Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR).
OBJECTIVE
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).


CONCLUSIONS
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.
Feezor
Robert J
RJ
Division of Vascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville 32610-0286, USA.
Martin
Tomas D
TD
Hess
Philip J
PJ
Klodell
Charles T
CT
Beaver
Thomas M
TM
Huber
Thomas S
TS
Seeger
James M
JM
Lee
W Anthony
WA
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D001018:Aortic Diseases / Q000503:physiopathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D002560:Cerebrovascular Circulation; D005260:Female; D006801:Humans; D007022:Hypotension / Q000150:complications; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015607:Stents; D020521:Stroke / Q000209:etiology* / Q000503:physiopathology; D013348:Subclavian Artery / Q000503:physiopathology; D016896:Treatment Outcome; D014711:Vertebral Artery / Q000503:physiopathology