Percutaneous Axillary Artery Access Research Articles

Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures: Presented at the plenary session of the 2022 Vascular Annual Meeting of the Society for Vascular Surgery, Boston, Massachusetts, June 15-18, 2022.

Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures: Presented at the plenary session of the 2022 Vascular Annual Meeting of the Society for Vascular Surgery, Boston, Massachusetts, June 15-18, 2022.

Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures

BackgroundPercutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. MethodsOne-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. ResultsOne-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. ConclusionsLarge-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.

Feasibility and Safety of Percutaneous Axillary Artery Access in a Prospective Series of 100 Complex Aortic and Aortoiliac Interventions

We aimed to review the feasibility and safe use of the percutaneous axillary artery (AxA, 100 patients) approach for endovascular repair (ER) of thoraco-abdominal aortic aneurysms (TAAA, 90 patients) using fenestrated, branched, and chimney stent grafts and other complex endovascular procedures (10 patients) necessitating AxA access. Percutaneous puncture of the AxA in its third segment was performed using sheaths sized between 6 to 14F. For closing puncture sites greater than 8F, two Perclose ProGlide percutaneous vascular closure devices (PVCDs) (Abbott Vascular, Santa Clara, CA, USA) were deployed in the pre-close technique. The median maximum diameter of the AxA in the third segment was 7.27 mm (range 4.50-10.80). Device success, defined as successful hemostasis by PVCD, was reported in 92 patients (92.0%). As recently reported results in the first 40 patients suggested that adverse events, including vessel stenosis or occlusion, occurred only in cases with a diameter of the AxA < 5 mm, in all subsequent 60 cases AxA access was restricted to a vessel diameter ≥ 5 mm. In this late group, no hemodynamic impairment of the AxA occurred except in six early cases below this diameter threshold, all of which could be repaired by endovascular measures. Overall mortality at 30 days was 8%. In conclusion, percutaneous approach of the AxA in its third segment is feasible and represents a safe alternative access to open access for complex endovascular aorto-iliac procedures. Complications are rare, especially if the maximum diameter of the access vessel (AxA) is ≥5 mm.

Percutaneous Axillary Artery Puncture: An Efficient Approach for Upper Extremity Access

The aim was to analyze the anatomic feasibility of the percutaneous axillary access (PAXA) using cadaverous models and then to analyze the complications associated with PAXA during Fenestrated or Branched Endovascular Aneurysm Repair (F/BEVAR) procedures. Cadaverous models were used to analyze axillary pedicle after a PAXA on an initial anatomical investigation. A subclavian approach was performed after puncture to assess the injuries caused by the needle. Then, in an observational study, patients who underwent F/BEVAR using a PAXA between July 2019 and July 2021 were included. PAXA-related events and complications were monitored. Eleven dissections were performed on cadavers. The axillary vein was injured twice (18.2%); the puncture site on the axillary artery was found on the arterial proximal part, behind the clavicle. Fifty-three patients underwent a F/BEVAR using a PAXA. The mean (SD) age of patients was 74.5 (9.7) years. Most indications for endovascular repair were para-renal aneurysms (66%). Two Proglide® closure devices served to close arterial access in all procedures. Adjunct balloon inflation was used in 19 (35.8%) patients. There were 5 (9.4%) PAXA-related events included preoperative blush in 2 (3.8%) patients, axillary artery dissection in 2 (3.8%), and 1 (1.9%) axillary artery stenosis. Five patients (9.4%) had a postoperative axillary hematoma without need for additional surgical procedure. No PAXA-related complication was found after discharge (mean [SD] 11.7 [7.4] months following surgery). Percutaneous axillary artery access was an efficient upper extremity access and associated with a low rate of PAXA-related events.

Optimal bail-out and complication management strategies in protected high-risk percutaneous coronary intervention with the Impella.

Despite the routine use of percutaneous mechanical circulatory support (pMCS) with the Impella heart pump, vascular and bleeding complications may occur during removal with or without pre-closure. To safely close the large-bore access (LBA), post-hoc selection of the appropriate treatment of vascular complications is critical to patient recovery and survival. Femoral artery access is typically utilized for LBA, and percutaneous axillary artery access is a common alternative, especially in the instance of severe peripheral artery disease. Optimization of patient outcomes and efficiency of pMCS can be achieved with adequate arterial access using state-of-the-art techniques. Impella removal techniques with or without pre-closure will be addressed as well as the management of large-bore femoral access complications. In addition, treatment strategies to manage patient deterioration during a protected high-risk percutaneous coronary intervention will be provided.

