Composite Dialysis, Paralysis, Stroke, Or Mortality After Endovascular Aortic Interventions In The Society For Vascular Surgery Vascular Quality Initiative

Thoracoabdominal aortic aneurysm life-altering events, which include a combination of permanent dialysis, permanent spinal cord ischemia, stroke, and/or death, have devastating effects after complex endovascular repair. However, the occurrence of these life-altering events after endovascular abdominal aortic aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) has not been studied. Therefore, we examined the effects of procedural and anatomic characteristics on a composite outcome of postoperative dialysis, stroke, paralysis, and/or mortality after any endovascular aortic repair. We identified all patients who had undergone infrarenal EVAR, complex EVAR, and TEVAR within the VQI registry between 2014 and 2020. The primary outcome was a composite of new postoperative dialysis, in-hospital paralysis, in-hospital stroke, and/or 30-day mortality. Multivariable logistic regression was used to identify the procedural and anatomic characteristics associated with the composite outcome. We identified 46,246 infrarenal EVARs, 2753 complex EVARs, and 5211 TEVARs. The composite outcome was 1.5% after EVAR, 7.6% after complex EVAR, and 9.0% after TEVAR (Table I). Aortic diameter >65 mm was independently associated with an increased risk of the composite outcome after all three types of repair (EVAR: odds ratio [OR], 1.9; 95% confidence interval [CI], 1.5-2.3; complex EVAR: OR, 1.6; 95% CI, 1.2-2.2; TEVAR: OR, 1.7; 95% CI, 1.3-2.3), as was urgent repair (EVAR: OR, 3.4; 95% CI, 2.7-4.2; complex EVAR: OR, 1.6; 95% CI, 1.1-2.3; TEVAR: OR, 2.2; 95% CI, 1.7-2.8; Table II). In patients undergoing infrarenal EVAR, the use of a proximal aortic extension cuff was also independently associated with the composite outcome (OR, 1.5; 95% CI, 2.7-4.2). Among patients undergoing complex EVAR, chimney EVAR was independently associated with the composite outcome (OR, 1.9; 95% CI, 1.3-2.7) as was a proximal landing zone above zone 6 (OR, 2.1; 95% CI, 1.5-2.8). In patients undergoing TEVAR, more proximal landing zones were associated with an increased risk of the composite outcome compared with zone 4 and 5 (zone 0 or 1: OR, 3.0; 95% CI, 2.0-4.6; zone 2: OR, 2.1; 95% CI, 1.5-3.1; zone 3: OR, 1.7; 955 CI, 1.2-2.3). Compared with no arm or neck access, either arm access or multiple access sites were associated with an increased risk of the composite outcome (arm access: OR, 1.5; 95% CI, 1.3-2.1]; multiple sites: OR, 3.1; 95% CI, 1.7-5.9). New dialysis, paralysis, stroke, and/or mortality after endovascular repair occurred more frequently after TEVAR and complex EVAR compared with infrarenal EVAR. Overall, more complex and proximal repairs and repairs that involved wire manipulation in the aortic arch were associated with an increased risk of our composite outcome. The aortic anatomy and anticipated procedural characteristics should be considered and factored into clinical decision-making.Table IPerioperative outcomes stratified by endovascular repair typeVariableEVAR (n = 46,246)Complex EVAR (n = 2753)TEVAR (n = 5211)Composite outcome714 (1.5)209 (7.6)468 (9.0)New dialysis196 (0.4)53 (1.9)73 (1.4)In-hospital paralysis65 (2.4)84 (1.6)In-hospital stroke99 (0.2)46 (1.7)188 (3.6)Perioperative mortality506 (1.1)123 (4.5)238 (4.6)EVAR, endovascular abdominal aortic aneurysm repair; TEVAR, thoracic endovascular aortic repair.Data presented as number (%). Open table in a new tab Table IIAdjusted analysis for composite outcome stratified by endovascular repair typeaCharacteristic associated with composite outcomeOR95% CIP valueAfter EVAR Aortic diameter >65 mm1.871.51-2.3365 mm1.611.18-2.21.003 Urgent repair1.591.08-2.33.018 Arm access1.110.93-1.33.23 Complex EVAR technique FEVARReference chEVAR1.871.30-2.70.001 Proximal landing zone 7 or belowReference 6 or above2.071.50-2.8465 mm1.711.32-2.23