Early and Mid-Term Outcomes of Zone 2 Thoracic Endovascular Aortic Repair With Open Left Subclavian Revascularization Versus Zone 2 Thoracic Branch Endoprosthesis

Objectives: The Gore TAG Thoracic Branch Endoprosthesis (TBE) was the first commercially available device designed for thoracic aortic repair to offer a fully endovascular alternative to open left subclavian artery (LSA) revascularization. In this study, we compared early and mid-term outcomes of zone 2 thoracic endovascular aortic repair (TEVAR) with open LSA revascularization and zone 2 TBE. Methods: This retrospective analysis was conducted at 2 tertiary referral centers and included all consecutive patients who underwent zone 2 TEVAR with LSA revascularization and zone 2 TBE between 2011 and 2024. Patient characteristics, procedural details, and 1-month and 1-year outcomes were compared across cohorts. Statistical significance was set at P < .05. Results: Forty-six patients underwent zone 2 TEVAR with open LSA revascularization (group 1), and 40 patients underwent zone 2 TBE (group 2). The overall median age of the cohort was 67 years, and 66.3% of the patients were male. The mean total operative time and length of stay were significantly shorter in the zone 2 TBE group (144.3 ± 63.7 vs 341.8 ± 106.8 minutes, P < .001; 2.9 ± 2.1 vs 4.1 ± 2.8 days, P = .025). Patients who underwent zone 2 TEVAR with LSA revascularization were more likely to experience major adverse events (MAEs) during the perioperative period (32.6% vs 12.5%, P = .028). The median follow-up time was 37.2 months (interquartile range [IQR], 15.2-75.8) for group 1 and 14.2 months (IQR, 3.7-23.3) for group 2. Kaplan-Meier analyses showed comparable 1-year freedom from all-cause mortality, endoleak, and reintervention between groups. Both groups achieved excellent primary LSA patency rates at 1 year (group 1, 95.3%; group 2, 100%). Conclusions: Zone 2 TBE was associated with reduced perioperative morbidity and similar 1-year outcomes to those of zone 2 TEVAR with open LSA revascularization. These findings show that zone 2 TBE is a feasible option in anatomically suitable patients, with postoperative outcomes and LSA patency through 1 year comparable to zone 2 TEVAR, and is associated with a shorter length of stay. Further long-term investigations are required to validate the sustained safety and durability of TBE repair. Clinical Impact This two-center, real-world comparison shows that zone 2 thoracic endovascular aortic repair (TEVAR) with the Gore TAG Thoracic Branch Endoprosthesis (TBE) achieves technical success, left subclavian artery patency, and 1-year freedom from mortality, endoleak, and re-intervention comparable to zone 2 TEVAR with open left subclavian revascularization, while shortening hospital stay and reducing perioperative morbidity by avoiding cervical exposure and its transfusion, nerve, and lymphatic complications. For clinicians, TBE offers an off-the-shelf, percutaneous option for anatomically suitable patients with aneurysmal, dissection-related, and traumatic pathology, reserving open revascularization for unsuitable anatomy. Longer follow-up is needed to confirm durability and clarify the risk of retrograde dissection.