Invited commentary

Abstract

Mirza and colleagues present outcomes of upper extremity access (UEA) for complex aortic repair of thoracoabdominal aortic aneurysms (TAAAs).1Mirza A.K. Oderich G.S. Sandri G.A. Tenorio E.R. Davila V.J. Kärkkäinen J.M. et al.Outcomes of upper extremity access during fenestrated-branched endovascular aortic repair.J Vasc Surg. 2019; 69: 635-644Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar To date, this is by far the largest retrospective study on the topic, and the authors are to be congratulated for their results and this important effort to cast some light on a frequently neglected topic. Except for a few reports, UEA for complex aortic repair has rarely been focused on and can be controversially discussed with a diversity of approaches.2Fiorucci B. Kölbel T. Rohlffs F. Heidemann F. Debus S.E. Tsilimparis N. Right brachial access is safe for branched endovascular aneurysm repair in complex aortic disease.J Vasc Surg. 2017; 66: 360-366Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 3Knowles M. Nation D.A. Timaran D.E. Gomez L.F. Baig M.S. Valentine R.J. et al.Upper extremity access for fenestrated endovascular aortic aneurysm repair is not associated with increased morbidity.J Vasc Surg. 2015; 61: 80-87Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The complication rate for UEA in the presented large study from a center of excellence is exceptionally low. However, the majority are strokes, and real-world data would presumably show a significantly higher rate of serious neurologic complications. Operator-reported neurologic outcomes without examination by a neurologist and diffusion-weighted magnetic resonance imaging have a tendency to underestimate the issue. Therefore, reported outcomes, as the authors mention, do not take into account silent brain injury, which is a frequent magnetic resonance finding in thoracic endovascular aortic repair and a growing concern because of induced neurocognitive decline.4Perera A.H. Rudarakanchana N. Monzon L. Bicknell C.D. Modarai B. Kirmi O. et al.Cerebral embolization, silent cerebral infarction and neurocognitive decline after thoracic endovascular aortic repair.Br J Surg. 2018; 105: 366-378Crossref PubMed Scopus (39) Google Scholar The superb illustrations in the article provide excellent visualization of the authors' preferred repair technique for dissected brachial arteries using xenogenic material in one of eight patients with UEA. Whereas the additional time required for UEA closure and patch angioplasty may prolong some of the procedures, reduced catheterization times for the target vessels seem to justify the effort. The absence of secondary procedures needed is an impressive result supporting the group's strategy of open UEA and a low threshold for patch angioplasty. In a significant proportion of complex endovascular repairs, UEA is optional, namely, when solely fenestrations are used to connect target vessels to the main graft (fenestrated endovascular aneurysm repair). Fenestrations can be connected from femoral access, although UEA may provide advantages when target vessels are caudally oriented. Differences in utilization of UEA are mostly due to tradition and surgical teaching. Mirza et al now give us valid information at what cost this frequently used optional step comes in endovascular TAAA repair. For endografts with directional branches (branched endovascular aneurysm repair), such as the t-Branch (Cook Medical, Bloomington, Ind), UEA has been judged unavoidable, and discussions have focused on the preferred side of UEA.1Mirza A.K. Oderich G.S. Sandri G.A. Tenorio E.R. Davila V.J. Kärkkäinen J.M. et al.Outcomes of upper extremity access during fenestrated-branched endovascular aortic repair.J Vasc Surg. 2019; 69: 635-644Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 2Fiorucci B. Kölbel T. Rohlffs F. Heidemann F. Debus S.E. Tsilimparis N. Right brachial access is safe for branched endovascular aneurysm repair in complex aortic disease.J Vasc Surg. 2017; 66: 360-366Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar However, recent experience has demonstrated that with the use of steerable sheaths, even four-branched repairs in challenging anatomy of TAAA could be performed from femoral access alone (Fig). Whereas some operators prefer left-sided UEA with the argument of reduced manipulation in the aortic arch and assumed reduced stroke risk, other operators prefer right-sided UEA because of the assumed better workflow and lower radiation dose. The authors conclude that left-sided UEA is associated with a lower stroke rate in their study but acknowledge a significant selection bias and describe a trend in their practice toward right-sided UEA for better workflow and lower radiation dose. Convincing evidence about the better access side is still lacking, and the authors' conclusion should be taken with caution as data do not support a recommendation for left-sided access in general. Outcomes of upper extremity access during fenestrated-branched endovascular aortic repairJournal of Vascular SurgeryVol. 69Issue 3PreviewUpper extremity (UE) access is frequently used during fenestrated-branched endovascular aortic repair (F-BEVAR) to facilitate catheterization of downgoing vessels. Limitations include risk of cerebral embolization and of UE arterial or peripheral nerve injury. The aim of this study was to assess outcomes of F-BEVAR using UE access. Full-Text PDF Open Archive