Stroke Following Thoracic Endovascular Aortic Repair and the Impact of Left Subclavian Artery Management

Abstract

Introduction: Stroke is a devastating complication following thoracic endovascular aortic repair (TEVAR). Studies have found conflicting results on stroke risk following TEVAR with concurrent left subclavian artery (LSA) coverage alone (pooled reported rates ranging between 4.7-7.8%) and whether LSA revascularization results in lower stroke rates (pooled reported rates ranging between 4.1-5.8%). Therefore, we compared stroke rate following TEVAR with differing LSA management strategies in the real-world setting of a nationwide clinical registry. Methods: We identified all patients undergoing non-emergent TEVAR and/or open LSA revascularization within a nationwide clinical registry between 2005-2017. We compared outcomes between TEVAR with vs. without LSA coverage, TEVAR with LSA coverage with vs. without revascularization, and isolated LSA revascularizations for thoracic aneurysm/dissection vs. occlusive disease. The primary outcome was 30-day stroke. Multivariable logistic regression was used to adjust for baseline differences and identify factors associated with stroke following TEVAR. Results: We identified 2,346 TEVARs,1,458 without LSA involvement, 660 with coverage alone, and 228 with both LSA coverage and revascularization. Additionally, we identified 768 isolated LSA revascularizations for occlusive disease and 395 isolated revascularizations for thoracic aneurysm/dissection. Overall, 79 (3.4%) patients undergoing TEVAR experienced a stroke: 2.3% following TEVAR without LSA involvement vs. 5.2% in those where the LSA was covered (P< .001). In TEVARs with coverage of the LSA, stroke rates were 7.5% when the LSA was concomitantly revascularized vs. 4.4% without revascularization (P=.072). During the same study period, isolated LSA revascularization for thoracic aneurysm/dissection demonstrated a stroke rate of 3.8% vs. 0.5% for those for occlusive indications (P< .001). Thirty-day mortality in TEVAR-patients experiencing stroke was 24% compared to 2.8% for those without stroke (P< .001). After risk-adjustment, coverage of the LSA was associated with higher stroke rates (odds ratio: 2.0; 95% CI: 1.2-3.4; P=.006), and in TEVARs with coverage, odds of stroke were higher in those undergoing concomitant LSA revascularization (1.9; 95%CI: 1.005-3.6; P=.048). Other preoperative factors independently associated with stroke after TEVAR were dyspnea (1.8; 95%CI: 1.1-3.0; P=.014), renal dysfunction (2.0; 95%CI: 1.003-3.8; P=.049), and elevated international normalized ratio (3.6; 95%CI: 1.03-13; P=.045).Tabled 1All TEVAR proceduresLSA-Covered TEVARs onlyNo LSA-CoverageLSA CoveredP-valueNo LSA RevascularizationConcomitant LSA RevascularizationP-valueN (%)N (%)N (%)N (%)N1,458888660228Stroke33 (2.3%)46 (5.2%)<.00129 (4.4%)17 (7.5%).07230-Day Mortality41 (2.8%)42 (4.7%).01529 (4.4%)13 (5.7%).42Major Complication186 (13%)179 (20%)<.001117 (18%)62 (27%).002[Univariate Analysis of Outcomes following TEVAR] Open table in a new tab [Univariate Analysis of Outcomes following TEVAR] Conclusion: Stroke following TEVAR with LSA coverage occurs more frequently in the real-world setting than reported in literature and concurrent LSA revascularization was not associated with lower stroke rates. Furthermore, stroke is strongly associated with perioperative death following TEVAR. Disclosure: HV is a consultant for Medtronic, WL Gore, Endologix, Abbott, Arsenal AAA MS is a consultant for Abbott Vascular, Cook Medical, Endologix, Medtronic, and Silk Road