Thoracic Aorta

Analysis of Stroke after TEVAR Involving the Aortic Arch

Melissano G, Tshomba Y, Bertoglio L, et al (Università Vita-Salute, Milano, Italy) Eur J Vasc Endovasc Surg 43:269–275, 2012^§

Abstract

Objective

To analyse the incidence of stroke after thoracic endovascular aortic repair (TEVAR) for aortic arch disease.

Methods

In the last decade, 393 patients received TEVAR at our Institution; in 143 cases the aortic arch was involved (32 zones ‘0’, 35 zones ‘1’ and 76 zone ‘2’). The left subclavian artery (LSA) was revascularised selectively in 75 cases; the proximal LSA was ligated or occluded with a plug in 55 cases before endograft (EG) deployment.

Results

Initial clinical success, perioperative mortality, spinal cord ischaemia and stroke in TEVAR patients with or without arch involvement were, respectively, 86.7% vs. 94.4%, 4.2% vs. 2.4%, 2.1% vs. 3.6% and 2.8% vs. 1.2%. The stroke rate was 9.4% (P < 0.02) in ‘zone 0’, 0% in ‘zone 1’ and 1.3% in ‘zone 2’ with scans showing severe atheroma and/or thrombus in all cases. Stroke was observed in patients with 2.6% or without 2.9% LSA revascularisation; however, it was never observed in patients in whom the LSA was occluded before EG deployment and in 4.5% of patients in whom it was patent at the time of EG deployment.

Conclusions

Stroke after TEVAR is not infrequent especially when the arch is involved. Careful patient selection together with a strategy to reduce embolisation such as occlusion of supra-aortic trunks before EG deployment may play a beneficial role (Fig 2, Tables 5–7).

Figure 2 (A) Guidewire manipulation of the aortic arch prior to surgical debranching may cause cerebral embolisation of atherothrombotic material through the patent supraaortic vessels. (B) Surgical by-passing of all the supra-aortic trunks, associated with ligation of the origin of the innominate artery and left common carotid, and endovascular occlusion of the LSA are performed prior to guidewire engagement of the aortic arch in order to reduce the risk of cerebral embolisation. (Reprinted from European Journal of Vascular and Endovascular Surgery, Melissano G, Tshomba Y, Bertoglio L, et al. Analysis of stroke after TEVAR involving the aortic arch. Eur J Vasc Endovasc Surg. 2012;43:269–275. Copyright 2012, with permission from the European Society for Vascular Surgery.)

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