Technical Predictors Of In-hospital Stroke After Thoracic Endovascular Aortic Repair (TEVAR)
Hanaa Dakour-Aridi, MD, Satinderjt Locham, MD, Omar Al-Nouri, DO, Andrew Barleben, MD, Ralph B. Dilley, MD, Mahmoud B. Malas, MD, MHS, FACS.
University of California San Diego, La jolla, CA, USA.
Objectives: Stroke remains a devastating and worrisome complication after TEVAR. This study aims to identify technical predictors of in-hospital stroke after TEVAR.
Methods: We included all patients (n=5,950) undergoing TEVAR for aneurysms and dissection in VQI (Jan.2014-Feb.2019). Preoperative risk factors associated with stroke were identified using stepwise logistic regression. Propensity score matching (PSM) was then used to match patients based on pathology and preoperative risk factors. Procedural factors were compared between the two matched groups to identify technical predictors of stroke.
Results: In-hospital stroke rate was 3.2% (n=190)(Table1).Predictors of stroke for aneurysms included female gender [OR(95%CI):1.7(1.2-2.5)],diabetes[1.7(1.0-2.7)],CKD[1.8(1.1-2.7)] and urgent procedures [2.1(1.2-3.8)] while preoperative beta-blockers were protective against stroke [0.62(0.40-0.98)].For dissection, risk factors included age [OR(95%CI):0.98(0.96-0.99)],CKD[1.8(1.1-3.1)],cerebrovascular disease [2.5(1.2-5.0)],prior aneurysm repair [0.28(0.1-0.8)],urgent [2.1(1.2-3.6)] and emergent procedures[3.7(2.0-7.1)](all p<0.05).In the matched cohort (n=164 each),patients with stroke had more proximal disease zones (0-2)[43.0% vs.26.1%, OR (95%CI):2.8(1.3-6.2)],more proximal landing zones[58.6% vs.37.4%,OR(95%CI):2.4(1.5-3.7)],and more than 2 endografts used [32.7% vs.20.4%,OR(95%CI):1.9(1.1-3.4)].They were also more likely to have arm/neck access[30.9% vs.18.6%, OR(95%CI):1.95(1.2-3.3)],and staged branch treatment for the innominate artery [13.2% vs.6.4%,95%CI:2.2(1.0-4.9)],LCCA [22.6% vs. 9.6%,OR(9%CI):2.8(1.5-5.3)] and left subclavian artery [59.7% vs.40.8%, OR(95%CI):2.2(1.4-3.4)]. Additionally, stroke patients had increased operative time (mean±SE:236±11.9 vs.163±8.8 minutes),intraoperative blood loss (mean±SE:502±74.8 vs.277±38.3 ml) and blood transfusions (pRBC units:1.20±0.2 vs.0.66±0.2 units) (all p<0.05,Table 2).
Conclusion: In addition to proper patient selection, identifying and controlling modifiable risk factors such as minimizing the number of implanted endografts and the use of arm/neck access in addition to the use of preoperative beta blockers can help lower the risk of stroke following TEVAR.
