Predictors of Delayed Ischaemic Stroke following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury

Delayed ischaemic stroke (DIS) remains a feared complication following thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI), particularly when the left subclavian artery (LSCA) is covered. This study aimed to understand the impact of LSCA revascularisation and other peri-operative factors on delayed stroke risk.

This was a retrospective cohort study querying the Aortic Trauma Foundation registry to identify patients with BTAI undergoing TEVAR from 2014 to 2025. Patients with DIS after TEVAR were identified, and patient level factors, intra-operative data, and post-operative course variables were analysed.

Six hundred and twenty TEVARs for BTAI were identified. The overall DIS rate was 3.1% (19 of 620). LSCA coverage occurred in 32.6% (202 of 620) and was associated with a significantly higher rate of DIS (5.4% vs. 1.9%; p = .017). Adjunctive LSCA revascularisation during or after TEVAR was undertaken in 11.4% (23 of 202) of patients. Among patients requiring LSCA coverage (n = 202), there was no significant difference in the incidence of DIS between those who underwent adjunctive revascularisation (one of 23; 4.3%) and those who did not (10 of 179; 5.6%) (p = .81). Factors associated with DIS included the need for any intra-operative transfusion, mechanical ventilation > 48 hours, and initial post-TEVAR pressor requirement. Traumatic brain injury related factors, age, sex, and TEVAR timing were not identified as being associated with an increased DIS risk.

LSCA coverage during TEVAR for BTAI is associated with a significant increase in DIS rates. These data do not, however, demonstrate that LSCA revascularisation procedures mitigate the risk of these events in this setting. These findings may be limited by the small number of revascularised patients. Peri-operative physiological indicators emerge as the most reliable predictors of DIS in acute trauma, supporting an individualised approach where global trauma burden is considered a primary driver of neurological outcomes.