Stroke risk and mid-term survival by proximal extent of endovascular aortic repair

Recent advancements in endovascular aortic repair (EVAR) have expanded treatment to increasingly proximal aortic segments, including the thoracic and thoracoabdominal aorta as well as the arch. Coherent real-world data on stroke risk after EVAR, stratified by the proximal landing zone, and the impact of perioperative stroke on mid-term survival are scarce.

A population-based multiregistry retrospective analysis was performed on prospectively collected data for all EVARs performed in Sweden between 15 May 2018 and 15 May 2023. Data were collected from the Swedish Vascular Registry (Swedvasc) and cross-referenced with the Swedish Patient Registry, the Swedish Cause of Death Registry, and the Swedish Stroke Registry. The effect of perioperative stroke on mid-term survival was analysed and the relationship between the incidence of stroke and the proximal landing zone was analysed.

Some 4842 EVARs were performed. Perioperative stroke occurred in 1.6% (79 of 4842). Stroke risk was associated with the proximal landing zone, with a stroke rate of 22% in zone 0. In multivariable analysis, the OR for stroke in zone 0 was 41.58 (95% c.i. 18.46 to 93.70); P < 0.001. The 30-day mortality rate was 24% (19 of 79) and 3.5% (169 of 4763) for patients with and without perioperative stroke respectively. This difference persisted over time, with a 4-year survival probability of 48.6% and 72.5% for patients with and without stroke respectively (HR 2.17 (95% c.i. 1.26 to 3.72); P < 0.001).

Stroke is strongly associated with the proximal landing zone, being more likely when landing proximal to the supra-aortic vessels. Perioperative stroke impacts patient survival and should be taken into consideration during patient selection, and efforts should be made to reduce the risk of stroke during proximal repair.