Risk factors for perioperative stroke after thoracic endovascular aortic repair.
BACKGROUND
Stroke has emerged as an important complication of thoracic endovascular aortic repair (TEVAR). Identifying risk factors for stroke is important to define the risks of this procedure.


METHODS
All neurologic complications were analyzed in a prospective database of patients in thoracic aortic stent graft trials from 1999 to 2006. Serial neurological examination was performed. Stroke was defined as any new onset focal neurologic deficit.


RESULTS
The TEVAR was performed on 171 patients; 52 had lesions requiring coverage of the proximal descending thoracic aorta (extent A), 50 requiring coverage of the distal descending aorta (extent B), and 69 requiring coverage of the entire descending thoracic aorta (extent C). The incidence of stroke was 5.8%. Eighty-nine percent (8 of 9) of strokes occurred within 24 hours of operation. Stroke was associated with a 33% in-hospital mortality rate. Risk factors identified for stroke included prior stroke (odds ratio [OR] 9.4, confidence interval [CI] 2.3 to 38.1, p = 0.002) and extent A or C coverage (OR 5.5, CI 1.7-12.5, p = 0.001). The stroke rate in patients with both prior stroke and extent A or C coverage was 27.7%. Severe atheromatous disease involving the aortic arch by computed tomographic scan was strongly associated with perioperative stroke (OR = 14.8, CI 1.7 to 675.6, p = 0.0016). Transesophageal echocardiography demonstrated mobile atheroma in two patients with stroke.


CONCLUSIONS
Stroke after TEVAR was associated with a high mortality. The TEVAR of the proximal descending aorta (extent A or C) in patients with a history of stroke had the highest perioperative stroke rate. These risk factors, together with high grade aortic atheroma of the aortic arch, predicted a high probability for cerebral embolization and can be used to identify patients at high risk for stroke as a consequence of TEVAR.
Gutsche
Jacob T
JT
Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. gutschej@uphs.upenn.edu
Cheung
Albert T
AT
McGarvey
Michael L
ML
Moser
William G
WG
Szeto
Wilson
W
Carpenter
Jeffrey P
JP
Fairman
Ronald M
RM
Pochettino
Alberto
A
Bavaria
Joseph E
JE
D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D001018:Aortic Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001705:Bioprosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D017678:Sex Distribution; D020521:Stroke / Q000453:epidemiology* / Q000209:etiology* / Q000503:physiopathology; D016019:Survival Analysis; D013908:Thoracotomy / Q000379:methods