Access-related Complications Research Articles

Males and females have similar mortality after thoracic endovascular aortic repair for blunt thoracic aortic injury

ObjectivePrior literature has demonstrated worse outcomes for female patients after abdominal aortic aneurysm repair. Also, prior studies in the context of thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysms have reported conflicting results regarding sex-related outcomes. Because the influence of sex on the outcomes after TEVAR for blunt thoracic aortic injuries (BTAIs) remains understudied, we evaluated the association between sex and outcomes after TEVAR for BTAI. MethodsWe identified patients who had undergone TEVAR for BTAIs in the Vascular Quality Initiative registry from 2013 to 2022 and included those who had undergone TEVAR within zones 2 to 5 of the thoracic aorta. Patients with missing information regarding the aortic injury grade (Society for Vascular Surgery aortic injury grading system) were excluded. We performed multivariable logistic regression and Cox regression to determine the influence of sex on the perioperative outcomes and long-term mortality, respectively. ResultsWe identified 1311 patients, of whom 27% were female. The female patients were significantly older (female, 47 years [interquartile range (IQR), 30-63 years]; male, 38 years [IQR, 28-55 years]; P < .001) with higher rates of comorbidities. Although the female patients had had higher Glasgow coma scale scores (median, 15 [IQR, 11-15]; vs 14 [IQR, 8-15]; P = .028), no differences were found in the aortic injury grade or other coexisting traumatic injuries between the sexes. Apart from the longer procedure duration for the female patients (median, 79 minutes [IQR, 52-119 minutes]; vs 69 minutes [IQR, 48-106 minutes]; P = .008), the procedural characteristics were comparable. After adjustment, no significant association was found between female sex and perioperative mortality (7.1% vs 8.1%; odds ratio, 0.76; 95% confidence interval [CI], 0.43-1.3; P = .34). The male and female patients had had comparable rates of postoperative complications (26% vs 29%; odds ratio, 0.89; 95% CI: 0.52-1.5]; P = .26) including access-related complications (0.5% vs 0.8%; P=.83). However, females had a significantly higher risk for reintervention during the index admission (odds ratio, 2.5; 95% CI, 1.1-5.5; P = .024). No significant difference was found between the male and female patients with respect to 5-year mortality (hazard ratio, 0.87; 95% CI, 0.57-1.35; P = .50). ConclusionsUnlike the sex-based outcome disparities observed after thoracic aortic aneurysm repair, we found no significant association between sex and perioperative outcomes or long-term mortality after TEVAR for BTAIs. This contrast in the sex-related outcomes after other vascular pathologies might be explained by differences in the pathology, demographics, and anatomic factors in these patients.

Early Femoral Access by Acute Care Surgeons: A Multidisciplinary Approach to Prevent Maternal Exsanguination in Placenta Accreta Spectrum.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) use has expanded to the obstetric condition of placenta accreta spectrum (PAS). Early reports of REBOA for PAS describe prophylactic catheter deployment. We developed a multidisciplinary approach to PAS, with early femoral artery access and selective REBOA deployment. We compared morbidity, mortality, and blood loss before and after implementation of our multidisciplinary protocol for PAS. Prior to, femoral access was obtained only emergently, and maternal death occurred in 2/3 cases (66%). Following protocol implementation, there was one maternal death (6%). There were no access-related complications. We have not yet needed to deploy the REBOA during PAS cases. In contrast to urgent hemorrhage control or prophylactic REBOA deployment, routine early femoral arterial access and selective REBOA deployment as part of a multidisciplinary team approach is a novel strategy for managing PAS. Our experience suggests most PAS cases do not require prophylactic REBOA deployment.

