrombosis and hoarseness were significantly higher in the direct group (42.9% vs 18.0%; P = .019; 33.3% vs 0.8%; P < .0001; 57.1% vs 18.0%; P < .001, respectively). The direct group was ∼3 times more likely to experience the composite outcome (odds ratio [OR], 3.41; 95% confidence interval [CI],1.28-9.08); similarly, this group was ∼6 times more likely to have hoarseness (OR, 5.88; 95% CI, 2.21-15.62) (Table I). After adjusting for these covariates, the group was not an independent predictor of mortality (Table II). There was no significant difference in mortality rates at 30 days, and 1, 3, 5, and 10 years of follow-up. Age, length of hospital stay, and congestive heart failure were identified as predictors of higher mortality. After adjusting for these covariates, the group was not an Independent predictor of mortality. Direct revascularization was associated with higher rates of bypass thrombosis, composite outcome, and hoarseness. Patients with aberrant aortic arch anatomy are at higher risks of these complications. However, mortality rates were not significantly different between the groups after adjusting for other factors.Table ICohort (direct versus indirect vertebral artery revascularization) differences for all outcomesOutcomeDirect n (%)Indirect n (%)P valueaComposite (death, stroke, nerve injury, thrombosis)9 (42.9)22 (18.0).019Bypass thrombosis7 (33.3)1 (0.8)<.0001Mortality6 (28.6)48 (39.3).48Posterior circulation stroke1 (4.8)6 (4.9).99Stroke (any)2 (9.5)12 (9.8).99Hoarseness12 (57.1)22 (18.0)<.001bPhrenic nerve injury03 (2.5).99Dysphagia4 (19.1)11 (9.1).24Anterior circulation stroke1 (4.8)9 (7.4).99Paraplegia1 (4.8)0.15Paraparesis1 (4.8)5 (4.1).99Readmission1 (4.8)17 (13.9).47Reoperation4 (19.1)25 (20.5).99aAll testing based on the Fisher exact test unless otherwise noted.bχ2 test. Open table in a new tab Table IIUnadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of patients’ characteristics for all-cause mortality assessed for all patientsCharacteristicUnadjusted HR (95% CI)P valueAdjusted HR (95% CI)P valueProcedure: direct vs indirect0.76 (0.32-1.77).520.58 (0.24-1.41).23Age, years1.06 (1.03-1.08)<.00011.06 (1.03-1.09)<.0001Length of hospital stay, days1.01 (1.01-1.02).00031.02 (1.01-1.02)<.0001Congestive heart failure (yes vs no)3.30 (1.48-7.35).00353.60 (1.55-8.35).0028Dysphagia (yes vs no)2.21 (1.07-4.56).031–– Open table in a new tab