Risk Factors for Perioperative Stroke during Thoracic Endovascular Aortic Repairs (TEVAR)

Abstract

Purpose:

To determine the clinical and anatomical risk factors for cerebrovascular accidents (CVA) in patients undergoing thoracic endovascular aortic repair (TEVAR).

Methods:

Between September 2000 and December 2006, 196 patients (135 men; mean age 68.6±13.5 years, range 17–92) underwent TEVAR for a variety of aortic pathologies. The majority (156, 79.6%) were treated with the TAG stent-graft. Demographics, pathologies, intraoperative procedure-related measures, device usage, and postoperative outcomes were assessed. CVA was defined as a new focal or global neurological (motor or sensory) deficit lasting >48 hours associated with acute intracranial abnormalities on computed tomography or magnetic resonance brain imaging. Spinal cord ischemia was excluded. In a subset of patients with planned left subclavian artery (LSA) coverage and an incomplete circle of Willis or a dominant left vertebral artery, prophylactic carotid-subclavian bypasses were performed.

Results:

Nine (4.6%) patients suffered a CVA. Factors not predictive of a CVA on univariate analysis included aortic pathology, urgency of repair, ASA classification, type of anesthesia, blood loss, procedure time, and device used. Proximal extent of repair (with or without extra-anatomical revascularization) was significantly associated with a higher incidence of strokes (zones 0–2 versus 3–4, p=0.025). Five (55.6%) patients with a CVA had documented intraoperative hypotension (systolic blood pressure <80 mmHg). Additionally, while 2 patients had hemispheric infarcts, 5 had acute posterior circulation infarcts involving the cerebellum and brainstem; a single patient had both anterior and posterior circulation infarcts. Seven of the CVA patients had proximal coverage of the thoracic aorta in zones 0–2; of these, 6 had posterior circulation infarcts. Selective LSA revascularization based on preoperative cerebrovascular imaging resulted in lower rates of CVA (6.4% to 2.3%, p=0.30) and posterior circulation infarcts (5.5% to 1.2%, p=0.13).

Conclusion:

Proximal extent of repair may serve as a surrogate marker for greater severity of degenerative disease of the aortic arch. Avoidance of intraoperative hypotension and preservation of antegrade vertebral perfusion may be important in prevention of posterior circulation strokes.

Keywords

thoracic aortic aneurysm thoracic endovascular aortic repair stent-graft stroke left subclavian artery

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References

Garzon

Fernandez-Velilla

Marti

. Endovascular stent-graft treatment of thoracic aortic disease. Radiographics. 2005; 25 Suppl 1: S229–244.

Patel

Williams

Upchurch

. Long-term results from a 12-year experience with endovascular therapy for thoracic aortic disease. Ann Thorac Surg. 2006; 82: 2147–2153.

Stone

Brewster

Kwolek

. Stent-graft versus open-surgical repair of the thoracic aorta: Midterm results. J Vasc Surg. 2006; 44: 1188–1197.

Scharrer-Pamler

Kotsis

Kapfer

. Complications after endovascular treatment of thoracic aortic aneurysms. J Endovasc Ther. 2003; 10: 711–718.

Görich

Asquan

Seifarth

. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs. J Endovasc Ther. 2002; 9(suppl II): II-39–II43.

Tehrani

Peterson

Katariya

. Endovascular repair of thoracic aortic tears. Ann Thorac Surg. 2006; 82: 873–878.

Peterson

Eskandari

Gleason

. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology. J Vasc Surg. 2006; 43: 433–439.

Hansen

Bui

Donayre

. Complications of endovascular repair of high-risk and emergent descending thoracic aortic aneurysms and dissections. J Vasc Surg. 2004; 40: 228–234.