Safety and Learning Curve of Percutaneous Axillary Artery Access for Complex Endovascular Aortic Procedures

Percutaneous axillary artery access is increasingly used for large-bore access during vascular and interventional cardiology procedures. The aim of this study is to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (FBEVAR) requiring large-bore upper extremity access and to discuss best practices for technique and complication management.

B-40 | Percutaneous Axillary Artery Access in Children with Congenital Heart Disease

Percutaneous axillary artery access has been underutilized in children. In this study, we aimed to describe the efficacy and safety of percutaneous axillary access in complex pediatric transcatheter interventions.

SCAI Position Statement on Best Practices for Percutaneous Axillary Arterial Access and Training.

Axillary artery access has become increasingly widespread as an alternative to the femoral route for large-bore transcatheter aortic valve replacement (TAVR), endovascular aortic repair (EVAR), and mechanical circulatory support (MCS) procedures. Advantages of percutaneous access include avoidance of a surgical incision, general anesthesia, and conduit graft infection. This statement aims to review the anatomic considerations and risks for percutaneous axillary artery access, suggest best practices for access techniques, hemostasis/closure strategies, and complication management, and recommend options for training and privileging.

Percutaneous Axillary Artery Access for Peripheral and Complex Endovascular Interventions: Clinical Outcomes and Cost Benefits

The aim of this study was to determine the safety, efficacy, and applicability of percutaneous axillary artery (pAxA) access in patients requiring upper extremity large sheath access during complex aortic, cardiac, and peripheral endovascular procedures. We also take this opportunity to address the potential cost-benefits offered by pAxA access compared to open upper extremity access. A total of 26 consecutive patients, between June 2018 and October 2020, underwent endovascular intervention, requiring upper extremity access (UEA). Ultrasound-guided, percutaneous access of the axillary artery was used in all 26 patients with off-label use of pre-close technique with Perclose ProGlide closure devices. Access sites accommodated sheath sizes that ranged from 6 to 14 French (F). End points were technical success and access site-related complications including isolated neuropathies, hematoma, distal embolization, access-site thrombosis, and post-operative bleeding requiring secondary interventions. Technical success was defined as successful arterial closure intraoperatively with no evidence of stenosis, occlusion, or persistent bleeding, requiring additional intervention. Of the 26 patients requiring pAxA access, 15 underwent complex endovascular aortic aneurysm repairs (EVAR) with branched, fenestrated, snorkel, or parallel endografts, 6 underwent peripheral vascular interventions, and 5 underwent cardiac interventions. Fifty-three percent accommodated sheath sizes of 12F or higher. Technical success was achieved in 100% of cases with no major perioperative access complications requiring additional open or endovascular procedures. In our series, we had one post-operative mortality secondary to myocardial infarction in a patient with significant coronary artery disease. Our data again demonstrated the proposed safety and efficacy attributable to pAxA access, while extending its application to wide spectrum of endovascular interventions which included peripheral or coronary vascular in addition to complex EVAR.

Managing vascular access and closure for percutaneous mechanical circulatory support.

Even with current generation mechanical circulatory support (MCS) devices, vascular complications are still considerable risks in MCS that influence patients’ recovery and survival. Hence, efforts are made to reduce vascular trauma and obtaining safe and adequate arterial access using state-of-the-art techniques is one of the most critical aspects for optimizing the outcomes and efficiency of percutaneous MCS. Femoral arterial access remains necessary for numerous large-bore access procedures and is most commonly used for MCS, whereas percutaneous axillary artery access is typically considered an alternative for the delivery of MCS, especially in patients with severe peripheral artery disease. This article will address the access, maintenance, closure and complication management of large-bore femoral access and concisely describe alternative access routes.

Safety and Efficacy of Percutaneous Axillary Artery Access for Endovascular Interventions

Safety and Efficacy of Percutaneous Axillary Artery Access for Endovascular Interventions

Emerging Role of Large-bore Percutaneous Axillary Vascular Access: a Step-by-step Guide

Advances in transcatheter structural heart interventions and temporary mechanical circulatory support have led to increased demand for alternative sites for large-bore vascular access. Percutaneous axillary artery access is an appealing alternative to femoral access in patients with peripheral arterial disease, obesity or for prolonged haemodynamic support where patient mobilisation may be valuable. In particular, axillary access for mechanical circulatory support allows for increased mobility while using the device, facilitating physical therapy and reducing morbidity associated with prolonged bed rest. This article outlines the basic approach to percutaneous axillary vascular access, including patient selection and procedure planning, anatomic axillary artery landmarks, access techniques, sheath removal and management of complications.

