The Sandwich Technique with Body Flossing Wire to Revascularize Left Subclavian Artery in Thoracic Endovascular Aortic Repair

Background: To evaluate the safety and efficacy of the sandwich technique with the body flossing wire to revascularize the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR). Methods: From April 2014 to April 2015, 20 consecutive patients with a variety of thoracic aortic pathologies who underwent LSA revascularization with the sandwich technique and body flossing wire during TEVAR were included. Outcomes including technical success, endoleaks, perioperative mortality and morbidity, and graft patency were analyzed. Results: There were 13 patients (65.0%) who presented with aortic dissection, 3 (15.0%) with thoracic aortic aneurysm, 3 (15.0%) with penetrating aortic ulcer, and 1 (5.0%) with traumatic aortic disruption. Technical success rate was 100%. But one type Ia endoleak (5.0%) was noted and treated with extended endografting. One sandwiched gutter leak (5.0%) resolved spontaneously at 6 months. One sandwiched graft (5.0%) was occluded but not treated because no related complications were found. At a mean follow-up of 9.7 months (range 4-17), all the patients with aortic aneurysm, penetrating aortic ulcer, or traumatic aortic disruption had complete thrombosis of the aortic pathologies. Patients with aortic dissection had thrombosed false lumen down to the distal aortic endograft edge (12/13, 92.3%) or the celiac artery level (8/13, 61.5%). There was no neurological deficit but 2 noneprocedure-related late deaths during the study period. Conclusions: Our early experience showed that the sandwich technique with the body flossing wire to maintain blood flow to the LSA is a safe and effective method. This technique can be applied in various clinical situations with a high technique success rate. However, outcomes are preliminary and larger studies are required.