931 EVALUATION OF IATROGENIC ATRIAL SEPTAL DEFECT CLOSURE AFTER TEER

Abstract Iatrogenic atrial septal defect (iASD) represents one of the main access-related cardiac complications after trancatheter edge to edge (TEER) mitral valve repair with Mitraclip system. Transesophageal echocardiography (TEE) guiding supports a controlled and safe transseptal puncture. The rate of persistent iASD is 57, 50, and 25% after 1, 6, and 12 months post procedure. An elevated left atrial pressure after clip positioning correlates with iASD persistence. Its clinical impact is controversially discussed: Post-TEER iASD has been associated with right heart volume overload, as well as increased rates of heart failure (HF) hospitalization and death in some studies. In contrast, other studies have shown an association between post-TEER iASD and improved hemodynamics. In theory, creation of an iASD can decompress an overloaded left atrium, mitigating heart failure. Some studies have demonstrated that iASD closure can reduce significantly both right and left heart failure symptoms. We did a retrospective study enrolling in the period 2012-2022 twenty-one patients with severe mitral regurgitation treated with TEER. Our aim was to evaluate the clinical outcomes (symptoms, signs of heart failure, NYHA functional class) and echocardiographic parameters (PAPs, TAPSE, Right Atrium Area) in two group of patients: Group A underwent iASD closure during the TEER and Group B after one month following the TEER. At 1-month follow-up all patients with repaired mitral regurgitation showed an improvement in the NYHA class (from IV-III to II-I) and no need for re-hospitalization with no significant differences between two groups. In the Group A there were two adverse events during the recovery (2 major bleeding); while there were no adverse events in patients undergoing iASD closure after wise. There was 1 death in the first month after the procedure in group A, while there wasn't any in group B. Statistical analysis showed no significant differences in terms of NYHA class improvement in the two groups (p=0.91). We observed a greater reduction in PAPs in patients going to encounter intraprocedural DIA closure which was found to be statistically significant (p=0.01). Regarding TAPSE, there was a difference in terms of improvement which was found to be greater in the group A. However, this finding was not found to be statistically significant. We also assessed the right atrium area: in group A, we registered a mean preprocedural value of 28 cmq and a postprocedural value of 34 cmq; in group B the values were 20 cmq and 24 cmq, respectively, with a nonstatistically significant difference in terms of atrial enlargement post device placement. In conclusion, we can assume that the improvements in symptomatology are not closely related to iASD closure. However, it must considered that patients in group A had more unfavorable echocardiographic values before the procedure than those in group B, and probably, if we had not closed the iASD immediately during the procedure, these patients would have had worse symptomatology. Therefore, targeted patient selection is essential.

Short-term and mid-term effects of thoracoscopic repair of esophageal atresia: No anastomotic leaks or conversions to open technique.

The frequency rate of esophageal anastomosis leaks after thoracoscopic correction of esophageal atresia (EA) in the current literature is reported as 5.6%-24.7% and a conversion rate of 2%-53%. The objective of this retrospective study was to examine the characteristics of EA and analysis of the safety and efficacy of EA repair with the use of the thoracoscopic approach in a single academic center, as well as risk factors analysis in the context of short-term and mid-term follow-up status. A retrospective analysis of the management of all consecutive newborns affected by EA hospitalized in our department over a period between 2013 and 2022, including preoperative, perioperative, and postoperative management, together with the outcome, complications and long-term follow-up status was performed. A total of 38 patients with a median birth weight of 2,570 g (range; 1,020-3,880) were treated over the study period, including 30/38 (78.9%) with additional congenital anomalies. Overall, 30 patients underwent primary anastomosis of the esophagus and eight underwent a multistaged procedure, with or without an initial ligation of the tracheoesophageal fistula and delayed primary anastomosis. Overall survival for all patients was 0.894 ± 0.050, with a median follow-up of 4.5 years. We noted neither anastomotic leaks nor conversions to open technique in our cohort. Implementation of vancomycin prophylaxis was successful in preventing postoperative central venous access-related infectious complications. At the end of the follow-up, 85% of patients have a Lansky performance score ≥80. Risk factors analysis for length of hospitalization, overall survival, Lansky performance status, and neurological impairment were analyzed. In conclusion, we have found that the outcome of thoracoscopic repair of EA in terms of surgery-dependent morbidity (anastomosis leakage, conversion rate to open surgery), provides benefit to those previously reported in the literature, regardless of the prognostic criteria of the classification system.

