Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution

Abstract

Summary: Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120 ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8 ± 13.6 years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n = 75, 48.7%), acute type B aortic dissections (n = 46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n = 28, 18.2%), and blunt traumatic aortic injuries (n = 5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0–1–2 (n = 75, 48.7%), zone 3 (n = 66, 42.9%) and zone 4 (n = 13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.

The impact of increasing saline flush volume to reduce the amount of residual air in the delivery system of aortic prostheses—a randomized controlled trial

“…In routine clinical practice, many clinicians have adopted the practice of flushing 120 ml of saline to reduce the volume of ambient air in the sheath, regardless of the type of graft being used. This amount of saline is approximately four times higher than the amount prescribed in the instructions for use (IFU), which is concordant with previous results (11,12). To evaluate the effect of the different flushing techniques, abdominal endovascular aneurysm repair (EVAR) is often used instead of TEVAR (6,9,13).…”

“…In 2019, Rylski et al (11) determined in an in vitro study that 120 ml saline flush instead of 40 ml saline flush leads to a significantly lower remaining air in the delivery system of a TEVAR. Two years later, a 120 ml flush of 0.9% heparinized saline solution seemed to minimalize neurological events after TEVAR in a retrospective study by Branzan et al (12). Our study investigates air embolism in EVAR, and our findings should be translated into practice in the use of TEVAR with caution.…”

The impact of increasing saline flush volume to reduce the amount of residual air in the delivery system of aortic prostheses – a randomized controlled trial

“…The result was observed mostly with big bubbles at the tip of the sheath. One year earlier, Saleptsis et al 10 were the rst to describe the correlation between larger perfused lumen diameter and the presence of remained air after EVAR. Types of graft were also studied, and EVAR was assessed with higher risk of presence of air than fenestrated EVAR or branched EVAR.…”

“…In 2019, Rylski et al 9 determined in an in vitro study, that 120 ml saline ush instead of 40 ml saline ush leads to a signi cantly lower remained air in the delivery system of a TEVAR. Two years later, 120 ml ush of 0,9% heparinized saline solution seemed to minimalize neurological events after TEVAR in a retrospective study by Branzan et al 10 This randomised controlled trial is a pioneer study comparing different volumes of saline ush. Our results show that, contrary to what one could expect, increased saline ush volume may not be associated to a decrease in the volume of trapped air inside a delivery system of an aortic prosthesis.…”

Investigation of Experimental Endovascular Air Embolisms Using a New Model for the Generation and Detection of Highly Calibrated Micro Air Bubbles

“…Besides the size of bubbles with subsequent brain ischemia, the localization on a critical, eloquent brain area is crucial for an overt neurological deficit. 4 Arterial AE with potential embolization to the brain can occur during any endovascular catheter-based diagnostic or therapeutic intervention on the ascending aorta or the aortic arch, such as thoracic endovascular aneurysm repair (TEVAR), [8][9][10][11] on the vessels supplying the heart (eg, heart valve interventions), 12,13 or the brain (eg, treatment of ischemic stroke, intracranial aneurysms, and vascular malformations). 4,14,15 Similarly, open surgical interventions can cause arterial embolism to the brain, with cardiopulmonary bypass surgery being one of the riskiest procedures.…”