Anomalous left vertebral artery in patients undergoing total arch replacement: Results from a prospective trial

Objective: Anomalous left vertebral artery (ALVA) originating from the aorta presents a challenge when performing total arch replacement. This has been addressed with in situ stent grafting using the hybrid branched stented anastomosis frozen elephant repair (B-SAFER) technique and studied as part of a prospective, physician-sponsored investigational device exemption trial. We describe management and outcomes in patients with ALVA undergoing B-SAFER. Methods: A total of 15 of 420 (4%) patients who underwent B-SAFER from May 2021 to February 2025 had ALVA. Average age was 63 ± 10 years, and 12 (80%) were male. Indications were acute dissection 7 (47%), chronic dissection 4 (27%), and degenerative aneurysm 4 (27%). No patients had a previous stroke, 3 (20%) had a history of transient ischemic attack (TIA), 4 (27%) had carotid artery disease, and 4 (27%) had a history of atrial fibrillation. Average circulatory arrest time was 55 ± 28 minutes. Average follow-up time was 525 ± 374 days. Results: ALVA was stent grafted in 13 (87%) patients and ligated/covered in 2 (13%) patients. Average ALVA diameter was 5.4 ± 1.7 mm in stented and 3.3 ± 0.4 mm in nonstented patients. One patient died from cardiac arrest on postoperative day 26 after hospital discharge. There were no acute strokes, TIAs, or spinal cord ischemia events. In late follow-up, 1 TIA occurred, and there were no strokes. Paraparesis occurred in 1 patient after thoracic endovascular aortic repair 5 months postoperatively. All ALVA stents were patent on follow-up computed tomography angiography. Mean modified Rankin scale score was 1.4 ± 1.2 after discharge and 0.9 ± 1.3 on most recent follow-up. Conclusions: Stent grafting of a prominent anomalous left vertebral artery during total arch replacement using the B-SAFER technique appears feasible and safe in selected patients and is durable at intermediate follow-up.