Abstract 14277: Comparison of Three Vascular Closure Devices for Vascular Access Closure After Cardiac Electrophysiology Procedures

Introduction: Vascular closure devices are commonly used for EP procedures to achieve rapid hemostasis. Different devices using different mechanisms of action are available, but the potential contribution of each type to the incidence of vascular complications is not clear. Methods: This is a single center, prospective study in which 138 contemporaneous patients undergoing EP procedures were categorized according to the vascular closure device type used: Vascade (collagen plug, n=57), Perclose (suture, n=41), and SiteSeal (external compression, n=40). The primary endpoint was access-related major vascular complications. Secondary endpoints included time to ambulation and delayed access-site bleeding requiring additional manual pressure. Results Mean age and BMI 68±11 years and 29.7±6.2 Kg/m 2 , 46 (33%) were female, 121 (88%) were on uninterrupted antithrombotic therapy (71% OAC, 14% OAC/APLT, 3% APLT). Femoral vein access was obtained in all, bilaterally in 113 (82%), with a mean of 3±1 access sites per patient and a sheath size ranging from 6- to 23-Fr. Femoral arterial access was obtained in 14 (10%), once per patient, with a sheath size ranging from 5- to 8-Fr. There were no arterial access complications. On the venous side, hematomas occurred in 3/57 (5%) of the Vascade group, 1/41 (2%) of the Perclose group, and 0/40 (0%) of the SiteSeal group (p=ns for all comparisons). Delayed access-site bleeding occurred in 5/57 (9%) of the Vascade group, 5/41 (12%) of the Perclose group, and 7/40 (18%) of the SiteSeal group (p=ns for all comparisons). Time to ambulation was comparable between groups (minutes: 139±51 Vascade, 137±34 Perclose, 123±11 SiteSeal, p=ns). Conclusion Vascade, Perclose, and SiteSeal are comparable in term of vascular complications and time to ambulation for patients undergoing EP procedures.

Dual ProGlide versus ProGlide and FemoSeal for vascular access haemostasis after transcatheter aortic valve implantation.

Large-bore arteriotomy for transcatheter aortic valve implantation (TAVI) requires percutaneous vascular closure devices, but real-world data comparing different closure strategies are limited. We sought to compare a dual ProGlide strategy vs a combination of one ProGlide and one FemoSeal for vascular closure after TAVI. We retrospectively analysed 874 propensity score-matched patients undergoing TAVI at the Munich University Hospital from August 2018 to October 2020. From August 2018 to August 2019, a dual ProGlide strategy was used for vascular closure. From October 2019 to October 2020, a combination of one ProGlide and one FemoSeal was used. The primary endpoint was defined as access-related major vascular complications or bleeding ≥Type 2 according to Valve Academic Research Consortium 3 criteria. Patients in the dual ProGlide group (n=437) had a higher incidence of the primary endpoint than patients treated with one ProGlide and one FemoSeal (n=437; 11.4% vs 3.0%; p<0.001). Furthermore, they had a higher rate of closure device failure (2.7% vs 0.9%; p=0.044) and more often required unplanned surgery or endovascular treatment (3.9% vs 0.9%; p=0.004). The incidence of death did not differ significantly between groups (3.4% vs 1.6%; p=0.08). A combined ProGlide and FemoSeal strategy might have the potential to reduce access-related vascular complications following TAVI.

Use of reverse angle guide catheter with trans-radial approach in patients undergoing middle meningeal artery embolization.

Trans-radial access (TRA) for MMA embolization has grown due to lower access site complications and greater patient satisfaction. Here, we describe the feasibility of utilizing a 6F Envoy Simmons 2 (6F-SIM2) as a guide catheter with TRA and compare outcomes with trans-femoral approach (TFA) in a single center case series. We performed a retrospective review of patients who underwent MMA embolization for management of chronic subdural hematoma (cSDH). TRA was performed by utilizing a combination of 6F 90cm Envoy (Codman & Shurtleff, Inc., Rayham, MA) Simmons 2 guide catheter and 5F 125cm Sofia (Microvention, Aliso Viejo, CA) intermediate catheter. Outcomes measured are Modified Rankin Score (mRS) at 90 days, inpatient mortality, post-embolization recurrence, fluoroscopy time and radiation exposure. A total of 71 patients underwent 97 MMA embolization overall with 65 (67%) in trans-femoral access group, 11 (11.3%) in trans-radial access without use of Simmons 2 Guide catheter group and 21 (21.6%) in trans-radial access with use of Simmons 2 Guide catheter group. There were no direct access-related complications in either group. One patient had thromboembolic stroke in trans-femoral group. There was no difference in average procedure-related total fluro time or radiation dose among all three groups. Trans-radial approach using 6F-SIM2 guide catheter coupled with 5F Sofia intermediate catheter is safe and effective. It provides an alternative approach to access distal branches of bilateral anterior circulation in elderly patients with difficult anatomy undergoing MMA embolization.

