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Left Subclavian Artery Coverage During Thoracic Endovascular Aortic Repair and Risk of Perioperative Stroke or Death
Study Questions:
What is the association between left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) and risk of perioperative stroke or death?
Methods:
Current procedural terminology (CPT) codes were used to identify patients undergoing TEVAR, LSA coverage, and subclavian revascularization procedures from the 2005-2008 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use Datafile. Patients undergoing coronary bypass, ascending aortic repair, abdominal aortic aneurysm repair, or nonvascular intra-abdominal procedures during the same operation were excluded. Perioperative stroke and mortality associations with LSA coverage were examined using logistic regression models for each outcome. Significance was assessed at α = 0.05, with univariable p < 0.05 required for multivariable model entry.
Results:
Eight hundred forty-five TEVAR procedures were identified, of which 52 patients were excluded due to additional major procedures performed with TEVAR. Seven hundred thirty-three of the remaining 793 procedures included CPT codes indicating primary placement of an initial thoracic endograft and form the basis of this analysis. LSA coverage occurred in 279 procedures (38%). Thirty-day stroke and mortality rates were 5.7% and 7.0%, respectively. LSA coverage was associated with increased 30-day risk of stroke in multivariable modeling (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.13-4.14; p = 0.019). Other significant multivariable risk factors for stroke included proximal aortic cuff placement during TEVAR (OR, 2.58; 95% CI, 1.30-5.16; p = 0.007) and emergency procedure status (OR, 3.60; 95% CI, 1.87-6.94; p < 0.001). No significant association between LSA coverage and perioperative mortality was identified (univariable OR, 1.70; 95% CI, 0.98-2.93; p = 0.0578).
Conclusions:
The authors concluded that LSA coverage during thoracic endovascular repair is associated with increased risk of perioperative stroke following TEVAR.
Perspective:
This study suggests that left subclavian artery coverage is associated with increased 30-day stroke risk among patients undergoing primary TEVAR, but no significant association between LSA coverage and perioperative mortality was observed. Other risk factors for perioperative stroke included proximal aortic cuff placement and emergent procedure status. Additional studies are needed to determine whether procedural modifications, including LSA revascularization, may reduce the incidence of stroke associated with TEVAR. Also indicated is development of multicenter registries with TEVAR-specific endpoints for overcoming sample size/power limitations of existing evidence.
Keywords: Odds Ratio, Stroke, Aortic Aneurysm, Thoracic, Endovascular Procedures, Risk Factors, Vascular Surgical Procedures, Registries, Subclavian Artery, Confidence Intervals, Coronary Artery Bypass, Aortic Aneurysm, Abdominal, United States, Logistic Models
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