When stroke strikes: Predictors of stroke after open thoracoabdominal aortic aneurysm repair

Postoperative stroke after thoracoabdominal aortic aneurysm (TAAA) repair is an uncommon but devastating complication that has been understudied. This analysis aimed to identify patients at greatest risk for ischemic or hemorrhagic stroke after TAAA repair.

We analyzed data from 3765 patients who underwent open TAAA repair from 1986 to 2024 at a single high-volume aortic surgery practice. We used multivariable logistic regression modeling to evaluate preoperative and operative predictors of all and persistent ischemic and hemorrhagic stroke. The effect of new-onset atrial fibrillation was evaluated.

Postoperative stroke persisted to death or hospital discharge in 93 patients (2.5%) and was transient in 29 (0.8%). Those with persistent stroke had a greater mortality rate (61.3%, n = 57/93) than those without any stroke (7.3%, n = 267/3643). Most persistent strokes were ischemic (76.3%) rather than hemorrhagic (26.9%). Significant predictors of persistent ischemic stroke included older age (odds ratio [OR], 1.04; P = .007) and chronic kidney disease (OR, 1.98; P = .01), whereas Crawford extent III (OR, 0.38; P = .01) and IV repairs (OR, 0.35; P = .008) were protective. Significant predictors of persistent hemorrhagic stroke included heritable thoracic aortic disease (OR, 2.34; P = .04) and prophylactic cerebrospinal fluid drainage (OR, 7.99; P = .006). Prolonged aortic clamp time (OR, 1.03, P = .03) was associated with greater odds of death after a stroke.

This analysis of a large, single-practice series identified variables associated with stroke and stroke-related mortality after TAAA repair. Although stroke remains infrequent, its lethality highlights the importance of risk modeling. Mitigating the risk of hemorrhagic stroke in patients with heritable thoracic aortic disease should be prioritized.