Procedural complexity tied to stroke after EVAR, TEVAR

In-hospital stroke is rare after elective endovascular aortic aneurysm repair, but it is more common after complex EVAR and thoracic endovascular aortic repair, researchers reported at the Society for Vascular Surgery Vascular Annual Meeting.

Nicholas J. Swerdlow, MD, vascular research fellow at Beth Israel Deaconess Medical Center, Marc Schermerhorn, MD, chief of the division of vascular and endovascular surgery at Beth Israel Deaconess, and colleagues performed a retrospective cohort study of 41,540 patients who had infrarenal EVAR, 1,371 patients who had complex EVAR (including fenestrated EVAR and chimney EVAR) and 4,600 patients who had TEVAR between 2011 and 2018 and were included in the Vascular Quality Initiative database.

According to the researchers, the in-hospital stroke rate was 0.1% after infrarenal EVAR, 0.9% after complex EVAR and 2.9% after TEVAR. In the complex EVAR cohort, stroke rate was 0.7% after fenestrated EVAR with a custom-manufactured device, 0.4% after fenestrated EVAR with a physician-modified endovascular graft and 2.1% after chimney EVAR.

Swerdlow and colleagues found that in the infrarenal EVAR cohort, the procedural characteristics independently associated with stroke were use of a proximal aortic extension (OR = 3.3; 95% CI, 1.4-7.9), aneurysm diameter > 65 mm (OR = 1.7; 95% CI, 1.1-2.7), and treatment of symptomatic aneurysms (OR = 2.1; 95% CI, 1.2-3.7).

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In complex EVAR, arm access was associated with elevated risk for stroke (OR = 7.6; 95% CI, 1.7-34) according to the researchers, who noted that the chimney technique was not associated with elevated stroke risk after adjustment for arm access.

In the TEVAR cohort, independent predictors of stroke were multiple arm/neck access sites (OR = 2.5; 95% CI, 0.9-7), left subclavian artery bypass (OR = 2.5; 95% CI, 1.5-4), left subclavian artery stenting, whether uncovered or using the chimney technique (OR = 2.4; 95% CI, 0.8-7.4) and covered/occluded left subclavian artery (OR = 2.5; 95% CI, 1.5-4.1), according to the researchers.

Also in the TEVAR group, patients who had an urgent procedure were more likely to have in-hospital stroke than patients who had an elective one (OR = 2.1; 95% CI, 1.3-3.6), Swerdlow and colleagues found.

“Increasing procedural complexity in EVAR and TEVAR is associated with higher stroke rate, a risk that should be factored into clinical decision-making,” Swerdlow and colleagues wrote in an abstract. “The strong association between stroke and arm access during complex EVAR warrants further study.” – by Erik Swain

Reference:

Swerdlow NJ, et al. Abstract RS08. Presented at: Society for Vascular Surgery Vascular Annual Meeting; June 12-15, 2019; National Harbor, Md.

Disclosures: Swerdlow reports no relevant financial disclosures. Schermerhorn reports he has financial ties with Abbott Vascular, Cook Medical, Endologix, Medtronic and Silk Road Medical.