Thoracic Endovascular Aortic Repair With Left Subclavian Artery Coverage Is Associated With a High 30-Day Stroke Incidence With or Without Concomitant Revascularization

• Published in: Journal of endovascular therapy Vol. 27; no. 5; p. 769
• Main Authors: Varkevisser, Rens R B, Swerdlow, Nicholas J, de Guerre, Livia E V M, Dansey, Kirsten, Li, Chun, Liang, Patric, Latz, Christopher A, Carvalho Mota, Mathijs T, Verhagen, Hence J M, Schermerhorn, Marc L
• Format: Journal Article
• Language: English
• Published: United States 01.10.2020
• Subjects: Aged; Aortic Aneurysm, Thoracic - diagnostic imaging; Aortic Aneurysm, Thoracic - mortality; Aortic Aneurysm, Thoracic - physiopathology; Aortic Aneurysm, Thoracic - surgery; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - instrumentation; Blood Vessel Prosthesis Implantation - mortality; Endovascular Procedures - adverse effects; Endovascular Procedures - instrumentation; Endovascular Procedures - mortality; Female; Humans; Incidence; Male; Middle Aged; Prosthesis Design; Registries; Risk Assessment; Risk Factors; Stents; Stroke - diagnosis; Stroke - epidemiology; Stroke - mortality; Subclavian Artery - diagnostic imaging; Subclavian Artery - physiopathology; Subclavian Artery - surgery; Time Factors; Treatment Outcome; United States - epidemiology; United States; LSA coverage; registry; thoracic endovascular aortic repair; revascularization; risk factors; stent-graft; thoracic aortic aneurysm; endograft; stroke; left subclavian artery; thoracic dissection
• ISSN: 1545-1550
• DOI: 10.1177/1526602820923044

To evaluate the perioperative stroke incidence following thoracic endovascular aortic repair (TEVAR) with differing left subclavian artery (LSA) coverage and revascularization approaches in a real-world setting of a nationwide clinical registry. The National Surgical Quality Improvement Program registry was interrogated from 2005 to 2017 to identify all nonemergent TEVAR and/or open LSA revascularization procedures. In this time frame, 2346 TEVAR cases met the selection criteria for analysis. The 30-day stroke incidence was compared between patients undergoing TEVAR with (n=888) vs without (n=1458) LSA coverage, for those with (n=228) vs without (n=660) concomitant LSA revascularization among those with coverage, and following isolated LSA revascularization for occlusive disease (n=768). Multivariable logistic regression was employed for risk-adjusted analyses and to identify factors associated with stroke following TEVAR. Results of the regression analyses are presented as the adjusted odds ratio (OR) with 95% confidence interval (CI). The stroke incidence was 2.3% following TEVAR without vs 5.2% with LSA coverage (p<0.001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized and 4.4% without concomitant revascularization, while stroke occurred in 0.5% of isolated LSA revascularizations. Of 33 TEVAR patients experiencing a perioperative stroke, 8 (24%) died within 30 days. LSA coverage was associated with stroke both with concomitant revascularization (OR 4.0, 95% CI 2.2 to 7.5, p<0.001) and without concomitant revascularization (OR 2.2, 95% CI 1.3 to 3.8, p=0.002). Other preoperative factors associated with stroke were dyspnea (OR 1.8, 95% CI 1.1 to 3.0, p=0.014), renal dysfunction (OR 2.2, 95% CI 1.0 to 3.8, p=0.049), and international normalized ratio ≥2.0 (OR 3.6, 95% CI 1.0 to 13, p=0.045). Stroke following TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.