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Debranching versus Fenestrated Repair for Left Subclavian Artery Revascularisation during Thoracic Endovascular Aortic Repair : The DEFENCE Multicentre Study

Ali, Ahmed Azhar ; Kölbel, Tilo LU ; Bertoglio, Luca ; Wanhainen, Anders ; Pratesi, Giovanni ; Cheng, Stephen ; Csobay-Novak, Csaba ; Dias, Nuno LU orcid ; Enzmann, Florian K. and Adam, Donald , et al. (2025) In European Journal of Vascular and Endovascular Surgery
Abstract

ObjectiveTo compare the early and midterm outcomes of left subclavian artery revascularization during thoracic endovascular aortic repair (TEVAR) following carotid subclavian bypass/transposition (CSB) vs. fenestrated repair when landing in zone 1/2. Propensity score matching (PSM) was applied to adjust for baseline differences.MethodsDEbranching versus FENestrated Repair for Left SubClavian Artery REvascularisation (DEFENCE) was a retrospective, international multicentre observational study conducted between January 2019 and July 2023 on consecutive patients who underwent open debranching or fenestration of the left subclavian artery before TEVAR for various aortic arch and descending aortic pathologies. PSM (68 pairs) was performed... (More)

ObjectiveTo compare the early and midterm outcomes of left subclavian artery revascularization during thoracic endovascular aortic repair (TEVAR) following carotid subclavian bypass/transposition (CSB) vs. fenestrated repair when landing in zone 1/2. Propensity score matching (PSM) was applied to adjust for baseline differences.MethodsDEbranching versus FENestrated Repair for Left SubClavian Artery REvascularisation (DEFENCE) was a retrospective, international multicentre observational study conducted between January 2019 and July 2023 on consecutive patients who underwent open debranching or fenestration of the left subclavian artery before TEVAR for various aortic arch and descending aortic pathologies. PSM (68 pairs) was performed using logistic regression. Primary endpoints included technical success and 30-day outcomes. Secondary endpoints included re-intervention, death, and aortic related complications at 12, 24, and 36 months.Results275 patients were included (198 CSB-TEVAR and 77 FTEVAR). Before PSM, statistically significant differences existed in patient demographics and the distribution of aortic pathology. In the matched cohort, CSB-TEVAR demonstrated higher overall re-intervention rates (15% vs. 3%, p = .031) and aortic related re-intervention rates (15% vs. 3%, p = .031) compared with FTEVAR. No statistically significant differences were observed in overall mortality rates (7% vs. 13%, p = .40) or aortic related mortality rate (3% vs. 3%, p = 1.0). Kaplan–Meier analysis indicated a statistically significant trend towards increased late re-intervention in the CSB-TEVAR group (log rank p = .019). Cox regression revealed that carotid subclavian bypass was associated with a fivefold increased independent risk of overall and aortic related re-interventions (hazard ratio 5.185, 95% confidence interval 1.13 – 23.86, p = .035).ConclusionCSB-TEVAR and FTEVAR achieved high technical success, long term durability, and similar mortality rates. FTEVAR is a durable, low re-intervention alternative, while CSB-TEVAR remains a practical option in urgent cases despite its higher incidence of peri-operative and access related morbidity.

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organization
publishing date
type
Contribution to journal
publication status
in press
subject
keywords
Aortic pathology, Carotid subclavian bypass, Fenestrated thoracic endovascular aortic repair, Left subclavian artery, Propensity score matching, Thoracic endovascular aortic repair
in
European Journal of Vascular and Endovascular Surgery
publisher
Elsevier
external identifiers
  • pmid:41380762
  • scopus:105034778867
ISSN
1078-5884
DOI
10.1016/j.ejvs.2025.12.008
language
English
LU publication?
yes
additional info
Publisher Copyright: © 2025 The Authors. Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY license. http://creativecommons.org/licenses/by/4.0/
id
db193850-97b2-4d34-88b9-93d25c1ae187
date added to LUP
2026-06-22 16:22:29
date last changed
2026-06-26 12:57:38
@article{db193850-97b2-4d34-88b9-93d25c1ae187,
  abstract     = {{<p>ObjectiveTo compare the early and midterm outcomes of left subclavian artery revascularization during thoracic endovascular aortic repair (TEVAR) following carotid subclavian bypass/transposition (CSB) vs. fenestrated repair when landing in zone 1/2. Propensity score matching (PSM) was applied to adjust for baseline differences.MethodsDEbranching versus FENestrated Repair for Left SubClavian Artery REvascularisation (DEFENCE) was a retrospective, international multicentre observational study conducted between January 2019 and July 2023 on consecutive patients who underwent open debranching or fenestration of the left subclavian artery before TEVAR for various aortic arch and descending aortic pathologies. PSM (68 pairs) was performed using logistic regression. Primary endpoints included technical success and 30-day outcomes. Secondary endpoints included re-intervention, death, and aortic related complications at 12, 24, and 36 months.Results275 patients were included (198 CSB-TEVAR and 77 FTEVAR). Before PSM, statistically significant differences existed in patient demographics and the distribution of aortic pathology. In the matched cohort, CSB-TEVAR demonstrated higher overall re-intervention rates (15% vs. 3%, p = .031) and aortic related re-intervention rates (15% vs. 3%, p = .031) compared with FTEVAR. No statistically significant differences were observed in overall mortality rates (7% vs. 13%, p = .40) or aortic related mortality rate (3% vs. 3%, p = 1.0). Kaplan–Meier analysis indicated a statistically significant trend towards increased late re-intervention in the CSB-TEVAR group (log rank p = .019). Cox regression revealed that carotid subclavian bypass was associated with a fivefold increased independent risk of overall and aortic related re-interventions (hazard ratio 5.185, 95% confidence interval 1.13 – 23.86, p = .035).ConclusionCSB-TEVAR and FTEVAR achieved high technical success, long term durability, and similar mortality rates. FTEVAR is a durable, low re-intervention alternative, while CSB-TEVAR remains a practical option in urgent cases despite its higher incidence of peri-operative and access related morbidity.</p>}},
  author       = {{Ali, Ahmed Azhar and Kölbel, Tilo and Bertoglio, Luca and Wanhainen, Anders and Pratesi, Giovanni and Cheng, Stephen and Csobay-Novak, Csaba and Dias, Nuno and Enzmann, Florian K. and Adam, Donald and Tsilimparis, Nikolaos and Stana, Jan and Panuccio, Giuseppe and Cambiaghi, Martina and Mani, Kevin and Dabravolskaitė, Vaiva and Bastianon, Martina and Tam, Jacky and Mitta, Nivedita and Karelis, Angelos and Kluckner, Michaela and Juszczak, Maciej}},
  issn         = {{1078-5884}},
  keywords     = {{Aortic pathology; Carotid subclavian bypass; Fenestrated thoracic endovascular aortic repair; Left subclavian artery; Propensity score matching; Thoracic endovascular aortic repair}},
  language     = {{eng}},
  publisher    = {{Elsevier}},
  series       = {{European Journal of Vascular and Endovascular Surgery}},
  title        = {{Debranching versus Fenestrated Repair for Left Subclavian Artery Revascularisation during Thoracic Endovascular Aortic Repair : The DEFENCE Multicentre Study}},
  url          = {{http://dx.doi.org/10.1016/j.ejvs.2025.12.008}},
  doi          = {{10.1016/j.ejvs.2025.12.008}},
  year         = {{2025}},
}