Gagandeep Grover1, Anisha H Perera1, Mohamad Hamady2, Nung Rudarakanchana1, Christen D Barras3, Abhinav Singh4, Alun H Davies1, Richard Gibbs1. 1. Imperial Vascular Unit, Department of Surgery and Cancer, Imperial College London, London, United Kingdom. 2. Department of Interventional Radiology, Imperial Healthcare College NHS Trust, London, United Kingdom. Electronic address: m.hamady@imperial.ac.uk. 3. Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom. 4. Department of Neuroradiology, Imperial College Healthcare NHS Trust, London, United Kingdom.
Abstract
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·cm2 (IQR, 1235-3392 mGy·cm2). 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 mm2 (IQR, 3-16 mm2). 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 (rs = 0.928; P = .01). Increased gaseous HITSs were associated with new DW-MRI lesions (rs = 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 mm2 (IQR, 0.08-9.18 mm2). 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.
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·cm2 (IQR, 1235-3392 mGy·cm2). 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 mm2 (IQR, 3-16 mm2). 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 (rs = 0.928; P = .01). Increased gaseous HITSs were associated with new DW-MRI lesions (rs = 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 mm2 (IQR, 0.08-9.18 mm2). 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.
Authors: Mario D'Oria; Kevin Mani; Randall DeMartino; Martin Czerny; Konstantinos P Donas; Anders Wanhainen; Sandro Lepidi Journal: Interact Cardiovasc Thorac Surg Date: 2021-05-10