Neurological Complications After Thoracic Endovascular Repair (TEVAR): A Narrative Review of the Incidence, Mechanisms and Strategies for Prevention and Management

<b>Background</b>: Thoracic endovascular aortic repair (TEVAR) has evolved the management of descending thoracic aortic disease, but neurological complications-particularly spinal cord ischemia (SCI), stroke, and postoperative delirium-remain among the most feared adverse events, adversely affecting survival, quality of life, and functional independence. <b>Objectives</b>: The aim of this study was to provide a contemporary narrative synthesis (2000-2025) of the incidence, mechanisms, risk factors, prevention, and management of neurological complications after TEVAR, emphasizing how current evidence supports individualized and risk-adapted strategies for prevention and management. <b>Methods</b>: A narrative, non-systematic search (PubMed/MEDLINE, Scopus, Cochrane Library; 2000-2025) was conducted using terms related to TEVAR, SCI, cerebrovascular events, delirium, and cognitive dysfunction. Priority was given to large registries, cohort studies, and systematic reviews in adult TEVAR populations. <b>Results</b>: Perioperative stroke occurs in ~2-6% of TEVAR cases, with higher rates in arch/zone 0-2 procedures and when the left subclavian artery (LSA) is covered without revascularization. SCI incidence ranges from ~2-9%, influenced by aortic extent and urgency; Vascular Quality Initiative data report SCI in 3.7% of procedures, with markedly reduced 1-year survival. Major SCI risk factors include extensive thoracic coverage, prior aortic repair, vertebral or hypogastric occlusion, emergency presentation, low perioperative mean arterial pressure, anemia, and chronic kidney disease. Postoperative delirium occurs in ~13% of TEVAR-treated type B dissections and correlates with longer hospitalization and early complications. Emerging nomograms for SCI and delirium enable individualized risk stratification. <b>Conclusions</b>: Neurological complications after TEVAR remain clinically significant. Contemporary evidence supports personalized prevention-selective cerebrospinal fluid (CSF) drainage, LSA revascularization, staging, neuromonitoring, and tailored hemodynamic targets-guided by anatomical complexity, comorbidities, collateral network integrity, and prior aortic history. Further research should refine prediction tools, standardize definitions, and evaluate individualized neuroprotective bundles.