Perioperative Neurologic Outcomes of Right Versus Left Upper Extremity Access for Fenestrated-Branched Endovascular Aortic Repair

Abstract

Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right versus left-side UE access. During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right versus left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications. UE access was used in 355 (88%) patients. The right-side was used in 232 (65%) and the left-side in 123 (35%) patients for the treatment of 84 (24%) juxtarenal, 135 (38%) suprarenal and 148 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 348 patients (98%). In-patient or 30-day mortality was 3%. Five (1.4%) perioperative strokes occurred in patients undergoing right UE access, of which two were ischemic and three were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated to permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .17). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5 [1.4%]) and femoral access only (1 [1%]). Arm access related complications occurred in 15 (5%) patients, 11 (3.8%) on the right-side and 4 (6%) on the left-side (P = .5). Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.