Neurologic injury with TEVAR. The mechanisms of neurologic injury are multifactorial with TEVAR.

Stroke may be caused by:

1. Systemic factors such as hypotension, hypertension, and anticoagulation
2. Intracranial changes related to edema, cerebrospinal fluid drainage, or contrast/drug infusion
3. Embolization of air, atheroma, or thrombus from the device or manipulation of devices within the aortic arch
4. Interruption of forward blood flow from injury or coverage of arch vessels

Paraplegia may be caused by:

1. Systemic factors such as hypotension, drug-induced vasoconstriction, and embolization
2. Local factors, including intraspinal hematoma, injury due to spinal cord drain placement
3. Lack of blood flow caused by coverage of intercostal, lumbar, middle sacral, hypogastric, or subclavian arteries. Spinal cord damage after TEVAR may cause complete or partial neurologic deficit. The onset of symptoms can be immediate or delayed, and in some cases the deficit can improve.

Arm ischemia and vertebrobasilar ischemia with TEVAR

When the LSA origin is acutely occluded, patients may experience left arm ischemia due to inadequate collateral perfusion. Symptoms may exacerbate when the patients exercise the ipsilateral upper extremity. Flow reversal in the left vertebral artery may also occur, resulting in steal of blood from the posterior circulation. At times this can cause a fullblown vertebral steal phenomenon with vertebrobasilar ischemic symptoms manifested as syncope, diplopia, or vertigo. In contrast to stroke and paraplegia, arm and vertebrobasilar ischemia may be addressed on a more elective basis.