Vascular Distribution of Stroke and Its Relationship to Perioperative Mortality and Neurologic Outcome After Thoracic Endovascular Aortic Repair

Objective: This study assessed the vascular distribution of stroke after thoracic endovascular aortic repair (TEVAR) and its relationship to perioperative death and neurologic outcome.

Methods: A retrospective review was performed for patients undergoing TEVAR between 2001 and 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 lasting>24 hours with radiographic confirmation of acute intracranial pathology.

Results: Perioperative stroke occurred in 20 of 530 patients (3.8%) undergoing TEVAR. The cohort was 55% male and a mean age of 75.2±8.9 years (range, 57-90 years). Among patients with perioperative strokes, the indication for surgery was degenerative aneurysm in 14 (mean diameter, 6.8 cm), acute type B dissection in four, penetrating atherosclerotic aneurysm in one, and aortic transection in one. Cases were performed urgently or as an emergency in 60%. The proximal landing zone was zone 2 in 11 or zone 3 in nine. All strokes were embolic. The vascular distribution of stroke involved the anterior cerebral (AC) circulation in eight (zone 2, n=5) and the posterior cerebral (PC) circulation in 12 (zone 2, n=6). Laterality of cerebral infarction included five right-sided, eight left-sided, and seven bilateral strokes. Nine strokes were diagnosed<24 hours after operation. There was no difference in baseline demographics, aortic pathology, acuity, zone coverage, preoperative left subclavian artery revascularization, number of stents, or estimated blood loss between stroke groups based on vascular distribution. Independent risk factors for any perioperative stroke were chronic renal insufficiency (odds ratios [OR], 4.65; 95% confidence interval [CI], 1.22-17.7; P=.02) and history of prior stroke (OR, 4.92; 95% CI, 1.69-14.4; P=.004); the risk factor for AC stroke was prior stroke (OR, 7.67; 95% CI, 1.25-46.9; P=.03) and the risk factors for PC stroke were age (OR, 1.11; 95% CI, 1.00-1.23; P=.04), prior stroke (OR, 7.53; 95% CI, 1.78-31.8; P=.006), zone 2 coverage (OR, 6.11; 95% CI, 1.15-32.3; P=.03), and penetrating atherosclerotic ulcer (OR, 32.7; 95% CI, 1.33-807.2; P=.03). Overall in-hospital mortality was 20% (n=4), with those sustaining PC strokes observed to trend toward increased mortality (33% vs 0%; P=.12). Patients with AC strokes were more likely than those with PC strokes to achieve complete recovery of neurologic deficits before discharge (75% vs 17%; P=.02).

Conclusions: Perioperative stroke after TEVAR is primarily an embolic event. Although infrequent, stroke was associated with significant morbidity and death, particularly among those with strokes involving the PC circulation.