Key result
Thoracic endovascular aortic repair with left subclavian artery coverage was associated with a significantly higher 30-day stroke incidence compared to repair without coverage (adjusted OR 2.7).
Why the study?
To evaluate the perioperative stroke incidence following TEVAR with differing left subclavian artery coverage and revascularization approaches in a real-world nationwide registry.
Does TEVAR with left subclavian artery coverage increase 30-day stroke incidence compared to TEVAR without coverage, and does concomitant revascularization mitigate this risk?
Cohort (n=3,114)
Yes
Does TEVAR with left subclavian artery coverage increase 30-day stroke incidence compared to TEVAR without coverage, and does concomitant revascularization mitigate this risk?
Odds Ratio: 2.7 (95% CI 1.7–4.3)
Absolute Event Rate: 5.2% vs 2.3%
p-value: p=<0.001
In a real-world registry, TEVAR with LSA coverage was associated with a significantly higher 30-day stroke risk that was not reduced by concomitant LSA revascularization.
Suggests caution with left subclavian coverage in TEVAR due to stroke risk; leaves open need for randomized confirmation.
Purpose: To evaluate the perioperative stroke incidence following thoracic endovascular aortic repair (TEVAR) with differing left subclavian artery (LSA) coverage and revascularization approaches in a real-world setting of a nationwide clinical registry. Materials and Methods: The National Surgical Quality Improvement Program registry was interrogated from 2005 to 2017 to identify all nonemergent TEVAR and/or open LSA revascularization procedures. In this time frame, 2346 TEVAR cases met the selection criteria for analysis. The 30-day stroke incidence was compared between patients undergoing TEVAR with (n=888) vs without (n=1458) LSA coverage, for those with (n=228) vs without (n=660) concomitant LSA revascularization among those with coverage, and following isolated LSA revascularization for occlusive disease (n=768). Multivariable logistic regression was employed for risk-adjusted analyses and to identify factors associated with stroke following TEVAR. Results of the regression analyses are presented as the adjusted odds ratio (OR) with 95% confidence interval (CI). Results: The stroke incidence was 2.3% following TEVAR without vs 5.2% with LSA coverage (p<0.001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized and 4.4% without concomitant revascularization, while stroke occurred in 0.5% of isolated LSA revascularizations. Of 33 TEVAR patients experiencing a perioperative stroke, 8 (24%) died within 30 days. LSA coverage was associated with stroke both with concomitant revascularization (OR 4.0, 95% CI 2.2 to 7.5, p<0.001) and without concomitant revascularization (OR 2.2, 95% CI 1.3 to 3.8, p=0.002). Other preoperative factors associated with stroke were dyspnea (OR 1.8, 95% CI 1.1 to 3.0, p=0.014), renal dysfunction (OR 2.2, 95% CI 1.0 to 3.8, p=0.049), and international normalized ratio ≥2.0 (OR 3.6, 95% CI 1.0 to 13, p=0.045). Conclusion: Stroke following TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.
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Varkevisser et al. (2020) conducted a cohort in Thoracic aortic aneurysm or dissection (n=3,114). TEVAR with left subclavian artery (LSA) coverage vs. TEVAR without LSA coverage was evaluated on 30-day stroke incidence (OR 2.7, 95% CI 1.7 to 4.3, p=<0.001). Thoracic endovascular aortic repair with left subclavian artery coverage was associated with a significantly higher 30-day stroke incidence compared to repair without coverage (adjusted OR 2.7).
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