Total Endovascular Repair in Arch TEVAR Is Plagued by High Stroke Rates

Document Type

Conference Proceeding

Publication Date

9-1-2024

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 between 2014 and 2023 were identified in the Vascular Quality Initiative (VQI). Patients were categorized based on head vessel revascularization technique: open revascularization (OR) of all head vessels, endovascular revascularization (ER) of all head vessels during TEVAR, and hybrid revascularization (HR) defined as endovascular repair of at least one head vessel with open debranching of the others. Univariate and Kaplan-Meier analyses were used to compare stroke and mortality rates. 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 and 2023, while that of HR increased from 4% to 54% (Fig 1). OR patients were younger (OR, 63; ER, 70; HR, 69 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 = .01). 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). Thirty-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). Conclusion: TEVAR covering the arch vessels is associated with high stroke and mortality rates. Total ER of the head vessels during TEVAR has more than two-fold higher stroke rate compared with OR or HR with no improvement in morbidity or mortality. Using current technology, ER is overshadowed by high perioperative stroke rates, and thus OR or HR of the head vessels should be strongly considered whenever feasible. [Formula presented] [Formula presented]

Volume

80

Issue

3

First Page

e77

Last Page

e78

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