Comparison of upper extremity and transfemoral access for fenestrated-branched endovascular aortic repair

ObjectiveThe use of upper extremity (UE) access is an accepted and often implemented approach for fenestrated/branched endovascular aortic aneurysm repair (F-BEVAR). The advent of steerable sheaths has enabled the performance of F-BEVAR using a total transfemoral (TF) approach without UE access, potentially decreasing the risks of cerebral embolic events. The purpose of the present study was to assess the outcomes of F-BEVAR using UE vs TF access. MethodsProspectively collected data from nine physician-sponsored investigational device exemption studies at U.S. centers were analyzed using a standardized database. All patients were treated for complex abdominal aortic aneurysms (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs) using industry-manufactured fenestrated and branched stent grafts between 2005 and 2020. The outcomes were compared between patients who had undergone UE vs total TF access. The primary composite outcome was stroke or transient ischemia attack (TIA) and 30-day or in-patient mortality during the perioperative period. The secondary outcomes included technical success, local access-related complications, and perioperative mortality. ResultsAmong 1681 patients (71% men; mean age, 73.43 ± 7.8 years) who had undergone F-BEVAR, 502 had had CAAAs (30%), 535 had had extent IV TAAAs (32%), and 644 had had extent I to III TAAAs (38%). UE access was used for 1103 patients (67%). The right side was used for 395 patients (24%) and the left side for 705 patients (42%). UE access was preferentially used for TAAAs (74% vs 47%; P < .001). In contrast, TF access was used more frequently for CAAAs (53% vs 26%; P < .01). A total of 38 perioperative cerebrovascular events (2.5%), including 32 strokes (1.9%) and 6 TIAs (0.4%), had occurred. Perioperative cerebrovascular events had occurred more frequently with UE access than with TF access (2.8% vs 1.2%; P = .036). An individual component analysis of the primary composite outcome revealed a trend for more frequent strokes (2.3% vs 1.2%; P = .13) and TIAs (0.54% vs 0%; P = .10) in the UE access group. On multivariable analysis, total TF access was associated with a 60% reduction in the frequency of perioperative cerebrovascular events (odds ratio, 0.39; P = .029). No significant differences were observed between UE and TF access in the technical success rate (96.5% vs 96.8%; P = .72), perioperative mortality (2.9% vs 2.6%; P = .72), or local access-related complications (6.5% vs 5.5%; P = .43). ConclusionsIn the present large, multicenter, retrospective analysis of prospectively collected data, a total TF approach for F-BEVAR was associated with a lower rate of perioperative cerebrovascular events compared with UE access. Although the cerebrovascular event rate was low with UE access, the TF approach offered a lower risk of stroke and TIA. UE access will continue to play a role for appropriately selected patients requiring more complex repairs with anatomy not amenable to the TF approach.

The optical puncture combined standard percutaneous nephrolithotomy versus the conventional percutaneous nephrolithotomy for kidney stones without hydronephrosis: a comparative study.

To compare the efficacy and safety of optical puncture combined with standard percutaneous nephrolithotomy (PNL) and conventional PNL for the treatment of patients with complex kidney stones with no or mild hydronephrosis. We retrospectively reviewed the data on patients with complex kidney stones treated by PNL in our hospital between May 2019 and February 2022. The patients were divided into two groups according to the puncture techniques applied. In the optical puncture group, 40 patients underwent optical puncture combined with standard PNL. In the control group, 44 patients underwent conventional standard PNL. The demographics and perioperative parameters were analyzed between the two groups. There mean puncture durations were significantly shorter in the optical puncture group (8.2 ± 2.16min) than in the control group (14.0 ± 6.76min) (P = 0.001). The re-puncture rates were lower in the optical puncture group (5%) compared with the control group (20.5%) (P = 0.036). The access loss rate in the optical puncture group (2.5%) was significantly lower than that in the control group (11.36%) (P = 0.037). The mean hemoglobin drop was significantly lower in the optical puncture group (12.6 ± 5.36g/L) compared with the control group (22.3 ± 11.61g/L) (P = 0.001). The mean hospital stay was significantly shorter in the optical puncture group (3.9 ± 1.65d) compared with the control group (5.1 ± 2.10d) (P = 0.042). The primary stone-free rate in the optical puncture group (87.5%) was similar to the control group (84.1%) (P = 0.656). The overall stone-free rates were 95% in the optical puncture group and 93.2% in the control group (P = 0.725). There were significantly more patients in the control group (18.2%) who suffered collecting system injury than in the optical puncture group (2.5%) (P = 0.020). There were no significant differences between the two groups in terms of blood transfusion (P = 0.292), fever (P = 0.696) and urosepsis (P = 0.946). We demonstrated that optical puncture combined with standard PNL could increase the precision and success rate of puncture, and reduce the access-related complications in patients with complex kidney stones without hydronephrosis.

