Quantification of aortic shagginess as a predictive factor of perioperative stroke and long-term prognosis after endovascular treatment of aortic arch disease

Abstract Objective Thoracic endovascular aortic repair (TEVAR) with supra-aortic debranching has recently been introduced as a treatment option for aortic arch disease. Although less invasive than open repair, TEVAR is associated with a risk of perioperative embolic stroke due to dislodgment of atherosclerotic plaque debris, especially in individuals with atheromatous degeneration of the aortic lumen. It is difficult to determine atheroma vulnerability, and there is no current method for predicting the risk of atheroembolism. This study aimed to evaluate the usefulness of our method of quantifying the shagginess of the aorta in predicting the short- and long-term outcomes of TEVAR involving the aortic arch. Methods The study included 77 patients (63 men and 14 women; median age, 78 years) who underwent elective TEVAR for aortic arch disease between 2009 and 2013. The proximal landing of the stent graft was in zone 0 in 22 patients, zone 1 in 23 patients, and zone 2 in 32 patients. The shagginess score of each patient was calculated from preoperative contrast-enhanced computed tomography images of the aorta using a workstation. The relationships between preoperative factors, including the shagginess score, and the development of perioperative stroke and late survival were analyzed retrospectively. Results Perioperative ischemic stroke occurred in nine patients, and no patient died within 30 days postoperatively. Univariate analyses demonstrated that the shagginess score was significantly higher in patients who developed postoperative cerebral infarction than in those who did not ( P  = .04). The median follow-up period was 1570 days, and the 5-year cumulative survival rate was 69.2%. Cox proportional hazards analyses showed that comorbid hypercholesterolemia was significantly associated with all-cause mortality (hazard ratio [HR], 3.22; 95% confidence interval [CI], 1.24-8.32; P  = .02). As for cardiovascular mortality, the shagginess score was a significant predictive factor (HR, 1.84; 95% CI, 1.04-3.28; P  = .04), whereas statin use was significantly protective (HR, 0.11; 95% CI, 0.02-0.66; P  = .02). Conclusions The shagginess score may be a useful predictive index of perioperative ischemic stroke as well as a prognostic factor of long-term outcomes after TEVAR with aortic arch involvement.