Cerebral Embolic Protection to Prevent Brain Inury in Thoracic Aortic Stent-Grafting (TEVAR)

Introduction - Stroke occurs in 2-8%1 and silent cebebral infraction (SCI) in up to 63%2 of patients undergoing thoracic endovascular aortic repair (TEVAR). The Sentinel Cerebral Protection System (SCPS) is a dual filter cerebral embolic protection device (CEPD) that protects the innominate and left common carotid artery during intervention. CEPDs have been used successfully in patients undergoing transcatheter aortic valve insertion to reduce SCI and prevent neurolocognitive decline.3 This study investigates the safety and feasbility of CEPD with TEVAR. Methods - The SPCS was tested on a pulsatile flow model using all commercially available thoracic stent grafts to ensure compatibility. Patients anatomically suitable underwent TEVAR with SCPS. Procedural time for SCPS, complications, additional radiation exposure, fluoroscopy time and contrast dose was recorded. All patients had a pre and post-operative DW-MRI to assess number and surface area of new cerebral lesions, and neurocognitive testing. All filters were sent for histopathological analysis. Results - Ten patients,mean age 68yrs, anatomically suitable undwerwent TEVAR with SCPS, Fig 1. Proximal landing zones were1-3, aortic arch atheroma1-4. Success rate for SCPS was 90% (1 distal filter could not be deployed). There were no strokes, MACCE or device related complications. Use of SCPS added an additional 7mins to the total procedure,3.3mins fluoroscopy time, dose-area-product(mG.cm2) was increased by 2.2% and contrast use by 23mls. Nine patients underwent post-operative DW MRI, 2 had no new lesions. 23 lesions were identified in 7/9 patients, median number 1(1-3),surface area mm2 6(3-16); 6/23 (26%) were in the anterior circulation (AC), 15/23 (26%) in the posterior circulation(PC) and 2/23(9%) in borderzone territory. Debris capture rate was high in all filters 18/19(95%). Total number of particles captured was 2128, total surface area of particles 5,416,823.4μm2(5416mm2). There was no neurocognitive decline at 6 months. Conclusion - This is the first study to report use of CEPD in TEVAR. It appears safe and feasabile with high rate of debris capture, and reduced new cerebral lesions compared with neuroimaging data in TEVAR2. References1.Gutsche JT, Cheung AT at al. Risk factors for periopertaive stroke after throacic endovascular repair. Ann Thorac Surg.2007:84:1195-2002.Kalhert P, Eggerbrecht H et al. Silent cerebral ischaemia after thoracic endovascular repair: a neuroimaging study. Ann Thorac Surg.2014;98:53-583.Giustino G, Mehran R at al. Neurological Outcomes with Embolic Protection Devices in Patients undergoing Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2016;24:2124-2133