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Ann Thorac Surg 2007;84:1195-1200
© 2007 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Risk Factors for Perioperative Stroke After Thoracic Endovascular Aortic Repair

^a Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
^b Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
^c Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

Accepted for publication April 24, 2007.

^_* Address correspondence to Dr Gutsche, Department of Anesthesiology and Critical Care, Dulles 6, Hospital of University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104. (Email: gutschej{at}uphs.upenn.edu).

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.

Backgound: Stroke has emerged as an important complication of thoracic endovascular aortic repair (TEVAR). Identifying risk factors for stroke is important to define the risks of this procedure.

Methods: All neurologic complications were analyzed in a prospective database of patients in thoracic aortic stent graft trials from 1999 to 2006. Serial neurological examination was performed. Stroke was defined as any new onset focal neurologic deficit.

Results: The TEVAR was performed on 171 patients; 52 had lesions requiring coverage of the proximal descending thoracic aorta (extent A), 50 requiring coverage of the distal descending aorta (extent B), and 69 requiring coverage of the entire descending thoracic aorta (extent C). The incidence of stroke was 5.8%. Eighty-nine percent (8 of 9) of strokes occurred within 24 hours of operation. Stroke was associated with a 33% in-hospital mortality rate. Risk factors identified for stroke included prior stroke (odds ratio [OR] 9.4, confidence interval [CI] 2.3 to 38.1, p = 0.002) and extent A or C coverage (OR 5.5, CI 1.7–12.5, p = 0.001). The stroke rate in patients with both prior stroke and extent A or C coverage was 27.7%. Severe atheromatous disease involving the aortic arch by computed tomographic scan was strongly associated with perioperative stroke (OR = 14.8, CI 1.7 to 675.6, p = 0.0016). Transesophageal echocardiography demonstrated mobile atheroma in two patients with stroke.

Conclusions: Stroke after TEVAR was associated with a high mortality. The TEVAR of the proximal descending aorta (extent A or C) in patients with a history of stroke had the highest perioperative stroke rate. These risk factors, together with high grade aortic atheroma of the aortic arch, predicted a high probability for cerebral embolization and can be used to identify patients at high risk for stroke as a consequence of TEVAR.

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