TEVAR Outcomes and Management

Introduction to TEVAR Complications

The American College of Cardiology recommends branch vessel revascularization or preservation before or during TEVAR to prevent devastating complications such as spinal cord injury, stroke, and visceral ischemia 1, 2

Preoperative left subclavian artery revascularization is a Class I recommendation before TEVAR when coverage is planned, to prevent spinal cord injury and reduce stroke risk, as suggested by the American Heart Association 1
Up to 40% of TEVAR cases for descending thoracic aortic aneurysms require left subclavian artery coverage, making this a common clinical scenario, according to the American College of Cardiology 1
Patients who undergo left subclavian coverage without revascularization face multiple ischemic complications, including vertebrobasilar insufficiency, left upper extremity ischemia, and compromise of existing left internal mammary artery coronary bypass grafts or dialysis access, as reported by the American College of Cardiology 1

Covering the celiac artery without confirming adequate collateral flow carries risk of fatal visceral ischemia, as warned by the American Gastroenterological Association 1
It is reasonable to confirm adequate collateralization between the celiac and superior mesenteric artery before intentional celiac coverage using CTA or angiography, as recommended by the Society of Interventional Radiology 1

Prophylactic cerebrospinal fluid drainage via lumbar drain is recommended for patients at high risk of spinal cord ischemic injury, such as those with extensive aortic coverage, prior aortic surgery, or planned left subclavian artery coverage without revascularization, as suggested by the American Association of Neurological Surgeons 2
The target CSF pressure should be maintained at <10 mmHg while optimizing mean arterial pressure to maintain adequate spinal cord perfusion pressure, as recommended by the Neurocritical Care Society 2

CT surveillance is required at 1 month and 12 months after TEVAR, then annually for life if stable, to detect endoleaks, stent graft migration, stent fracture or collapse, retrograde type A dissection, and progressive aortic dilation, as recommended by the Society for Vascular Surgery 3
Endoleak rates after TEVAR are substantial, with 11% at 30 days, 6% at 1 year, and 9% at 2 years, as reported by the Journal of Vascular Surgery 3

TEVAR is associated with reintervention rates ranging from 7% to 23%, substantially higher than open repair, as reported by the American College of Cardiology 3

Increased aortic tortuosity in the proximal landing zone significantly increases endoleak risk, particularly type III endoleaks, as warned by the Journal of the American College of Radiology 4
Bird-beak configuration is associated with higher risk of type Ia endoleak and occurs with highly angulated or curved aortic arch anatomy, as reported by the Journal of the American College of Radiology 4

When the landing zone is adjacent to or overlapping with the left subclavian artery takeoff, embolization or bypass must be considered, as recommended by the Society for Vascular Surgery 4
Assessment of iliofemoral artery diameters, calcification extent, and tortuosity is critical for TEVAR planning, as suggested by the Journal of the American College of Radiology 4

The American Heart Association recommends monitoring left upper extremity pulses and blood pressure bilaterally to detect any flow compromise in patients with patent left subclavian artery via fenestration 5, 6
The American College of Cardiology suggests that since the subclavian remains patent, major complications of coverage without revascularization, such as vertebrobasilar insufficiency, left arm ischemia, and compromise of left internal mammary artery grafts or dialysis access, can be avoided 5, 6, 7
Any new left arm symptoms, such as claudication, weakness, or coolness, warrant urgent imaging to detect potential fenestration-specific complications 5, 6
If delayed paraplegia develops despite patent subclavian fenestration, consider CSF drainage if not already in place, as recommended by the American Heart Association (Class IIb recommendation) 6