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Goyal A, Fatima L, Jain H, Tariq MD, Mushtaq F, Suheb MZK, Lu E, Khan R, Sohail AH. Comparison of Outcomes Between Right and Left Upper Extremity Access in Endovascular Aortic Repair for Patients with Thoracoabdominal and Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis. Cardiol Rev 2024:00045415-990000000-00278. [PMID: 38814082 DOI: 10.1097/crd.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Traditionally, left-sided upper extremity (LUE) access has been preferred in patients undergoing endovascular aortic repair (EVAR) to manage aortic aneurysms and decrease the risk of cerebrovascular adverse events. Recently, right-sided upper extremity access (RUE) has gained popularity owing to its greater maneuverability and ergonomics. However, synthesized data comparing the safety and efficacy of RUE and LUE accesses are limited. A comprehensive literature search was conducted on various databases from inception to September 2023 to retrieve all studies that compared RUE and LUE access in EVAR. Data on stroke, 30-day mortality, technical success, access-site complications, total time required for fluoroscopy, and contrast agent requirement were extracted, pooled, and analyzed. Forest plots were generated using a random-effects model on review manager by pooling the risk ratios (RRs) and standard mean differences (SMDs). Ten observational studies with a total of 3994 patients were included in our analysis with 1186 patients in the RUE and 2808 patients in the LUE access groups. EVAR using RUE access was associated with a significantly lower amount of contrast agent requirement than the LUE access group [SMD, -0.23; 95% confidence interval (CI), -0.45 to -0.02; P = 0.03]. There was no significant difference between the 2 groups in terms of the risk of stroke (RR, 1.62; 95% CI, 0.81-3.22; P = 0.17), 30-day mortality (RR, 1.42; 95% CI, 0.50-4.06; P = 0.51), rate of technical success (RR, 0.98; 95% CI, 0.95-1.01; P = 0.18), risk of access-site complications (RR, 1.00; 95% CI, 0.72-1.39; P = 0.99), and total time required for fluoroscopy (SMD, 0.07; 95% CI, -0.39 to 0.26; P = 0.69). The use of RUE access in EVAR appears to be comparable to LUE access in terms of the risk of stroke, access-related complications, all-cause mortality, technical success rate, and fluoroscopy duration. The RUE group required a lower volume of contrast agent.
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Affiliation(s)
- Aman Goyal
- From the Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Laveeza Fatima
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Hritvik Jain
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Muhammad Daoud Tariq
- Department of Internal Medicine, Foundation University Medical College, Islamabad, Pakistan
| | - Fiza Mushtaq
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | | | - Eileen Lu
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Rozi Khan
- Department of Internal Medicine, Medical University of South Carolina, Charleston, SC
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, NM
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Rogers RT, Lemmens CC, Tenorio ER, Schurink GWH, DeMartino RR, Oderich GS, Mees BME, Mendes BC. Fenestrated/branched endovascular aortic repair using unilateral femoral access in patients with iliac occlusive disease. J Vasc Surg 2023; 77:722-730. [PMID: 36372375 DOI: 10.1016/j.jvs.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/01/2022] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Fenestrated/branched endovascular aortic repair (F/BEVAR) in patients with occluded iliac arteries is challenging owing to limited access for branch vessel catheterization and increased risk for leg and spinal ischemic complications. The aim of this study was to analyze technical strategies and outcomes of F/BEVAR in patients with unilateral iliofemoral occlusive disease. METHODS We performed a retrospective review of all consecutive patients treated by F/BEVAR in two institutions (2003-2021). Patients with unilateral iliofemoral occlusive disease were included in the analysis. All patients had one patent iliac artery that was used for advancement of the fenestrated-branch component. Preloaded catheter/guidewire systems or steerable sheaths were used as adjuncts to facilitate catheterization. Primary endpoints were technical success, mortality, major adverse events (stroke, spinal cord injury, dialysis or decrease in the glomerular filtration rate of more than 50%, bowel ischemia, myocardial infarction, or respiratory failure), primary iliac patency, and freedom from reinterventions. RESULTS There were 959 patients treated with F/BEVAR. Of these, 15 patients (1.56%; mean age, 74 years; 80% male) had occluded iliac arteries and 1 patent iliofemoral access and were treated for a thoracoabdominal aortic aneurysm (n = 8) or juxtarenal abdominal aortic aneurysm (n = 7). Brachial access was used in 14 of the 15 patients and preloaded systems in 7 of the 15 patients (47%). The remaining 53% had staggered deployment of stent grafts. There were seven physician-modified endovascular grafts, seven custom-made devices, and one off-the-shelf device used. Thirteen patients (87%) had distal seal using aortouni-iliac stent grafts and two (13%) had distal seal in the infrarenal aorta. Concomitant femoral crossover bypass (FCB) was performed in two patients and six patients had a prior FCB. Technical success was 100%. There were no intraoperative complications or early lower extremity ischemic complications, and all FCB were preserved. There was one mortality (7%) within 30 days owing to retrograde type A dissection. Major adverse events occurred in 20% of patients. The median follow-up was 12 months (range, 0-85 months). Two patients (13%) required three reinterventions. One patient required proximal stent graft extension for an acute type B dissection (3 months) and another required iliac extension for type Ib endoleak of an aortouni-iliac graft (21 months) and thrombolysis of that extension (50 months). At last follow-up, all patients had primary graft patency except one with secondary graft patency without new claudication. One patient had a single renal artery stent occlusion at follow-up with no r-intervention. The overall survival rate was 60%, without aortic-related deaths. CONCLUSIONS Although challenging, F/BEVAR with unilateral femoral/brachial approach is feasible in patients with occluded iliac limbs, with an important rate of ischemic complications, but satisfactory outcomes.
