Upper Extremity Arterial Access During Endovascular Aortic Repair

Abstract

The goal of this study was to identify the incidence of complications associated with upper extremity access in patients undergoing endovascular aortic repair (EVAR) at a regional aortic center. Patients who had upper extremity access during EVAR were identified from 2013 to 2016. In-hospital and clinic records were reviewed to identify upper extremity access indications, technique, and complications. Of 359 EVARs performed from 2013 to 2016, the upper extremity was used as access 72 times for 70 EVARs. Indication for upper extremity access was mostly for branch stent or coil placement (n = 46 [64%]) and establishing a brachiofemoral access (n = 24 [33%]). Other indications included branch cannulation for localization (n = 11 [15%]) and difficult contralateral gate cannulation (n = 6 [8%]; Table). The brachial artery was used most frequently (n = 61; 33 percutaneous, 28 direct cutdown), followed by the axillary artery (n = 7; 1 percutaneous, 6 direct cutdown), with access into the pre-existing prosthetic graft or open conduit creation occurring least often (n = 4; 1 prior axillofemoral bypass, 2 concurrent carotid-subclavian bypass, 1 concurrent carotid-axillary bypass; Fig 1). Overall complication rate was 15.3% (11 of 72; Fig 2). Strokes were observed in three patients (4.2%), all of whom had a concurrent or old carotid-subclavian bypass or transposition. Local complications included seroma (axillary cutdown, n = 1), hematoma (brachial cutdown, n = 2; brachial percutaneous, n = 2), transient peripheral neuropathy (brachial cutdown, n = 1; brachial percutaneous, n = 1), and local dissection leading to pseudoaneurysm (brachial percutaneous, n = 1). Only one local complication required a secondary intervention (hematoma evacuation after brachial percutaneous access with a 5F sheath). All other patients with access complications were managed nonoperatively, with complete symptom resolution. There was no statistical difference in complications between the different access techniques or sites (P = .359). Local complications associated with upper extremity access during EVAR did not differ between access techniques. Strokes after upper extremity access occurred in patients with concomitant supra-aortic trunk reconstructions.Fig 2Complication by technique.View Large Image Figure ViewerDownload Hi-res image Download (PPT)TableIndication for upper extremity access by index case typeIndex case typeTotal cases (No.)Branch stent or coil (No.)Branch localization (No.)Brachiofemoral access (No).Contralateral cannulation (No.)Fenestrated/branched99050Parallel (chimney, snorkel)22202120Thoracic EVAR154140Infrarenal EVAR2613836 Total724611246EVAR, Endovascular aortic repair. Open table in a new tab