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

Abstract

Purpose: 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. Materials and Methods: 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). Results: 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). Conclusion: 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.

One-Year Outcome of Postoperative Stroke and Nerve Injury After Supraclavicular Revascularization of The Left Subclavian Artery for Proximal Landing Zone Extension in Thoracic Endovascular Aortic Repair

“…7 Varkevisser et al confirmed this as well: of the 33 TEVAR patients experiencing a perioperative stroke 8 (24%) died within 30 days. 18 One patient (2%) died in-hospital and 8 during median follow-up of 3 years, and none of the LSA revascularizations in our series required reintervention during follow-up. We report an overall survival rate of 94% and 83% and primary assisted patency rate of 98% after one and 5 years, respectively.…”

“…17 Similarly, Varkevisser et al confirmed a higher risk for stroke of 5.2% in patients undergoing TEVAR with LSA coverage vs. 2.3% without LSA coverage, but found a higher stroke incidence when the LSA was concomitantly revascularized 7.5% vs. 4.4% without concomitant LSA revascularization. 18 Konstantinou et al recommended a staged approach, first with LSA revascularization and then TEVAR, after finding significantly higher 30-day mortality and stroke rate in single stage procedures. 14 All strokes in our group occurred after concomitant LSA revascularization during TEVAR, 3 of them in an emergency setting.…”

Outcomes of Total Endovascular Aortic Arch Repair with Surgeon-Modified Fenestrated Stent-Grafts on Zone 0 Landing for Aortic Arch Pathologies

“…Despite lack of common consensus for proximal landing at ascending aorta, clinicians have gradually explored the safety and feasibility of this practice with promising outcomes. 2,15–17 Kuo et al used handmade fenestrated stent-grafts to preserve all supra-aortic branches in TEVAR for 13 patients with zone 0 landing. Over a mean follow-up of 20 months, no aortic-related mortality and complication resulting from proximal landing zone and fenestration occurred, and secondary endovascular procedures were performed on 6 patients.…”

Long-term results of left subclavian artery coverage during thoracic endovascular aortic repair: A single center study

“…[17][18][19] Stroke following TEVAR with LSA coverage frequently occurs in the real-world setting, and concurrent LSA revascularization is not associated with a lower stroke incidence. [20] Hypogastric hypoperfusion due to visceral atherosclerosis may be eliminated by collateral circulation from the subclavian artery. The LSA closure in these cases may cause stroke and spinal ischemia.…”