The Effect of Left Subclavian Artery Coverage and Revascularization on Postoperative Stroke Rate following Endovascular Repair of the Thoracic Aortic
Rens R.B. Varkevisser, BS1, Nicholas J. Swerdlow, MD1, Livia E.V.M. De Guerre, MD1, Kirsten Dansey, MD1, Chun Li, MD1, Patric Liang, MD1, Hence J.M. Verhagen, MD, PhD2, Marc L. Schermerhorn, MD1
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Erasmus University Medical Center, Rotterdam, Netherlands
OBJECTIVES: Stroke is a devastating complication following thoracic endovascular aortic repair (TEVAR). The impact of TEVAR with concurrent left subclavian artery (LSA) coverage and revascularization on perioperative stroke shows conflicting results. A recent meta-analysis suggested that stroke rates in patients undergoing TEVAR with LSA-coverage were lower in those undergoing concomitant LSA-revascularization. However, publication bias may be applicable in these studies. Therefore, we compared stroke rate following TEVAR with differing LSA-management strategies as and compared to isolated revascularizations for atherosclerotic/occlusive indications in the real-world setting of a nationwide registry.
METHODS: We identified all patients undergoing non-emergent TEVAR and/or open LSA-revascularization within the American College of Surgeons National Surgical Quality Improvement Program registry between 2005-2016. We stratified TEVAR-patients into those without LSA-involvement, with LSA-coverage only, LSA-revascularization only, and both LSA-coverage and revascularization. Patients undergoing isolated LSA-revascularization with an indication other than atherosclerosis/occlusive disease were excluded. The primary outcome was the occurrence of 30-day stroke. Multivariable logistic regression was used to adjust for baseline differences.
RESULTS: We identified 1,879 TEVARs, of which 63% were performed without LSA involvement, 6% with both LSA coverage and revascularization, 29% with coverage only, and 2% with revascularization only. Additionally, we identified 921 isolated LSA-revascularizations for occlusive disease. Overall, 70 patients undergoing TEVAR experienced a stroke (3.7%), which was 2.4% for TEVAR without LSA involvement, 7.6% with coverage and revascularization, 5.4% with coverage only, and 8.1% with LSA revascularization only (P<.001; table). Isolated LSA-revascularization for occlusive indications demonstrated a stroke rate of 0.5%. Thirty-day mortality in patients experiencing stroke was 23% compared to 2.8% for those without stroke (P<.001). After adjustment, TEVAR with either coverage (odds ratio: 2.3; 95% CI: 1.3-3.9), revascularization (4.3; 95% CI: 1.2-15), or coverage and revascularization (3.2; 95% CI: 1.4-7.0) was associated with higher stroke rates compared to TEVAR without LSA-involvement.
CONCLUSIONS: These data show that stroke following TEVAR occurs more frequently in the real-world setting than reported in literature, and that stroke often leads to perioperative death. Concurrent LSA-revascularization does not demonstrate lower stroke rates. The rarity of strokes following isolated LSA-revascularization suggests that the main drivers of stroke after hybrid procedures are the extent of disease and aortic arch manipulation rather than the additional procedure.
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