Neurologic Complications Associated With Endovascular Repair Of Thoracic Aortic Pathology. Incidence And Risk Factors. A Study Of The EUROSTAR Registry.

Jacob Buth¹, Peter L Harris², Roel Hobo¹, Randolph van Eps¹, Hans Sybrandy¹, Lina Leurs.^1
1Catharina Hospital, Eindhoven, The Netherlands; ²Royal and University Hospital Liverpool, Liverpool, United Kingdom.

OBJECTIVES: Endovascular treatment of thoracic aortic disease demonstrated a lower rate of spinal cord ischemia (SCI), but not of intracranial stroke, compared with open surgical repair. The aim of this study was to assess which clinical factors were associated with the occurrence of neurologic adverse events after endovascular thoracic aortic repair.

METHODS: The EUROSTAR thoracic registry comprised 606 patients with prospective enrolment on to the database between July 2000 and July 2006. Patients were recruited by 58 different European institutions. The mean age was 63 years (range 13 - 91 years), 78% were men, and 22% were women. Thoracic aortic pathologies, with either emergency or elective presentation, included: degenerative aneurysm (N = 291, 48%), aortic dissection (N = 215, 35%), traumatic rupture (N = 67, 11%), false anastomotic aneurysm (N = 24, 4%), and infectious or not characterized disorders (N = 9, 1.5%). Study endpoints included perioperative evidence of spinal cord ischemia or stroke. Regression analysis was used to assess the significance of a number of clinical factors that potentially may influence the occurrence of neurological sequelae.

RESULTS: The overall one-month mortality was 60 (9.9%). Fifteen patients (2.5%) developed paraplegia or paraparesis and 19 (3.1%) stroke. Two of these patients had both complications combined. At multivariate regression analysis independent correlation with paraplegia or paraparesis was observed for three factors: (1) left subclavian artery covering without revascularization (p = .023, Odds Ratio = 3.9), (2) renal failure (p = .017, OR = 3.7) and (3) number of used stentgrafts ≥ 3 (p = .041, OR 3.4). In patients with perioperative stroke the duration of the procedure was the only correlating factor (p = .0045, OR = 6.4).

CONCLUSIONS: Perioperative paraplegia or paraparesis was significantly associated with blockage of the left subclavian artery without revascularization. The clinical significance of this source of collateral perfusion of the spinal cord had not been confirmed previously. In addition extensive covering of intercostal arteries reflected by the use of multiple stentgrafts correlated with SCI. Intracranial stroke was associated with lengthy manipulation of wires, catheters and introducer sheaths within the aortic arch.