| No Stroke | Stroke | P value | |
| Number of Patients | 5,760 (96.8) | 190 (3.2) | |
| Pathology | <0.001 | ||
| Aneurysm | 3,957 (70.1) | 100 (55.0) | |
| Acute Dissection | 1,042 (18.5) | 67 (36.8) | |
| Chronic Dissection | 645 (11.4) | 15 (8.2) | |
| Proximal Disease Zone | <0.001 | ||
| 0-2 | 1,042 (20.3) | 70 (42.7) | |
| 3-5 | 2,581 (50.3) | 77 (47.0) | |
| 6-8 | 1,106 (21.6) | 13 (7.9) | |
| ≥ 9 | 398 (7.8) | 4 (2.4) | |
| Age, years | 70 (61-77) | 69.5 (58-77) | 0.05 |
| Female Gender | 1,958 (34.0) | 82 (43.2) | 0.01 |
| Non-White Race (Black and Others) | 1,554 (27.0) | 70 (36.8) | <0.01 |
| Transfer from Hospital or Rehabilitation Unit | 1,359 (23.6) | 77 (40.5) | <0.001 |
| Smoking | 0.01 | ||
| Prior Smoker | 2,608 (45.3) | 66 (34.7) | |
| Current Smoker | 1,810 (31.5) | 76 (40.0) | |
| Comorbidities | |||
| CVD | 581 (10.8) | 31 (18.1) | <0.01 |
| CKD | 2,126 (38.2) | 96 (51.9) | <0.001 |
| Prior Vascular Procedures | |||
| CABG/PCI | 1,361 (23.6) | 38 (20.0) | 0.25 |
| CEA/CAS | 165 (2.9) | 9 (4.7) | 0.13 |
| Prior aneurysm repair | 1,293 (22.5) | 28 (14.7) | 0.01 |
| Pre-operative medications | |||
| Aspirin | 3,243 (56.4) | 101 (53.2) | 0.38 |
| Anticoagulant | 651 (11.3) | 21 (11.0) | 0.91 |
| Beta blocker | 3,883 (67.5) | 120 (63.2) | 0.21 |
| Statin | 3,361 (58.4) | 107 (56.3) | 0.56 |
| ACE inhibitors | 2,467 (43.0) | 75 (39.5) | 0.33 |
| P2Y12 Inhibitors | 573 (10.0) | 13 (6.8) | 0.16 |
| ASA class | |||
| IV/V: Severe | 2,952 (51.4) | 132 (69.5) | <0.001 |
| Maximum Aortic Diameter (mm) | 56 (± 16.0) | 54 (± 18.0) | 0.06 |
| Symptomatic Presentation | 2,083 (38.8) | 102 (59.7) | <0.001 |
| Emergent Cases | 346 (6.0) | 38 (20.0) | <0.001 |
| No Stroke (N=164) | Stroke (N=164) | P-value | |
| Proximal Disease Zone | 0.01 | ||
| 0-2 | 41 (26.1) | 68 (43.0) | |
| 3-5 | 91 (58.0) | 74 (46.8) | |
| 6-8 | 22 (14.0) | 13 (8.2) | |
| ≥ 9 | 3 (1.9) | 3 (1.9) | |
| Anesthesia | 0.12 | ||
| Local/Regional | 6 (3.7) | 1 (0.6) | |
| General | 158 (96.3) | 163 (99.4) | |
| IVUS | 87 (53.4) | 92 (56.1) | 0.62 |
| TEE | 21 (13.0) | 29 (18.0) | 0.21 |
| Procedure Time, mean (± SE) | 163 (± 8.8) | 236 (± 11.9) | <0.001 |
| Estimated Blood loss in ml, mean (SE) | 277 (± 38.3) | 502 (± 74.8) | 0.01 |
| Total units of Blood Transfusion, mean (SE) | 0.66 (± 0.16) | 1.20 (± 0.19) | 0.03 |
| Access | |||
| Femoral Access | 157 (95.7) | 151 (92.1) | 0.17 |
| Iliac access | 12 (7.3) | 16 (9.8) | 0.43 |
| Aorta, abdominal | 1 (0.61) | 0 | 1.00 |
| Aorta, Ascending | 2 (1.2) | 8 (4.9) | 0.10 |
| Arm/Neck Access | 30 (18.6) | 50 (30.9) | 0.01 |
| Number of Implanted Aortic Devices | 0.04 | ||
| 1 | 57 (35.2) | 48 (29.6) | |
| 2 | 72 (44.4) | 61 (37.7) | |
| >=3 | 33 (20.4) | 53 (32.7) | |
| Modified/Customized Device | 15 (9.3) | 14 (8.7) | 0.86 |
| False Lumen treatment | 3 (1.8) | 8 (5.0) | 0.14 |
| Device Access Arterial Injury | 6 (3.7) | 13 (7.9) | 0.10 |
| Device proximal Fixation zone | |||
| 0-2 | 58 (37.4) | 92 (58.6) | <0.001 |
| 3 | 48 (31.0) | 39 (24.8) | 0.23 |
| 4 | 18 (11.6) | 9 (5.7) | 0.07 |
| ≥ 5 | 31 (20.0) | 17 (10.8) | 0.03 |
| Staged Branch Treatment | |||
| Innominate | 10 (6.4) | 21 (13.2) | 0.04 |
| Left common carotid artery | 15 (9.6) | 36 (22.6) | <0.01 |
| Left Subclavian | 64 (40.8) | 95 (59.7) | <0.01 |
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