Incidence of vascular complications for electrophysiology procedures in the ultrasound era: a single-centre experience over 10,000 procedures in the long term.

Ultrasound (US) is being increasingly used to guide vascular access for electrophysiology (EP) procedures in many centres. Nonetheless, the incidence and predictors of vascular complications in the US era are limited. In this study, we describe our experience of vascular access-related complications associated with EP procedures which were performed with the routine use of US-guided vascular access. A total of 10,158 consecutive EP procedures in 8361 patients performed from April 2014 (when our centre moved to a policy of routine US-guided vascular access for EP procedures) to March 2022 were included. The outcome of interest was any vascular access-related complication that occurred within 7days of the procedure; these were classified as severe if surgical intervention and/or blood transfusion was required, major if non-surgical intervention or delayed hospital discharge was required, or minor if it did not fulfil the criteria for severe or major. During the study period, 2 (0.02%) severe vascular complications occurred, including 1 pseudo-aneurysm requiring surgery and 1 retroperitoneal haemorrhage requiring blood transfusion. Nine (0.09%) major complications occurred, including 6 hematomas managed by compression devices, 1 type B aortic dissection, 1 AV fistula managed conservatively and 1 haematoma managed conservatively but delayed hospital discharge. Eighteen (0.18%) minor haematomas were seen that did not require any intervention or delayed hospital discharge. On multivariable analysis, female sex [OR (95% CI): 2.5 (1.2, 5.4)] and use of an arterial access [OR (95% CI): 19.3 (7.1, 52.3)] were seen to be independent predictors of the 29 vascular complications. With the use of US-guided vascular access in EP procedures, major vascular complications are exceedingly rare, particularly those needing surgical intervention. Our results provide additional evidence for scientific guidelines to support US use.

Therapeutic plasma exchange for myasthenia gravis, Guillain-Barre syndrome and other immune-mediated neurological diseases, over a 40-year experience

ABSTRACT Background Therapeutic plasma exchange (TPE) was first used in neurology in the 1980s for myasthenia gravis (MG) and Guillain-Barré syndrome (GBS). Indications have since grown. Fear of complications with this treatment modality limit its use. Research design & methods A study of patients undergoing TPE for neurological diseases (1981-2020) in a university hospital in Madrid, Spain. Clinical indications, complications, procedure number, apheresis technique and replacement fluids were prospectively recorded and retrospectively analysed. Historical trends were studied. Results Over 40 years, 159 patients (48.69±18.15 years, 54.3% females) underwent TPE using central-venous catheter and replacement fluid albumin. We performed 1207 procedures over 189 cycles (6.4±3.8 procedures/cycle). Most patients underwent TPE for category I-II indications, mainly GBS and MG (77.7%). Complication rate was low (3.9% procedures), mostly hypotensive/vasovagal reactions (55.3%) and vascular access-related complications (38.3%). Most were mild-moderate (92.9%), permitting TPE completion, and somewhat more frequent during the first procedure (38.3%) and after periods of little TPE use. GBS patients were more prone to complications than MG patients (6.5% vs. 1.2%,p<0.001) mainly hypotensive/vasovagal reactions (3.7% vs. 1.0%,p=0.008). Conclusions TPE is well-tolerated with low complication rate (<4% procedures), mainly hypotensive/vasovagal reactions. Patients with GBS seem more prone to them than MG patients. Acquaintance with this technique seems necessary.

