Risk Factors For Stroke With Zone 0-2 Thoracic Endovascular Aortic Repair
Alexander DiBartolomeo, MD.
University of Southern California, Los Angeles, CA, USA.
OBJECTIVES:Novel devices are being developed to enable total endovascular thoracic endovascular aortic repair (TEVAR) within the aortic arch, which requires coverage and manipulation of the supra-aortic trunk vessels with complex and coordinated procedures from multiple access sites. While the risk of more proximal landing zones is intuitive, the relative risk of procedural techniques remains unclear. This study evaluates the procedural risk factors for stroke with zone 0-2 TEVAR.
METHODS:Patients in the thoracic endovascular aortic repair registry of the Vascular Quality Initiative between 2010 and 2020 who underwent TEVAR with proximal landing zone 0-2 were included. The primary outcome was perioperative in-hospital stroke. The secondary outcome was one-year survival. Univariate analysis was performed to evaluate the association of proximal endograft landing zone (0-2), branch vessel revascularization technique (open, endo, hybrid), access site location (arm, neck), procedure time, and demographics with postoperative outcomes. Multivariable logistic regression was performed using risk factors significant in the univariate analysis.
RESULTS:Of the 1,867 patients who met criteria for analysis their proximal landing zones were: zone 0 (151, 8%), zone 1 (221, 12%) and zone 2 (1,495, 80%). Stroke rate was three times higher in zone 0 than zones 1 or 2 (14.6% vs. 5.4% vs. 5.1%, P<0.0001). Patients had more pre-operative comorbidities and one-year survival was lower in more proximal landing zones (80.8 vs. 82.8% vs. 88.8%, P=0.0006). The most common revascularization strategy was open surgical revascularization for each branch vessel. The impact of branch vessel revascularization technique on stroke was dependent on proximal landing zone and was only associated with rate of stroke for zone 0 TEVAR. On multivariable analysis, after adjusting for other significant risk factors, zone 0 was independently associated with increased stroke (OR 2.4 [95% CI 1.4-4.3], P=0.002) and mortality (OR 1.8 [95% CI 1.0-3.3], P=0.0342). In zone 0, the rates of stroke for endovascular, hybrid, and open revascularization were (39% vs. 20% vs. 14%, P=0.03).
CONCLUSIONS:TEVAR in zone 0 is associated with increased risk of stroke and lower one-year survival. In zone 0, open revascularization of the supra-aortic trunk vessels is associated with a lower rate of postoperative stroke. Total endovascular repair of the aortic arch remains a clinically significant unmet need with high risk of perioperative stroke.
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