Comparative Analysis of Stroke Rates in Arch TEVAR: Total Endovascular Repair Plagued by High Stroke Rates

Document Type

Conference Proceeding

Publication Date

6-1-2024

Publication Title

J Vasc Surg

Abstract

Objectives: Endovascular stent-grafting extending into the ascending aorta (zone 0) is becoming more prevalent in the treatment of aortic arch disease. This study aims to evaluate the risk of stroke in patients undergoing zone 0 thoracic endovascular aortic repair (TEVAR) for aortic arch disease, considering various techniques of head vessel revascularization. Methods: Patients undergoing zone 0 TEVAR covering all arch vessels were identified in the Vascular Quality Initiative (VQI) between 2014-2023. Exclusions included cases of aortic rupture or trauma. Patients were categorized based on head vessel revascularization technique: a) open revascularization (OR) of all head vessels, b) endovascular revascularization (ER) of all head vessels during TEVAR, and c) hybrid revascularization (HR) defined as endovascular repair of at least one head vessel with open debranching of the others. Univariate analysis was performed to compare stroke rates among the three groups. Kaplan-Meier (KM) analysis and long-rank test were used to estimate and compare survival. Results: Among 382 patients receiving Zone 0 TEVAR involving the head vessels, 201 (53%) underwent OR, 76 (20%) underwent ER, and 105 (27%) underwent HR. The rate of OR dropped from 83% to 31% between 2013-2023, while that of HR increased from 4% to 54% (Fig 1). OR patients were younger (OR 63 ± 12 years, ER 70 ± 10 years, HR 69 ± 12 years; P <.001) and more likely to be symptomatic at presentation (P =.002). Otherwise, the groups exhibited similar baseline characteristics, pathologies, and distal landing zones. Hospital stay (P =.267) and ICU stay (P =.117) were comparable. The overall perioperative stroke and 30-day mortality rates were 12.5% and 10.1%, respectively. ER showed the highest incidence of stroke (ER 22.4%, OR 11.4%, HR 7.6%; P =.010). Postoperative myocardial infarction was least in patients undergoing OR (OR 1.5%, ER 11.8%, HR 10.5%; P <.001), and no difference in pneumonia rates was observed (P =.878). KM estimates of 30-day mortality (OR 9.1%, ER 10.4%, HR 11.7%) and 1-year mortality (OR 16.5%, ER 16.6%, HR 21.3%) were similar (Fig 2). Conclusions: TEVAR covering the arch vessels is associated with high stroke and mortality rates. Total endovascular revascularization of the head vessels after TEVAR has more than 2- fold higher stroke rate compared to open or hybrid revascularization with no improvement in morbidity or mortality. Using current technology, ER is overshadowed by high perioperative stroke rates, and thus open or hybrid revascularization of the head vessels should be favored (or strongly considered) whenever feasible. [Formula presented] [Formula presented]

Volume

79

Issue

6

First Page

e289

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