Comparison of open femoral exposure and percutaneous access in endovascular reconstruction of the thoracic aorta: a two-center retrospective study

Aim. To analyze the efficacy and safety of the percutaneous transfemoral puncture technique for TEVAR (thoracis endovascular aortic repair).Material and methods. The retrospective study included 89 patients with aortic pathologies, for whom endovascular repair was performed: 51 patients (57%) with aortic dissection (type I DeBakey — 30 cases (58,8%) and type III — 21 (41,2%)), 38 (43%) patients with aortic aneurism. 82% of patients were male, the median age was 57 years (minimum age 17 years, maximum age 75 years). All patients were divided into two groups: in the first group (48 patients) endovascular aortic repair was performed under endotracheal anesthesia with open femoral exposure of the common femoral artery (CFA), in the second group (41 patients) — by percutaneous puncture method under local anesthesia. Technical and clinical aspects of procedures were analyzed.Results. Technical success of endovascular repair was achieved in 100% cases in both groups. The duration of the operation in the group with percutaneous access was statically significantly shorter (120 (94-150) minutes vs 87(60-120) minutes, p=0,001). Also, the time spent by patients in the intensive care unit and the period of hospitalization (18 (14-22) hours versus 1 (0-3) hours, p=0,001; 5 (4-6) days versus 4 (3-5) days, p=0,03) was shorter. In the open access group 2 (4,2%) patients developed access-related complications - acute thrombosis of the common femoral artery and hematoma of the postoperative wound, which required additional surgical aid - thrombectomy from the CFA, the second patient had evacuation of the hematoma of the postoperative wound. Cite-related complications in the second group were not observed. No major complications including neurological deficits and hospital mortality were observed in both groups.Conclusions. Thoracic endovascular aortic repair (TEVAR) using percutaneous access under local anesthesia in stable patients has proven to be safe and effective. The operation time is significantly reduced and this approach in most cases eliminates the need for the patient to stay in the intensive care unit in the early postoperative period. Possibility of early mobilization of the patient appears with reducing of the duration of hospitalization.

REBOA and the Open Abdomen

Background: Uncontrolled hemorrhage is a significant cause of death worldwide. Rapid bleeding control is a major life saving goal. Resuscitative endovascular balloon of the aorta (REBOA) is a minimally invasive technique that temporarily occludes the aorta and achieves hemorrhage control.Methods: We present a case series of patients that underwent emergent laparotomy due hemorrhagic shock and were stabilized intraoperatively using REBOA.Results: Between December 2018 and September 2021, intraoperative REBOA was inserted in six patients. Etiologies included two postpartum hemorrhages, two gastrointestinal bleeds and two trauma cases. REBOA was positioned and inflated in the descending aorta (n = 3) and infrarenal aorta (n = 3). In all cases, REBOA resulted in immediate stabilization of blood pressure, enabling definitive treatment. Partial inflation was performed in all cases after initial stabilization. There was one minor access related complication, treated successfully. There was no mortality at 6 months follow up.Conclusions: REBOA is another important resuscitative tool to be considered, also in the open abdomen. It allowsfor hemodynamic stabilization and enables definitive surgical repair of other major injuries.

Hemodialysis Access Outcome in Elderly Population and its Association with Mortality

Objective: to determine the outcome of arteriovenous fistula in the elderly compared to the younger age group and its association with mortality so that the best approach to hemodialysis access can be defined.&#x0D; Study Design: Prospective longitudinal study&#x0D; Place and Duration of Study: Department of Vascular Surgery, CMH, Lahore Pakistan, from Jan 2020 to Aug 2021.&#x0D; Methodology: All the Patients who presented to access the Surgical Clinic were categorized into three groups according to their age. Outcome variables like fistula maturation, complications and mortality were compared according to age groups.&#x0D; Result: A total of 184 patients were recruited. We found that in the age group &gt;70 years, there was male predominance (12, 54.5%), three-quarters of them were on hemodialysis at the time of access surgery, only half of them were functional at one year of follow-up, and 6 (27.3%) were not alive at the time of contact. In addition, the pseudo aneurysm was the most common complication in this group, which was the most dreadful of all access-related complications and further put the already frail at risk.&#x0D; Conclusion: No single optimal approach can be expected to meet the needs of all, and an extensive patient-centred case-based discussion is required for each patient in the hope that optimal dialysis access can be created. Age cannot be defined as an independent risk factor for access creation.

