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

## TL;DR

This study finds that stroke risk during aortic repair increases with the proximity of the repair site to the heart and that strokes significantly reduce patient survival.

## Contribution

The study provides real-world data on stroke risk and survival outcomes stratified by proximal landing zones in endovascular aortic repair.

## Key findings

- Perioperative stroke occurred in 1.6% of endovascular aortic repair cases.
- Stroke risk was highest in zone 0, with a 22% incidence and an odds ratio of 41.58.
- Patients with perioperative stroke had a 4-year survival probability of 48.6%, compared to 72.5% for those without stroke.

## Abstract

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.

This was a population-based multiregistry study of all endovascular aortic repairs (EVARs) performed in Sweden between 15 May 2018 and 15 May 2023. The aim was to analyse the risk of perioperative stroke in relation to the proximal aortic landing zone and to analyse the effect of perioperative stroke on mid-term survival. Out of 4842 patients who underwent EVAR, 1.6% developed stroke, which was strongly associated with the proximal landing zone, with the highest risk of perioperative stroke associated with landing zone 0 (22%). Additionally, perioperative stroke affected the mid-term survival of patients, with an HR of 2.17. This should be accounted for when planning proximal EVAR.