Percutaneous AXillary Artery (PAXA) Access at the First Segment During Fenestrated and Branched Endovascular Aortic Procedures

The aim of this study was to assess the feasibility and safety of percutaneous axillary access with vessel closure device closure after puncturing the first segment during endovascular treatment of complex aneurysms with fenestrated and branched endografts (F/BEVAR). The PAXA (Percutaneous AXillary Access) study is a physician initiated, single centre, ambispective, non-randomised study (clinicaltrials.gov: NCT03223311). The primary endpoint was the closure success rate defined as the absence of any vascular injury to achieve haemostasis at the puncture site, requiring any treatment other than manual compression or adjunctive endovascular ballooning. The secondary endpoints were minor access complications, cerebrovascular complication rate, short term access vessel patency, and study cohort anatomical evaluation of the axillary artery. Sixty-four patients required an upper extremity access during F/BEVAR procedure during study period (November 2016 to July 2019) and were screened for the PAXA study: 59 patients (47 males; median age: 75 years, IQR 69-78) met the study inclusion criteria and were enrolled (one patient had bilateral access). Closure success was obtained in 54 cases (90%) with no open conversion required: five patients received abare or covered stenting to the AXA and in one patient mechanical failure of the delivery system wasrecorded. No 30 day permanent peripheral nerve injuries and two non-ipsilateral ischaemic strokes (3.4%) were recorded. Seven patients (12%) had access haematomas managed conservatively associated with closure failure (p=.002), oral anticoagulants therapy (p=.005) and procedure length (p=.028). Atshort term follow up (6 months), no late complications were observed, and all access vessels were patent. PAXA on the first segment using a large sheath (10-16F) is technically feasible, relatively safe withno need for open conversion but it may require access related secondary endovascular procedures. Further prospective studies are needed to modify the device instruction for use and to put the procedure on label.

3:36 PM Abstract No. 186 Safety and efficacy of percutaneous axillary artery access for peripheral endovascular interventions

3:36 PM Abstract No. 186 Safety and efficacy of percutaneous axillary artery access for peripheral endovascular interventions

Percutaneous Axillary Artery Access During Fenestrated and Branched Thoracoabdominal Aortic Procedures

Percutaneous Axillary Artery Access During Fenestrated and Branched Thoracoabdominal Aortic Procedures

Percutaneous Axillary Artery Access for the Endovascular Treatment of Complex Thoraco-Abdominal Aortic Aneurysms

Introduction - Our aim is to study the feasibility of percutaneous trans-axillary artery approach using percutaneous closure devices in the treatment of complex endovascular repair of thoraco-abdominal aortic aneurysms using branched, fenestrated and chimney stent grafts.

Safety and Effectiveness of Percutaneous Axillary Artery Access for Complex Aortic Interventions

The aim of this study is to evaluate the safety and effectiveness of percutaneous axillary artery access in patients requiring upper extremity large sheath access during complex aortic interventions. Consecutive patients who had percutaneous axillary artery access with a large-bore sheath during endovascular thoracoabdominal aortic artery aneurysm repair within an Food and Drug Administration-approved, physician-sponsored investigational device exemption study or visceral artery interventions during other complex aortic interventions were included in the study. All patients had percutaneous axillary artery ultrasound-guided access and deployment of 2 Perclose ProGlide devices (Abbott Vascular, Santa Clara, CA) prior to introduction of a large sheath. Completion angiography was performed to assess technical success of percutaneous access site closure, which was defined as hemostatic arterial closure without evidence of axillary artery stenosis or occlusion requiring intervention. Follow-up computed tomography scans and patient records were also reviewed for access site associated complications. A total of 46 patients underwent percutaneous axillary artery access. Largest sheath profile was 16F in 1 (2%), 12F in 42 (91%), 10F in 1 (2%), 9F in 1 (2%), and 8F in 1 (2%) patient. Technical success was achieved in 41 of 46 patients (89%). Five patients required endovascular covered stent placement during the index operation to control persistent access site bleeding. Two of 46 patients (4%) suffered access-related complications; both patients experienced ipsilateral upper extremity paresthesias without motor weakness, with persistent digit numbness in one. There was no incidence of conversion to open axillary artery repair and no additional access site complications (stenosis, occlusion, or dissection) but neurologic complications were observed during follow-up. Percutaneous axillary artery access can be used to provide upper extremity arterial access during complex aortic interventions with high rates of safety and technical success. Overall complication rates are low and occurred mainly during the early experience, indicating that there is an associated learning curve effect. Elimination of surgical cutdown incisions and arterial conduits by using percutaneous axillary access may reduce operative times and wound-related complications during complex aortic interventions requiring large-bore upper extremity access.

