Journal
JOURNAL OF VASCULAR SURGERY
Volume 68, Issue 6, Pages 1656-1666Publisher
MOSBY-ELSEVIER
DOI: 10.1016/j.jvs.2017.11.098
Keywords
CEPD; DW-MRI; Embolization; HITS; TEVAR
Categories
Funding
- Stroke Association
- Imperial College Healthcare charity
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Background: Stroke occurs in 3% to 8% and silent cerebral infarction in >60% of patients undergoing thoracic endovascular aortic repair (TEVAR). We investigated the utility of a filter cerebral embolic protection device (CEPD) to reduce diffusion-weighted magnetic resonance imaging (DW-MRI) detected cerebral injury and gaseous and solid embolization during TEVAR. Methods: Patients anatomically suitable underwent TEVAR with CEPD, together with intraoperative transcranial Doppler to detect gaseous and solid high-intensity transient signals (HITSs), pre- and postoperative DW-MRI, and clinical neurologic assessment <= 6 months after the procedure. Results: Ten patients (mean age, 68 years) underwent TEVAR with a CEPD. No strokes or device-related complications developed. The CEPD added a median of 7 minutes (interquartile range [IQR], 5-16 minutes) to the procedure, increased the fluoroscopy time by 3.3 minutes (IQR, 2.4-3.9 minutes), and increased the total procedural radiation by 2.2%. The dose area product for CEPD was 1824 mGy.cm(2) (IQR, 1235-3392 mGy.cm(2)). The average contrast volume used increased by 23 mL (IQR, 24-35 mL). New DW-MRI lesions, mostly in the hindbrain, were identified in seven of nine patients (78%). The median number was 1 (IQR, 1-3), with a median surface area of 6 mm(2) (IQR, 3-16 mm(2)). A total of 2835 HITSs were detected in seven patients: 91% gaseous and 9% solid. The maximum number of HITSs were detected during CEPD manipulation: 142 (IQR, 59-146; 95% gaseous and 5% solid). The maximum number of HITSs during TEVAR occurred during stent deployment: 82 (IQR, 73-142; 81% gas and 11% solid). Solid HITSs were associated with an increase in surface area of new DW-MRI lesions (r(s) = 0.928; P =.01). Increased gaseous HITSs were associated with new DW-MRI lesions (r(s) = 0.912; P =.01), which were smaller (< 3 mm; r = 0.88; P =.02). Embolic debris was captured in 95% of the filters. The median particle count was 937 (IQR, 146-1687), and the median surface area was 2.66 mm(2) (IQR, 0.08-9.18 mm(2)). Conclusions: The use of a CEPD with TEVAR appeared to be safe and feasible in this first pilot study and could serve as a useful adjunct to reduce cerebral injury. The significance of gaseous embolization and its role in cerebral injury in TEVAR warrants further investigation.
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