Safety-Oriented Endovascular-First Revascularization for Proximal Subclavian Artery Chronic Total Occlusion: Real-World Strategy Selection and Mid-Term Outcomes

Vollständiger Abstract

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Purpose: To report real-world outcomes of a safety-oriented, endovascular-first strategy for proximal atherosclerotic subclavian artery chronic total occlusion (CTO) and to develop a pragmatic computed tomography angiography (CTA)-based open-first consideration aid for anatomically unfavorable cases. Materials and Methods: This single-center retrospective study included consecutive patients treated between January 2020 and December 2024. Endovascular-first revascularization was pursued when feasible, with bypass used as primary therapy or after failed endovascular attempts. Computed tomographic angiography morphology was assessed using prespecified definitions. Factors associated with endovascular technical success were evaluated using logistic regression. Hemodynamically significant restenosis during follow-up was defined as recurrence or progression of inter-arm systolic blood pressure difference ≥20 mm Hg relative to the post-discharge baseline. Time-to-event outcomes were assessed using Kaplan-Meier analysis. A CTA-based open-first consideration score (0-4) was derived among patients undergoing definitive revascularization (bypass vs successful endovascular repair). Results: Among 122 patients, endovascular-first treatment was attempted in 101, with technical success in 75 (74.3%); definitive revascularization was achieved in 112 patients (91.8%) after inclusion of bypass. Right-sided laterality, absent proximal stump (