Division of Vascular Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA.
Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
J Vasc Surg. 2023 Dec;78(6):1559-1566.e5. doi: 10.1016/j.jvs.2023.05.014. Epub 2023 May 17.
Thoracic endovascular aortic repair (TEVAR) involving the aortic arch may increase the opportunity for stroke owing to disruption of cerebral circulation and embolization. In this study, a systematic meta-analysis was performed to examine the impact of proximal landing zone location on stroke and 30-day mortality after TEVAR.
MEDLINE and Cochrane Library were searched for all original studies of TEVAR reporting outcomes of stroke or 30-day mortality for at least two adjacent proximal landing zones, based on the Ishimaru classification scheme. Forest plots were created using relative risks (RR) with 95% confidence intervals (CI). An I of <40% was regarded as minimal heterogeneity. A P value of <.05 was considered significant.
Of the 57 studies examined, a total of 22,244 patients (male 73.1%, aged 71.9 ± 11.5 years) were included in the meta-analysis, with 1693 undergoing TEVAR with proximal landing zone 0, 1931 with zone 1, 5839 with zone 2, and 3089 with zone 3 and beyond. The overall risk of clinically evident stroke was 2.7% for zones ≥3, 6.6% for zone 2, 7.7% for zone 1, and 14.2% for zone 0. More proximal landing zones were associated with higher risks of stroke compared with distal (zone 2 vs ≥3: RR, 2.14; 95% CI, 1.43-3.20; P = .0002; I = 56%; zone 1 vs 2: RR, 1.48; 95% CI, 1.20-1.82; P = .0002; I = 0%; zone 0 vs 1: RR, 1.85; 95% CI, 1.52-2.24; P < .00001; I = 0%). Mortality at 30 days was 2.9% for zones ≥3, 2.4% for zone 2, 3.7% for zone 1, and 9.3% for zone 0. Zone 0 was associated with higher mortality compared with zone 1 (RR, 2.30; 95% CI, 1.75-3.03; P < .00001; I = 0%). No significant differences were found in 30-day mortality between zones 1 and 2 (P = .13) and between zone 2 and zones ≥3 (P = .87).
The risk of stroke from TEVAR is lowest in zone 3 and beyond, increasing significantly as the landing zone is moved proximally. Furthermore, perioperative mortality is increased with zone 0 compared with zone 1. Therefore, risk of stent grafting in the proximal arch should be weighed against alternative surgical or nonoperative options. It is anticipated that the risk of stroke will improve with further development of stent graft technology and implantation technique.
主动脉弓内的胸主动脉腔内修复术（TEVAR）可能会因破坏脑循环和栓塞而增加中风的机会。在这项研究中，进行了系统的荟萃分析，以检查近端着陆区位置对 TEVAR 后中风和 30 天死亡率的影响。
根据 Ishimaru 分类方案，检索 MEDLINE 和 Cochrane 图书馆中所有报告至少两个相邻近端着陆区中风或 30 天死亡率结果的 TEVAR 原始研究。使用相对风险（RR）和 95%置信区间（CI）创建森林图。<40%的 I 被认为是最小的异质性。P 值<.05 被认为是显著的。
在检查的 57 项研究中，共有 22244 名患者（男性 73.1%，年龄 71.9±11.5 岁）纳入荟萃分析，其中 1693 名患者接受近端着陆区 0 的 TEVAR，1931 名患者接受近端着陆区 1 的 TEVAR，5839 名患者接受近端着陆区 2 的 TEVAR，3089 名患者接受近端着陆区 3 及以上的 TEVAR。近端着陆区≥3 的临床明显中风风险为 2.7%，近端着陆区 2 的中风风险为 6.6%，近端着陆区 1 的中风风险为 7.7%，近端着陆区 0 的中风风险为 14.2%。与远端相比，近端着陆区的中风风险更高（近端着陆区 2 与近端着陆区≥3：RR，2.14；95%CI，1.43-3.20；P=.0002；I=56%；近端着陆区 1 与近端着陆区 2：RR，1.48；95%CI，1.20-1.82；P=.0002；I=0%；近端着陆区 0 与近端着陆区 1：RR，1.85；95%CI，1.52-2.24；P<.00001；I=0%）。30 天死亡率为近端着陆区≥3 的 2.9%，近端着陆区 2 的 2.4%，近端着陆区 1 的 3.7%，近端着陆区 0 的 9.3%。与近端着陆区 1 相比，近端着陆区 0 的死亡率更高（RR，2.30；95%CI，1.75-3.03；P<.00001；I=0%）。近端着陆区 1 和 2 之间（P=.13）以及近端着陆区 2 和近端着陆区≥3 之间（P=.87）的 30 天死亡率无显著差异。
TEVAR 引起的中风风险在近端着陆区 3 及以上最低，随着着陆区向近端移动而显著增加。此外，与近端着陆区 1 相比，近端着陆区 0 的围手术期死亡率更高。因此，应权衡近端弓部支架移植的风险与替代手术或非手术选择。预计随着支架技术和植入技术的进一步发展，中风的风险将得到改善。
