Endovascular Repair of Complex Abdominal Aortic Aneurysms is Associated with Higher Stroke Rate than Repair of Infrarenal Aneurysms
Nicholas J. Swerdlow, MD, Rens RB Varkevisser, BS, Patric Liang, MD, Chun Li, MD, Livia EVM De Guerre, MD, Kirsten Dansey, MD, Marc L. Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Objective: Stroke is a rare, but devastating complication of endovascular abdominal aortic aneurysm repair (EVAR). Complex abdominal aortic aneurysms (AAA) have introduced additional technical complexity to EVAR, including increased brachial access use, and thus increased aortic arch manipulation. Therefore, we evaluated the rate of stroke following complex EVAR.
Methods: We performed a retrospective analysis of prospectively collected data from all patients undergoing EVAR from 2011 to 2016 within the National Surgical Quality Improvement Project Targeted Vascular Module. We excluded patients with unknown aneurysm extent (6.6%), unknown indication (3.7%), and those undergoing concomitant TEVAR (0.5%). We defined complex EVAR as EVAR for juxtarenal, suprarenal, or type IV thoracoabominal aneurysms. We compared baseline demographics/comorbidities and procedural characteristics, including use of brachial access, between complex and infrarenal EVAR. Our primary outcome was 30-day stroke rate. We adjusted for baseline differences between the cohorts using multivariable logistic regression.
Results: We included 9,878 patients undergoing infrarenal EVAR and 1,181 undergoing complex EVAR. Complex patients were older (75±9 vs 74±9 yrs, P=.01), more often female (23% vs 19%, P=.001), and more likely to be on dialysis (4.0% vs 1.2%, P<.001). Complex EVARs were performed for larger aneurysms (5.7 [IQR: 5.2-6.5] vs 5.5 [5.1-6.2] cm, P<0.001) and more frequently used brachial access (5.3% vs 0.6%, P<0.001). The 30-day stroke rate was 1.0% following complex EVAR (3.2% with brachial access, 0.9% without; P=.08) and 0.3% following infrarenal EVAR (1.9% with brachial access, 0.3% without; P=.05) (P=.001). After adjustment for indication (elective vs symptomatic vs ruptured), brachial access, age, sex, renal dysfunction, and dialysis, complex EVAR was associated with 2.4 times higher odds of stroke
than infrarenal EVAR (95% CI 1.1-4.9, P=.02). Brachial access was also independently associated with perioperative stroke, with an odds ratio of 4.1 (95% CI 1.2-14.6, P=.03). Brachial access was associated with perioperative stroke within both the complex EVAR cohort (OR 3.2) and the infrarenal EVAR cohort (OR 4.9), though these associations did not reach statistical significance within these subgroups.
Conclusions: Complex EVAR is associated with a higher rate of 30-day stroke compared to infrarenal EVAR. Use of brachial access is also independently associated with higher 30-day stroke rate. This elevated stroke risk must be taken into consideration when determining a treatment plan for patients with complex AAAs.
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