Percutaneous Axillary Artery Access for Endovascular Treatment of Complex Thoraco-abdominal Aortic Aneurysms

The aim of this study was to determine the feasibility and safety of percutaneous axillary artery (AxA) access using vascular closure devices (VCD) for endovascular repair (ER) of thoraco-abdominal aortic aneurysms (TAAA) using fenestrated, branched, and chimney stent grafts. Between September 2013 and December 2017, 40 high risk patients (27 men; mean age: 72.7±7.4 years) with TAAA underwent total percutaneous endovascular aortic repair by percutaneous puncture of the third segment of the left AxA, using a 12F sheath for delivery of the bridging visceral stent grafts. Percutaneous closure was performed using ultrasound guidance and two Perclose ProGlide VCDs per puncture site. Endpoints were device success defined as successful haemostasis of the axillary puncture site by VCD, procedure success defined as endovascularly assisted haemostasis of the AxA, major cerebrovascular and peripheral neurological complications, and 30 day mortality. The median diameter of the AxA in the third segment was 6.5mm (range 4.4-10.4mm). The procedure success was 100%. Device success was achieved in 33 patients (82.5%). Device success in patients with AxA diameter >5mm was 97%. All patients with diameter of the AxA <5mm developed stenosis or occlusions of the vessel (n=6), which were treated by percutaneous stent implantation. One bleeding at the AxA puncture site was treated with trans-femoral implantation of a covered stent. No secondary open procedures were required. No neurological deficit of the left upper limb was seen at discharge. Overall mortality at 30 days was 10%. Direct puncture of the AxA in the third segment and its use as an access vessel for large sheaths during total percutaneous treatment of complex endovascular aortic procedures appear to be feasible and safe in arteries with a diameter >5mm. Complications can be managed using endovascular techniques.

Percutaneous Axillary Artery Access in Complex Endovascular Aortic Repair

PurposeThis study was designed to assess the feasibility and safety of percutaneous axillary access in complex endovascular aortic repair (EVAR) with use of a percutaneous closure device. Materials and MethodsAll patients undergoing percutaneous axillary artery access between 2012 and 2017 were included. Left percutaneous axillary access was the sole antegrade aortic approach used. Patient and intervention characteristics were documented. Mortality, procedural success, technical success, peri- and postoperative complications, and repeat interventions were examined. A total of 25 percutaneous axillary access procedures were performed in 23 patients. The mean age of the treated patients was 72.2 years, and 71% were male. Percutaneous axillary access was obtained for a variety of indications (chimney EVAR, thoracoabdominal aortic aneurysm repair, thoracic EVAR, and type B dissections). Vascular access sheath sizes ranged from 6 F to 12 F. ResultsThe procedural success rate was 96%. Technical success of vascular closure was 100%. The perioperative access complication rate was 8%: 1 dissection of the axillary artery and 1 stenosis occurred. No hematoma, hemorrhage, or neuropathies were seen. One access-related repeat intervention had to be performed. The 30-d mortality rate was 4%. ConclusionsDirect puncture and percutaneous closure of the axillary artery for complex aortic procedures is safe and feasible.

Safety and Effectiveness of Percutaneous Axillary Artery Access for Complex Aortic Interventions

To evaluate the safety and effectiveness of preclose percutaneous axillary artery access in patients requiring upper extremity large sheath access during complex aortic interventions. Between October 2017 and April 2018, 17 patients undergoing endovascular thoracoabdominal aortic artery aneurysm repair or visceral artery interventions had percutaneous axillary artery access with a 12-Fr sheath using an off-label preclose technique with PerClose Proglide (Abbott Vascular, Santa Clara, Calif) suture-mediated closure system. Percutaneous access to the third portion of the axillary artery was obtained under ultrasound guidance at the lateral border of the pectoralis minor muscle. Two PerClose devices were deployed before introducing a 12-Fr sheath. Completion angiography was performed to assess technical success, which was defined as successful arterial closure without evidence of persistent hemorrhage or axillary artery stenosis or occlusion requiring intervention. Technical success was achieved in 16 of the 17 patients (94%). One patient required endovascular covered stent placement during the index operation to control persistent access site bleeding. Two of the 17 patients (12%) suffered access-related complications. Two patients experienced transient ipsilateral upper extremity paresthesias without motor weakness. There was no incidence of conversion to open repair of the axillary artery and on follow-up computed tomography scan no access site complications (stenosis, occlusion, or dissection) were observed. Percutaneous axillary artery access using PerClose Proglide devices for hemostasis can be used to provide upper extremity arterial access during complex aortic interventions with high rates of technical success and safety. Accessing the lateral axillary artery under ultrasound guidance provides a preferred target where pressure may be applied to assist in achieving hemostasis. Overall complication rates are low; however, neurologic complications in the form of ipsilateral paresthesias can occur.