A Systematic Review of the Literature on the Current Revascularization Strategies for Aberrant Left Vertebral Artery During Total Endovascular and Hybrid Treatment of Aortic Arch Disease

Background/Objectives: The aim of this study was to assess the current management strategies of Isolated Left Vertebral Artery (ILVA) arising directly from the aortic arch during total endovascular or hybrid repair of aortic arch pathologies and their safety and efficacy. Methods: A systematic literature review was undertaken to assess the current management strategies for ILVA during total endovascular or hybrid repair of aortic arch pathologies on three databases (PubMed, SCOPUS and Web of Science) from inception to February 2025, according to PICO and PRISMA guidelines (PROSPERO CRD42024562104). The safety (overall and aortic-related mortality; neurological complications) and efficacy (revascularization patency, endoleak and reintervention rate) of both approaches were investigated. Results: Out of 224 articles found, seven retrospective cohort studies (178 patients) were included. Overall, 149 patients (74.2% male, mean age 63 years) underwent ILVA revascularization. Two studies reported open ILVA revascularization through transposition; three studies reported endovascular revascularization strategies, and one study reported both open and endovascular techniques. The overall mortality rate was 1.3% at 30 days and 5.4% at a mean follow-up of 46 months (range 6–120) with a reported rate of aortic mortality of 0.7%. In the transposition group (55 patients), the rate of minor neurological complications was 16.6%, and the rate of major neurological complications was 7.3%; loss of patency rate was 16.3% and reintervention rate was 11.7%. Endovascularly treated patients (94 patients) experienced a rate of minor neurological complications of 2.1% and major neurological complications of 1%; the loss of patency rate was 2.1%, and the reintervention rate was 3.1%. Conclusions: Both surgical and endovascular techniques for ILVA revascularization seem to assure an acceptable rate of mortality and neurological complications during treatment of arch pathologies. However, currently available data are poor, non-standardized and based on single-center experiences. Therefore, until more robust data are available to indicate the superiority of one approach over another, the management strategies for aberrant ILVA should be individualized based on the anatomic characteristics and the center experience. Our findings underscore the need for prospective studies with standardized protocols.