A Review Of Clinical Trial Data Details Factors Predictive Of Stroke And Paraplegia After Thoracic Endovascular Aortic Repair (TEVAR)

Main Category: Cardiovascular / Cardiology
Also Included In: Stroke
Article Date: 24 Nov 2008 - 9:00 PST

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Ronald Fairman, M.D., Professor of Surgery and Chief, Division of Vascular Surgery at the Hospital of the University of Pennsylvania, Philadelphia, described University of Pennsylvania data regarding development of a stroke or paraplegia following TEVAR.

Both complications are devastating and the identification of risk factors would be helpful. In the series at the University of Pennsylvania, the incidence of stroke was 5.8% with 89% of the strokes presenting less than 24 hours of the procedure.

Stroke carried an ominous outcome, with 33% in-hospital mortality. Risk factors for stroke in the Penn cohort were prior stroke and extent A or C coverage.

Also, severe atheromatous disease of the aortic arch on CT angiogram (CTA) was strongly associated with perioperative stroke. With regard to paraplegia following TEVAR, deficits may be observed immediately following TEVAR, but deficits can develop hours to days postoperatively in association with hypotensive episodes.

Prior abdominal surgery and extensive coverage of the thoracic aorta are known risk factors, and recognition of a postoperative deficit should be managed by immediate interventions to augment spinal cord perfusion.

In the Penn series, the incidence of spinal cord ischemia following TEVAR was 6.7% and the majority of patients had extent C coverage. The majority improved or completely recovered and the incidence of permanent deficits dropped to 2.7%.

Most cases of spinal cord ischemia could be detected intraoperatively by increased CSF pressure and / or the disappearance of lower extremity somatosensory evoked potential.

In the U Penn experience the contributing factors for spinal cord ischemia included prior abdominal aortic aneurysm (AAA) repair, perioperative hypotension, retroperitoneal hemorrhage / hematoma, injury to the external iliac artery, and extent B or C coverage. Dr. Fairman believes the efficacy of routine lumbar CSF drainage during TEVAR warrants further study.

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Source
Pauline T. Mayer
www.ptmhcm.com