Stroke risk and long-term outcome by proximal extent of endovascular aortic repair – a nationwide population-based registry study

Abstract Introduction Perioperative stroke in endovascular aortic repair is a devastating complication. The aim of this study is to analyze real-world data on stroke risk in relation to the proximal landing zone and describe long-term survival after perioperative stroke. Method A population-based registry study on all endovascular aortic repair performed in Sweden from May 2018 to May 2023. Data was collected from the Swedvasc and cross-referenced with National Patient Registry, Cause of Death Registry and Riksstroke. Stroke risk was analysed in relation to the proximal aortic landing zone and the effect of stroke on long-term survival was explored. Result 4842 endovascular aortic repairs were identified. Elective procedures were 76%, subacute 18% and acute 6%. Aneurysms were treated in 93% of the cohort and dissections in 7%. Perioperative stroke occurred in 1.6% (n=79). 30-day mortality was 24% (n=19) and 3.5% (n=169) in patients with and without stroke respectively. Stroke was strongly associated with proximal landing zone, where procedures in the arch had the highest stroke risk (7-22%) followed by the descending aorta (2-4%), then visceral aorta (0-1.5%) and lowest risk in aortic infrarenal cases (0-0.6%). In a multivariate analysis, stroke had significant effect on long-term survival with HR 2.2 and a 4-year survival of 49% compared to 73% in patients without stroke. Discussion The proximal landing zone for endovascular aortic repair is significantly associated with perioperative stroke with large impact on patient survival. This should be taken into consideration during patient selection and consent for proximal aortic repair.