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Affiliation(s)
- Richard T Rogers
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Charlotte C Lemmens
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Geert Willem H Schurink
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Barend M E Mees
- Division of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN.
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DiBartolomeo AD, Miranda E, Pyun AJ, Fleischman F, Magee GA, Han SM. Utilization of retrograde left subclavian branch portal of Gore TAG Thoracic Branch Endoprosthesis for physician modified fenestrated branched endovascular repair of thoracoabdominal aortic aneurysm. J Vasc Surg Cases Innov Tech 2023; 9:101135. [PMID: 36970139 PMCID: PMC10033987 DOI: 10.1016/j.jvscit.2023.101135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
A 75-year-old man who had undergone zone 2 thoracic endovascular repair of a symptomatic penetrating aortic ulcer using a Gore TAG thoracic branch endoprosthesis (TBE) device (W.L. Gore & Associates) 5 years before had presented with an enlarging extent I thoracoabdominal aortic aneurysm. A physician-modified five-vessel fenestrated-branched endograft repair was performed using preloaded wires. The visceral renal vessels were sequentially catheterized from the left brachial access via the TBE portal, and the endograft was deployed in staggered fashion. At 1 year of follow-up, imaging studies demonstrated a stable aneurysm sac, patent visceral renal branches, and no endoleak. The retrograde portal of Gore TAG TBE can facilitate fenestrated-branched endovascular repair of thoracoabdominal aortic aneurysms.
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Witheford M, Roche-Nagle G. Commentary on tightrope technique for facilitating complex endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8:875-876. [PMID: 36568953 PMCID: PMC9768233 DOI: 10.1016/j.jvscit.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - Graham Roche-Nagle
- Correspondence: Graham Roche-Nagle, MD, MBA, University of Toronto, University Health Network, Department of Vascular Surgery, 200 Elizabeth St, 6th Floor, Eaton North, Room 218, Toronto, ON, Canada M5G 2C4
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Single-Center Experience with the Femoral-to-Brachial Preloaded Delivery System for Fenestrated-Branched Endovascular Repair of Complex Aortic Aneurysms. Cardiovasc Intervent Radiol 2022; 45:1451-1461. [PMID: 36050563 DOI: 10.1007/s00270-022-03252-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 08/06/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To assess technical aspects and outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) using a femoral-to-brachial (FTB) preloaded delivery system (PDS) with two separate configurations. METHODS Clinical data of all consecutive patients enrolled in a prospective study to evaluate FB-EVAR for complex abdominal and thoracoabdominal aortic aneurysms (CAAAs & TAAA) between 2013 and 2020 were reviewed. Patients treated with FTB-PDS were included. The two configurations included 4 trans-brachial preloaded wires (4BR) or 2 trans-brachial and 2 transfemoral preloaded wires (2BR-2FE). Outcome measures included technical success, procedural metrics, 30-day or in-hospital mortality, major adverse events (MAEs), and target-vessel outcomes. RESULTS There were 115 patients with a mean age of 73.8 ± 8 years, treated with FTB-PDS. Of these, 62 patients (54%) had 4BR and 53 patients (46%) had 2BR-2FE FTB-PDS. There were 106 TAAA (92%) and 9 CAAAs (8%). Technical success, defined as successful implantation of the stent-graft and all intended target-vessel stents without type I or III endoleak, was 97%, with no differences in total operating time, endovascular time, and radiation dose between groups. There were 3 deaths (3%) at 30 days. MAEs were noticed in 21 patients (18%) with no difference between groups, including new-onset dialysis (2% vs. 4%, P = 0.59), and paraplegia (7% vs. 11%, P = 0.51), for 4BR and 2BR-2FE, respectively. Patient survival and freedom from aortic-related mortality at 2-years were 79 ± 5% and 97 ± 1.7%, respectively, with no difference between groups. CONCLUSION The use of FTB-PDS for FB-EVAR is safe with high technical success and a reasonable rate of MAEs. Each configuration provides specific benefits based on patient anatomy, while having similar procedural metrics and clinical outcomes.
