Multivariate Analysis of Risk Factors of Cerebral Infarction in 439 Patients Undergoing Thoracic Endovascular Aneurysm Repair

Abstract

The aim of the study is to identify the potential risk factors of cerebral infarction associated with thoracic endovascular aneurysm repair (TEVAR). TEVAR was developed as a less invasive surgical alternative to conventional open repair for thoracic aortic aneurysm treatment. However, outcomes following TEVAR of aortic and distal arch aneurysms remain suboptimal. Cerebral infarction is a major concern during the perioperative period. We included 439 patients who underwent TEVAR of aortic aneurysms at a high-volume teaching hospital between July 2006 and June 2013. Univariate and multivariate logistic regression analyses were performed to identify perioperative cerebral infarction risk factors. Four patients (0.9%) died within 30 days of TEVAR; 17 (3.9%) developed cerebral infarction. In univariate analysis, history of ischemic heart disease and cerebral infarction and concomitant cerebrovascular disease were significantly associated with cerebral infarction. "Shaggy aorta" presence, left subclavian artery coverage, carotid artery debranching, and pull-through wire use were identified as independent risk factors of cerebral infarction. In multivariate analysis, history of ischemic heart disease (odds ratio [OR] 6.49, P = 0.046) and cerebral infarction (OR 43.74, P = 0.031), "shaggy aorta" (OR 30.32, P < 0.001), pull-through wire use during surgery (OR 7.196, P = 0.014), and intraoperative blood loss ≥800 mL (OR 24.31, P = 0.017) were found to be independent risk factors of cerebral infarction. This study identified patient- and procedure-related risk factors of cerebral infarction following TEVAR. These results indicate that patient outcomes could be improved through the identification and management of procedure-related risk factors.

FIGURE 1

(A) Total debranching TEVAR. (B) TEVAR following carotid–carotid–left subclavian artery bypass. (C) 3D image following chimney TEVAR, (D) 3D image following TEVAR with a double-inner-branch stent graft. TEVAR = thoracic endovascular aneurysm repair.

FIGURE 2

Retrograde in-situ stent graft (RIBS) technique. (A) A 18G PTGBD needle for RIBS, (B) a thoracic stent graft is punctured by a PTGBD needle after the deployment of a stent graft. (C) The puncture site is dilated using a PTA balloon. (D) 3D image before TEVAR. (E) 3D image after TEVAR. PTA = percutaneous transluminal angioplasty, PTGBD = percutaneous transhepatic gallbladder drainage, RIBS = Retrograde in-situ stent grafting, TEVAR = thoracic endovascular aneurysm repair.

FIGURE 3

(A) Stroke prevention technique using balloon occlusion and clamping of neck branches. (B) Aortography confirming stagnant neck blood flow.