Total Transfemoral Approach Is Associated With Lower Rates of Cerebrovascular Events and Improved Outcomes Compared With Upper Extremity Approach During Fenestrated-Branch Endovascular Aortic Repair

Abstract

Upper extremity (UE) access has been widely used during fenestrated-branched endovascular aortic repair (FB-EVAR) but potentially increases the risk of cerebrovascular events. Steerable sheaths have allowed more liberal use of a total transfemoral (TF) approach (Fig), but this technique may increase technical difficulty, operative time, and lower extremity ischemia. The aim of this study was to compare procedural metrics and early outcomes of FB-EVAR for complex abdominal and thoracoabdominal aortic aneurysms using either the UE or TF approach for vessel incorporation. Patients enrolled in a prospective, nonrandomized study to investigate FB-EVAR were analyzed (2013-2022). End points included procedural metrics, technical success, 30-day mortality, major adverse events (MAEs), and rates of cerebrovascular events in patients who had a UE or TF approach for renal-mesenteric vessel incorporation. A total of 541 patients (70% male; mean age 74 ± 8 years) were treated by FB-EVAR using the UE approach in 366 (68%) patients and TF access in 177 (33%) patients. A total of 2107 renal-mesenteric arteries were incorporated with a mean of 3.9 ± 0.5 vessels per patient. The TF approach was used in 8% of patients between 2013 and 2018 and progressively increased to 31% between 2018 and 2020 and 96% between 2020 and 2022 (P < .05). Both groups had similar characteristics, except for significantly (P < .05) less ASA >3 (51% vs 75%), less complex abdominal aortic aneurysms (24% vs 37%), and more thoracoabdominal aortic aneurysms (76% vs 63%) among patients who had a UE approach as compared to a TF approach, respectively. The use of the TF approach was associated with lower fluoroscopy time (P = .001), lower operative time (P < .001), similar cumulative air kerma (P = .20), and similar technical success (P = .96) as compared with the UE approach (Table). Mortality was 1% for all patients, with no difference between the groups (P = .67). Patients treated by the UE approach had significantly higher rates of MAEs (18% vs 8%, P = .006) and more cerebrovascular events (3% vs 0%, P = .035). Access complications occurred in 2% of patients, mostly related to femoral access sites, with no difference between the groups (P > .99). The total TF approach has been increasingly used during FB-EVAR and was associated with lower rates of MAEs and cerebrovascular events. There was no difference in technical success between the two approaches, but the TF approach was associated with a shorter operative time.TableDifferences in procedural metrics and outcomes between patients treated by fenestrated-branched endovascular repair using an upper extremity (UE) or total femoral (TF) approachUE (n = 366)TF (n = 175)P valueFluoroscopy time, minutes83 ± 3272 ± 39<.001Total operating time, minutes249 ± 78194 ± 71<.001Total endovascular time, minutes166 ± 63147 ± 58<.001Cumulative air kerma, mGy2 039.4 ± 1 7591 635.2 ± 1 304.2030-day mortality5 (1.4)1 (0.6).6730-day MAE67 (18)16 (9).006Acute kidney injury35 (9.6)13 (7.6).45Any cerebrovascular event10 (2.7)0 (0).035Any access complication8 (2.2)3 (1.7)>.99Any femoral access complication7 (1.9)3 (1.7)>.99Any UE access complication1 (0.3)0 (0)>.99MAE, Major adverse event.Continuous variables are presented as mean ± standard deviation, and categorical variables as number (%).Boldface P values represent significance P < .05. Open table in a new tab