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Marques de Marino P, Hagen M, Katsargyris A, Botos B, Verhoeven EL. Outcomes of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2022; 64:332-338. [PMID: 35963515 DOI: 10.1016/j.ejvs.2022.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/16/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This study aims to assess the safety of upper access with surgical exposure of the axillary artery in fenestrated and branched endovascular aneurysm repair (F/B-EVAR), evaluating neurologic and local complications as well as reinterventions associated with this technique. METHODS All patients undergoing a 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 reinterventions related to the upper extremity access. Complications related to the technique included stroke/transient ischaemic attack, wound infection, peripheral nerve injury and arterial complications. RESULTS 264 patients (192 male, mean age 70 ± 7 years) were included. Upper 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 postoperative bleeding and two with acute arm ischaemia. Two patients with postoperative bleeding and both patients with ischaemic complications required reintervention. One of these patients with arm ischaemia died five weeks after the reintervention due to sepsis complications related to patch infection. Sixteen (6%) patients presented transient arm paraesthesia or sensory neurologic deficit postoperatively. The symptoms completely recovered in all cases with no residual deficits. Perioperative 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. CONCLUSIONS Upper access with surgical exposure of the axillary artery is a safe method for antegrade catheterization of fenestrations and branches in complex endovascular aneurysm repair.
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Affiliation(s)
- Pablo Marques de Marino
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Maike Hagen
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Balazs Botos
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
| | - Eric L Verhoeven
- Department of Vascular and Endovascular Surgery, General Hospital Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany.
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Porras-Colon J, Knowles M, Timaran CH. Outcomes and strategies for utilization of brachial access and preloaded systems during F/BEVAR. Semin Vasc Surg 2022; 35:287-296. [DOI: 10.1053/j.semvascsurg.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 11/11/2022]
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Tenorio ER, Dias-Neto MF, Lima GBB, Baghbani-Oskouei A, Oderich GS. Lessons learned over two decades of fenestrated-branched endovascular aortic repair. Semin Vasc Surg 2022; 35:236-244. [DOI: 10.1053/j.semvascsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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Chait J, Mendes BC, DeMartino RR. Anatomic factors to guide patient selection for fenestrated-branched endovascular aortic repair. Semin Vasc Surg 2022; 35:259-279. [DOI: 10.1053/j.semvascsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/11/2022]
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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Meertens MM, van Herwaarden JA, de Vries JPPM, Verhagen HJM, van der Laan MJ, Reijnen MMPJ, Schurink GWH, Mees BME. Multicenter Experience of Upper Extremity Access in Complex Endovascular Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1150-1159. [PMID: 35709857 DOI: 10.1016/j.jvs.2022.04.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/10/2022] [Accepted: 04/26/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Upper extremity access (UEA) for antegrade cannulation of aortic side branches is a relevant part of endovascular treatment of complex aortic aneurysms and can be achieved using several techniques, sites and sides. The purpose of this study was to evaluate different UEA strategies in a multicenter registry of complex endovascular aortic aneurysm repair (EVAR). METHODS In six aortic centers in the Netherlands, all endovascular aortic procedures from 2006 to 2019 were retrospectively reviewed. Patients who received upper extremity access during complex EVAR were included. Primary outcome was a composite endpoint of any access complication, excluding minor hematomas. Secondary outcomes were access characteristics, access complications considered individually, access reinterventions and incidence of ischemic cerebrovascular events. RESULTS 417 patients underwent 437 UEA for 303 fenestrated/branched EVARs, and 114 chimney EVARs. Twenty patients had bilateral, 295 left-sided, and 102 right-sided UEA. 413 approaches were performed surgically and 24 percutaneously. Distal brachial access was used in 89 cases, medial brachial in 149, proximal brachial in 140 and axillary access in 59 cases. No significant differences regarding the composite endpoint of access complications were seen (DBA 11.3% vs. MBA 6.7% vs. PBA 13.6% vs. AA 10.2%; p=.29). Postoperative neuropathy occurred most after proximal brachial access (DBA 1.1% vs. MBA 1.3% vs. PBA 9.3 % vs. AA 5.1%; p=.003). There were no differences in cerebrovascular complications between access sides (right 5.9% vs. left 4.1% vs. bilateral 5%; p=.75). Significantly more overall access complications were seen after a percutaneous approach (29.2% vs. 6.8%; p=.002). In multivariate analysis the risk for access complications after open approach was decreased by male gender (OR 0.27; CI 95% 0.10 - 0.72; p= .009), while an increase in age per year (OR 1.08; CI 95% 1.004 - 1.179; p=.039) and diabetes mellitus type 2 (OR 3.70; CI 95% 1.20 - 11.41; p= .023) increased the risk. CONCLUSION Between the four access localizations, there were no differences in overall access complications. Female gender, diabetes mellitus type 2 and ageing increased the risk for access complications after surgical approach. Furthermore, a percutaneous upper extremity access resulted in higher complication rates than a surgical approach.
