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A Comprehensive Propensity Matched Analysis of Cerebral Infarction Following TEVAR with Left Subclavian Artery Coverage
Ahmad Tabatabaeishoorijeh1, Maham Rahimi2
1Texas A&M School of Engineering Medicine (ENMED), Houston, TX;2Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX

BACKGROUND: Left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR) has been associated with an increased risk of cerebral infarction in the postoperative period. This study aims to compare outcomes and provide a deeper understanding of the long-term effects of LSA coverage in patients undergoing TEVAR.
METHODS: We retrospectively analyzed patients undergoing TEVAR for various aortic conditions between August 1994 and August 2024 using the TriNetX database. Patients were grouped by the presence or absence of left subclavian artery (LSA) coverage, excluding those with prior cerebral infarction. Outcomes, including cerebral infarction, mortality, and new aortic dissections, were compared at multiple intervals pre- and post-propensity score matching. We conducted a decade-based analysis (2004-2014 vs. 2014-2024) on the risk of cerebral infarction with LSA coverage. Kaplan-Meier analysis estimated freedom from cerebral infarction in matched cohorts.
RESULTS: The study included a total of 8,008 TEVAR procedures. Of these, 3,421 (43%) involved left subclavian artery (LSA) coverage, while 4,587 (57%) were performed without LSA coverage. Compared to patients who underwent TEVAR with LSA coverage, those without LSA coverage were older (63±18 vs 61±17; P<.001) and had a higher proportion of male genders (61% vs 58%; P=.003). Rates of hyperlipidemia, chronic kidney disease, heart failure, type 2 diabetes mellitus, peripheral arterial disease, and smoking were similar between the cohorts, while patients without LSA coverage had higher rates of coronary artery disease (29% vs 26%; P=.005). Propensity score matching yielded 3,254 matched patients in both cohorts. Patients with LSA coverage had higher rates of cerebral infarction during the first month (3% vs 1.3%; P<.001), but there were no significant differences in mortality rates. The rate of cerebral infarction remained significantly higher at 3 and 6 months, and at 1, 3, and 5 years (P<.001) (Table). Mortality rates remained unchanged between the cohorts over the years. In the decade-based analysis, TEVARs with LSA coverage in the third decade had a significantly lower rate of cerebral infarctions at 1 month compared to those in the second decade (2% vs 5.4%; P=.003). At 3 and 5 years, there was a significantly higher rate of ascending aortic dissection in patients with LSA coverage (3-year: 1.9% vs 1.2%; P=.031; 5-year: 2.4% vs 1.5%; P=.01).
CONCLUSIONS: LSA coverage during TEVAR is associated with a significantly increased risk of cerebral infarction, particularly in the early postoperative period, with this risk persisting up to five years postoperatively. The decade-based analysis revealed a significant reduction in the rate of cerebral infarctions in the more recent decade (2014-2024) compared to the previous decade (2004-2014). Although mortality rates did not differ between the groups, patients with LSA coverage exhibited a higher incidence of subsequent ascending aortic dissections at 3 and 5 years. These findings underscore the importance of carefully considering the risks associated with LSA coverage during TEVAR and highlights the potential benefits of advancements in TEVAR techniques over time.

Interval cerebral infarction outcomes in propensity matched cohorts (n=3254 pairs) undergoing TEVAR
Cerebral InfarctionTEVAR w/ LSA Coverage (n = 3254)TEVAR wo/ LSA Coverage (n = 3254)P Value
1 Month100 (3%)42 (1.3%)<.001
3 Month133 (4.1%)72 (2.2%)<.001
6 Month146 (4.5%)88 (2.7%)<.001
1 Year171 (5.3%)109 (3.3%)<.001
3 Year231 (7.1%)162 (5%)<.001
5 Year277 (8.5%)193 (5.9%)<.001


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