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Title: Neurological injury associated with thoracic endovascular aortic repair
Author: Perera, Anisha Helen
ISNI:       0000 0004 8504 5549
Awarding Body: Imperial College London
Current Institution: Imperial College London
Date of Award: 2019
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Thoracic endovascular aortic repair (TEVAR) has improved patient outcomes compared to open surgery, although stroke and paraplegia remain complications. Silent cerebral infarction (SCI; imaging evidence of infarction without neurological dysfunction) has also emerged as a risk. Meta-analysis performed of SCI with seven endovascular procedures shows risk of SCI is significant, with rates of almost 70% with transcatheter aortic valve implantation and TEVAR. The neurological injury with aortic stenting study investigates transcranial Doppler-detected cerebral embolisation, SCI and neurocognitive decline following TEVAR in 52 patients. Higher rates of embolisation were detected with greater aortic atheroma and during stent-graft deployment and contrast injection. Left subclavian bypass, proximal landing zone 0 and 1 and arch hybrid procedures were identified as predictors of cerebral emboli. Cerebral infarction was detected in 25/31(81%) undergoing magnetic resonance imaging: 21 silent (68%) and four clinical strokes (13%). Neurocognitive decline was seen in 6/7 domains assessed in 15 patients with SCI, with age a significant predictor of decline. The robotic navigation study investigates cerebral embolisation during wire and catheter placement in the aortic arch and compares robotic versus manual techniques. It demonstrates robotic navigation is feasible during TEVAR, and results in significantly less cerebral embolisation compared to manual techniques. The health-related quality of life (HRQOL) study assesses HRQOL in three groups with thoracic aortic disease (TAD); patients under surveillance, post-TEVAR and prospectively undergoing TEVAR. It found surveillance may increase anxiety in older patients, and TEVAR does not appear to decrease HRQOL compared to surveillance. However, major post-operative complications and re-intervention are risks for impaired HRQOL, anxiety and depression. The vascular metabonomic profiling study was the first to perform 1H nuclear magnetic resonance analysis of cerebrospinal fluid (CSF) in TAD patients undergoing complex vascular surgery. It demonstrates inositol metabolites within CSF have the potential to be developed as biomarkers of ischaemia in TAD.
Supervisor: Gibbs, Richard ; Bicknell, Colin ; Rudarakanchana, Nung Sponsor: European Society for Vascular Surgery ; NIHR Imperial Biomedical Research Centre
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral