Association of Upper Extremity and Neck Access With Stroke in Endovascular Aortic Repair

Abstract

Upper extremity and neck access is increasingly being used for complex endovascular aortic repairs. We sought to compare perioperative stroke and other complications of (1) arm/neck with femoral/iliac access (AN) vs femoral/iliac access alone (FI), (2) right- vs left-sided AN, and (3) arm vs neck access sites. Patients entered in the thoracic endovascular aortic repair/complex endovascular aneurysm repair registry in the Vascular Quality Initiative from 2009 to 2018 were analyzed. Patients with a missing access variable were excluded. The primary outcome was perioperative stroke. Secondary outcomes were other postoperative complications and 1-year survival. Kaplan-Meier curves and log-rank test were used for survival analysis. Of 11,774 patients, 9229 met criteria for analysis (2364 AN, 6865 FI). AN patients had a higher rate of smoking history (77.3% vs 72.8%; P < .0001) and prior cerebrovascular events (11.8% vs 9.6%; P = .004). Operative time (250 ± 123 minutes vs 155 ± 102 minutes; P < .0001), contrast material load (136 ± 77 mL vs 105 ± 67 mL; P < .0001), and estimated blood loss (250 mL vs 100 mL; P < .0001) were larger in the AN group indicating these were likely to be more complex cases. Overall, AN had a higher rate of stroke (4.2% vs 2.8%; P = .0005) than FI (Table I). There was no difference in stroke in comparing right and left AN access (4.9% vs 3.8%; P = .28; Table II). Stroke rates were similar between arm, axillary, and carotid access but were significantly higher in patients with multiple simultaneous AN access sites (3.9% vs 4.1% vs 4.4% vs 11.4%; P = .01). AN also had higher rates of puncture site hematoma, access site occlusion, arm ischemia, and in-hospital mortality (Table I). There was no difference in 1-year survival (87.6% vs 85.9%; P = .12). Upper extremity and neck access for complex aortic repairs has a higher risk of stroke compared with femoral and iliac access alone. Right-sided access does not have a higher stroke rate than left-sided access. Neck access does not have a higher stroke rate than arm access, but stroke rate is increased when multiple arm and neck sites are used.Table IPostoperative complications in arm/neck (AN) access compared with femoral/iliac (FI) accessComplicationAN access (n = 2364), No. (%)FI access (n = 6865), No. (%)P valueStroke100 (4.2)191 (2.8).0005Postoperative complications723 (30.6)1512 (22)<.0001Puncture site hematoma104 (4.4)123 (1.8)<.0001Access site occlusion29 (1.2)31 (0.5)<.0001Arm ischemia25 (1.1)34 (0.5).003In-hospital mortality338 (4.9)156 (6.6).002 Open table in a new tab Table IIPostoperative complications comparing right- and left-sided arm/neck (AN) accessComplicationRight (n = 427), No. (%)Left (n = 1826), No. (%)P valueStroke21 (4.9)60 (3.8).28Postoperative complications143 (33.5)544 (29.8).14Puncture site hematoma21 (4.9)77 (4.2).53Access site occlusion5 (1.2)24 (1.3).99Arm ischemia4 (1)21 (1.2).99 Open table in a new tab