The Impact of Large-Bore Access Complications on Outcomes of Patients Undergoing Thoracic Endovascular Aortic Repair

The Impact of Large-Bore Access Complications on Outcomes of Patients Undergoing Thoracic Endovascular Aortic Repair

The effect of percutaneouS vs. cutdoWn accEss in patients after Endovascular aorTic repair (SWEET): Study protocol for a single-blind, single-center, randomized controlled trial

BackgroundEndovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have become the first-line treatment for aortic diseases, but current evidence is uncertain regarding whether a percutaneous approach has better outcomes than cutdown access, especially for patient-centered outcomes (PCOs). This study is designed to compare these outcomes of percutaneous access vs. cutdown access after endovascular aortic repair.MethodThe SWEET study is a randomized, controlled, single-blind, single-center non-inferiority trial with two parallel groups in two cohorts respectively. After eligibility screening, subjects who meet the inclusion criteria will be divided into Cohort EVAR or Cohort TEVAR according to clinic interviews. And then participants in two cohorts will be randomly allocated to either intervention groups receiving percutaneous access endovascular repair or controlled groups receiving cutdown access endovascular repair separately. Primary clinician-reported outcome (ClinRO) is access-related complication, and primary patient-centered outcome (PCO) is time back to normal life. Follow-up will be conducted at 2 weeks, 1 month, 3 months postoperatively.DiscussionThe choice of either percutaneous or cutdown access may not greatly affect the success of EVAR or TEVAR procedures, but can influence the quality of life and patient-centered experience. Given the very low evidence for ClinROs and few data for PCOs, comparison of the percutaneous vs. cutdown access EVAR and TEVAR is essential for both patient-centered care and clinical decision making in endovascular aortic repair.Trial registrationChinese Clinical Trial Registry ChiCTR2100053161 (registered on 13th November, 2021).

Initial experiences with percutaneous endovascular aortic reconstruction

Introduction: Percutaneous aortic reconstruction is another milestone in aortic surgery. The evolution of vascular closure devices played a key role by enabling arterial closure after large -bore endovascular devices without the need of arterial cut -down.Objective: Our objective was to determine technical success of percutaneous endovascular aortic repair and to report our initial experience using this technique in a Hungarian cohort.Method: Between 15 October 2020 and 21 March 2021, patients who underwent endovascular aortic reconstruction were prospectively and consecutively collected. Patients who were deemed suitable for common femoral artery per cutaneous access were enrolled to the study. Technical success, access -site complications and risk factors were ana- lyzed.Results: A total of 43 patients underwent endovascular aortic reconstruction during the study period, of whom 38 were deemed feasible for percutaneous repair. Dominantly infrarenal aortic aneurysms were treated (n = 26, 68.4%). After ultrasound -guided access, suture -mediated devices were used 2 (1-4) per artery (median, min-max) for clo- sure. Technical success was reported in 37 out of 38 cases (97.4%). Access site complication was reported in 3 (7.9%) cases. The mean (+/- SD) in -hospital stay was 4.9 (+/- 1.7) days. Out of the 3 cases, 1 required intraoperative femoral cut-down. Sheath-size larger than 18 Fr (1.26, 0.09-17.75, 0.862) and body mass index (1.17, 0.923-1.5, 0.19) were positively associated with access site complication but no significant correlation was reported (OR, 95% CI, p- value). However, in patients with larger than 30 kg/m2 body mass index (n = 12), access-related complication was significantly higher than in smaller patients (p = 0.008).Conclusion: Percutaneous endovascular aortic repair is a promising and safe option that has a high technical success rate in patients deemed eligible for common femoral artery access.

Outcomes of Upper Extremity Access with Surgical Exposure of the Axillary Artery in Fenestrated and Branched Endovascular Aneurysm Repair

This study aims to assess the safety of upper extremity access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurological and local complications as well as re-interventions associated with the technique. All patients undergoing an F/B-EVAR procedure with surgical exposure of the axillary artery between January 2010 and March 2020 were included in this retrospective single centre study. Endpoints were neurological and access related complications and re-interventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury, and arterial complications. 264 patients (192 male, mean age 70 ± 7 years) were included. Upper extremity access was performed over the left axillary artery in 257 (97%) of the cases, and over the right axillary artery in the remaining seven cases. Six (2.2%) patients had early complications related to the arterial access: four with post-operative bleeding and two with acute arm ischaemia. Two patients with post-operative bleeding and both patients with ischaemic complications required re-intervention. One of these patients with arm ischaemia died five weeks after the re-intervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented with transient arm paraesthesia or sensory neurological deficit post-operatively. The symptoms completely recovered in all cases with no residual deficits. Peri-operative ischaemic stroke occurred in three (1%) patients (two minor, one major). No other access related complications were recorded during follow up in any of the patients with no cases of late stenosis/occlusion. Upper extremity access with surgical exposure of the axillary artery is a safe method for antegrade catheterisation of fenestrations and branches in complex endovascular aneurysm repair.

