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A Comprehensive Propensity Matched Analysis Of Cerebral Infarction Following Tevar With Left Subclavian Artery Coverage
Ahmad Tabatabaeishoorijeh
1, Maham Rahimi, MD PhD
2.
1Texas A&M School of Engineering Medicine (ENMED), Houston, TX, USA,
2Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA.
OBJECTIVES: Left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) has been associated with an increased risk of cerebral infarction postoperatively. This study compares outcomes to better understand the long-term effects of LSA coverage in TEVAR patients.
METHODS: We retrospectively analyzed TEVAR patients from August 1994 to August 2024 using the TriNetX database, grouping them by LSA coverage and excluding those with prior cerebral infarction. Outcomes, including cerebral infarction, mortality, and new dissections, were compared. A decade-based analysis (2004-2014 vs. 2014-2024) assessed cerebral infarction risk with LSA coverage, and Kaplan-Meier analysis estimated freedom from infarction in matched cohorts.
RESULTS: The study included 8,008 TEVAR procedures: 3,421 (43%) with LSA coverage, and 4,587 (57%) without. Patients without LSA coverage were older (63±18 vs. 61±17; P<.001) and had a higher proportion of male genders (61% vs. 58%; P=.003). Rates of chronic kidney disease, type 2 diabetes mellitus, and peripheral arterial disease were similar between groups, but those without LSA coverage had higher coronary artery disease rates (29% vs. 26%; P=.005). After propensity matching, patients with LSA coverage had higher cerebral infarction rates during the first month (3% vs. 1.3%; P<.001), but no significant differences in mortality. The cerebral infarction rate remained higher at 3, 6 months, and 1, 3, and 5 years (P<.001) (Table). Mortality rates remained unchanged. At 3 and 5 years, ascending aortic dissection rates were higher with LSA coverage (3-year: 1.9% vs. 1.2%; P=.031; 5-year: 2.4% vs. 1.5%; P=.01). TEVARs with LSA coverage in 2014-2024 had a significantly lower cerebral infarction rate at 1 month compared to 2004-2014 (2% vs. 5.4%; P=.003).
CONCLUSIONS: LSA coverage during TEVAR increases cerebral infarction risk, especially early post-op, persisting up to five years. The 2014-2024 decade shows reduced infarction rates compared to 2004-2014. Despite similar mortality, LSA coverage led to higher aortic dissection rates at 3 and 5 years. These findings underscore the importance of weighing LSA risks and the benefits of TEVAR advancements.
Interval cerebral infarction outcomes in propensity matched cohorts (n=3254 pairs) undergoing TEVAR| Cerebral Infarction | TEVAR w/ LSA Coverage (n = 3254) | TEVAR wo/ LSA Coverage (n = 3254) | P Value |
| 1 Month | 100 (3%) | 42 (1.3%) | <.001 |
| 3 Month | 133 (4.1%) | 72 (2.2%) | <.001 |
| 6 Month | 146 (4.5%) | 88 (2.7%) | <.001 |
| 1 Year | 171 (5.3%) | 109 (3.3%) | <.001 |
| 3 Year | 231 (7.1%) | 162 (5.0%) | <.001 |
| 5 Year | 277 (8.5%) | 193 (5.9%) | <.001 |
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