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Anatomic Distribution of Stroke and its Relationship to Perioperative Mortality and Neurologic Outcome following TEVAR
Brant W. Ullery, M.D., Michael L. McGarvey, M.D., Albert T. Cheung, M.D., Ronald M. Fairman, M.D., Benjamin M. Jackson, M.D., Edward Y. Woo, M.D., Nimesh Desai, M.D., Grace J. Wang, M.D..
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.


Objective: To assess the anatomic distribution of stroke after TEVAR and its relationship to perioperative mortality and neurologic outcome.
Methods: A retrospective review was performed for patients undergoing TEVAR between 2001-2010. Aortic arch hybrid and abdominal debranching cases were excluded. Demographics, operative variables, and neurologic complications were examined. Stroke was defined as any new focal or global neurologic deficit with radiographic confirmation of cerebral infarction.
Results: Perioperative stroke occurred in 20 of 530 (3.8%) patients undergoing TEVAR. Mean age of this cohort was 75.2 ± 8.9 years (range,57-90) and 55% were male. Indication for surgery was degenerative aneurysm (n=15; mean diameter, 6.8 cm), acute type B dissection (n=4), or aortic transection (n=1). Sixty percent of cases were performed either emergently or urgently due to contained rupture (n=9) or severe back pain (n=3). Proximal landing zone was either Zone 2 (n=11) or Zone 3 (n=9) in all patients. Nine of 20 patients had EEG monitoring, with only 11% demonstrating intraoperative EEG changes. All strokes were embolic in nature. Distribution of stroke included the anterior cerebral circulation (AC) in 8 patients (Zone 2, n=5) and posterior cerebral circulation (PC) in 12 patients (Zone 2,n=6). Laterality of cerebral infarction varied, including 5 right, 8 left, and 7 bilateral strokes. Nine strokes were diagnosed <24 hours postoperatively; the remainder occurred at a median of 72 hours post-procedure. Neurologic deficits were focal in 16 patients and global in 4 patients. Presence of bilateral stroke was significantly associated with global deficits (p=0.01). Overall in-hospital mortality was 20% (n=4), with those suffering PC strokes trending toward increased mortality (33% vs. 0%;p=0.12). PC strokes suffered during the emergent/urgent setting had a mortality rate of 50%, whereas all patients suffering AC strokes in the emergent/urgent setting survived (p=0.21). Patients with AC strokes were more likely than those with PC strokes to achieve complete recovery of neurologic deficits prior to discharge (75% vs.17%;p=0.02). Mean ICU and hospital length of stay for those surviving to discharge was 8 ± 11 and 16 ± 11 days, respectively. 75% of patients required an interim stay at a rehabilitation facility post-discharge.
Conclusion: While stroke following TEVAR is an infrequent event, our data indicate it is associated with significant morbidity and mortality, particularly among those who suffer posterior circulation strokes.


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