Total Arch Thoracic Endovascular Aortic Repair Using Double Fenestrated Physician-Modified Stent-Grafts: 100 Patients

Objective: The aim was to evaluate early and medium-term outcomes of double fenestrated physician-modified endovascular grafts for total endovascular aortic arch repair. Methods: This single-center retrospective analysis of prospectively-collected data included 100 patients, from January 2017 to December 2021, undergoing thoracic endovascular aortic repair (TEVAR) for zone 0. The fenestrations were a proximal larger fenestration that incorporated the brach2iocephalic trunk and left common carotid artery and a distal smaller fenestration for the left subclavian artery (LSA). Only the LSA fenestration was stented. Results: The median duration for stent-graft modification was 23±6 minutes. Of the 100 patients, 70 were men. The mean patient age was 70±10.5 years. Indications for treatment included degenerative aortic arch aneurysm (n=32), dissecting aortic arch aneurysm after type A dissections (n=23) and (n=19) after type B dissections, acute complicated type B dissection (n=16), and other pathologies (n=10). Technical success rate was 97%. The 30 day mortality was 2% (n=2). Four patients (4%) had minor stroke with full recovery. One patient (1%) had a type IA endoleak, 1 patient (1%) had a type IB endoleak, and 2 patients (2%) have a type II endoleak from the LSA. Eight patients (8%) required reintervention: 1 type IA endoleak, 1 type IB endoleak, 1 retrograde type A dissection, and 5 because of access-related complications. During a mean follow-up of 24±7.2 months, there were no aortic rupture, paraplegia, and all supra-aortic trunks were patent. Conclusions: Double homemade fenestrated TEVAR is both feasible and effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The long-term durability will need to be assessed in studies with long-term follow-up. Clinical Impact Double homemade fenestrated TEVAR is effective for total endovascular aortic arch repair avoiding the need for anatomical and extra-anatomical surgical revascularization. The standout feature of this double fenestrated device is its simple handling during operation with the proximal fenestrations being directed to the orifices of the BT and LCCA automatically when the LSA fenestration is catheterized and secured by covered stent placement. The deployment algorithm actively steers the operator away from superfluous manipulations of the device within the arch and avoids guidewire manipulation in carotid arteries. The long-term durability will need to be assessed in studies with long-term follow-up.

Comparison between the Right and Left Distal Radial Access for Patients Undergoing Coronary Procedures: A Propensity Score Matching Analysis.

Introduction Distal radial access for coronary procedures decreases hemostasis time, prevents radial occlusion, and improves patient comfort compared to conventional transradial access. Initially described for left distal radial access (lDRA), the right distal radial access (rDRA) is feasible. However, there are no comparative studies to date. This study aimed to evaluate the impact of the access site on vascular access and procedural performance. Methods From August 2020 to October 2021, coronary procedures performed through distal radial access were prospectively recorded. After propensity score matching, the rDRA and lDRA were compared. The primary endpoint was the proportion of approach success. The secondary endpoints included access time, coronary procedural success, radial spasm, exposition to ionizing radiation, patient comfort, and vascular access-related complications. Results From a total of 385 procedures in 382 patients, after a propensity score matching, 182 procedures were compared between the rDRA and lDRA. There were no differences in the baseline characteristics between the groups. Compared to the lDRA, the rDRA presented similar approach success (96.7% vs. 96.7%, p=1.0), less access time (39 (25–60) sec vs. 50 (29–90) sec, p=0.018), comparable coronary procedural success after sheath placement (100% vs. 100%, p=1.000), and not statistically significant radial spasm (2.19% vs. 6.59%, p=0.148). No differences in dose-area product (32 (20–56.2) Gy.m2 vs. 32.3 (19.4–46.3) Gy.m2; p=0.472) and fluoroscopy time (4.4 (2.5–9.1) min vs. 4.3 (2.4–7.5) min, p=0.251) were detected between the groups. No vascular access-related complications were observed in any group. Conclusions The rDRA, compared to the lDRA, had the same proportion of approach success and procedural performance, with a slight reduction in access time for patients undergoing coronary procedures.