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Affiliation(s)
- M M Meertens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - J A van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J P P M de Vries
- Department of Vascular Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - M J van der Laan
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - M M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, and Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, the Netherlands
| | - G W H Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; European Vascular Center Aachen-Maastricht, the Netherlands/ Germany
| | - B M E Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; European Vascular Center Aachen-Maastricht, the Netherlands/ Germany.
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Evaluation of Safety of Overhead Upper Extremity Positioning During Fenestrated-Branched Endovascular Repair of Thoracoabdominal Aortic Aneurysms. Cardiovasc Intervent Radiol 2021; 44:1895-1902. [PMID: 34708266 DOI: 10.1007/s00270-021-02992-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Peripheral nerve and brachial plexus injury can occur from compression or stretching during positioning for operative procedures. The aim of this study was to evaluate the safety of overhead upper extremity positioning to optimize imaging during fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs). METHODS Forty-four consecutive patients enrolled in a prospective non-randomized study underwent FB-EVAR with overhead upper extremity positioning. Patients underwent intra-operative neuromonitoring of upper and lower extremities and neurological examination prior to discharge and at 2 months following the procedure. End points were peripheral or brachial plexus nerve injury, quality of lateral projection and cone beam computed tomography (CBCT) and major adverse event (MAEs). RESULTS There were 28 (64%) male patients with mean age of 74 ± 8 years treated for 10 PRAs (23%) and 34 (78%) TAAAs. Mean body mass index was 29 ± 7 kg/m2, with 17 obese patients (39%). Open surgical upper extremity access was used in 19 patients (43%). Three patients (16%) had access-related complications, all focal brachial artery dissections treated by patch angioplasty. Two patients (5%) developed upper extremity changes in neuromonitoring, which immediately resolved with repositioning of the upper extremity. Technical success was 95%. Lateral projection and rotational CBCT were feasible in all patients with satisfactory imaging quality for catheterization and stenting of the celiac axis and superior mesenteric artery. There was one mortality (2%) at 30 days, and six patients (14%) had MAEs. There were no upper extremity neurological injuries. CONCLUSION Overhead upper extremity position allows optimal imaging on lateral projections and rotational CBCT during FB-EVAR. There were no upper extremity neurological injuries in this study.
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Zimmermann A, Menges AL, Rancic Z, Meuli L, Dueppers P, Reutersberg B. E-nside Off-the-Shelf Inner Branch Stent Graft: Technical Aspects of Planning and Implantation. J Endovasc Ther 2021; 29:167-174. [PMID: 34569343 PMCID: PMC8928429 DOI: 10.1177/15266028211047967] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose This article aims to present all aspects regarding patient selection, planning, and implantation technique for a new off-the-shelf pre-cannulated multi-inner branch stent graft. The stent graft comes in 4 different versions with proximal diameters of 33 and 38 mm and distal diameters of 26 and 30 mm. The 4 inner branches are located in the middle segment, which has a diameter of 24 mm. Technique With inner branch technology, the field of application for the treatment of thoracoabdominal aortic aneurysms (TAAA) has been further extended. In addition to routine use in elective cases the pre-cannulation of the inner branches predisposes especially for emergencies. Pre-cannulation is intended to reduce the time to cannulation and the radiation dose. All steps of planning, stent-graft deployment, and cannulation of the inner branches are described in detail. Conclusion The E-nside stent graft represents a promising new endovascular therapy in the treatment of acute and elective TAAA. By using inner branch technology, this endograft combines the advantages of fenestrated and branched stent grafts. Indication, planning, and implantation require experience in branched and fenestrated stent graft technology.
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Affiliation(s)
| | - Anna-Leonie Menges
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Zoran Rancic
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Philip Dueppers
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
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Zymvragoudakis V, Donati T, Gkoutzios P, Abisi S. WILD Sheath Technique: "WIre Loop Directional" Sheath for Retrograde Femoral Access in Branched Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2021; 75:518-522. [PMID: 33823251 DOI: 10.1016/j.avsg.2021.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/25/2021] [Accepted: 03/07/2021] [Indexed: 11/29/2022]
Abstract
Branched endovascular aortic aneurysm repair (BEVAR) necessitates upper limb access (ULA) to facilitate the antegrade cannulation of downward directional branches and the placement of the bridging stent grafts. Various technical solutions to avoid ULA have been proposed and successfully applied in a limited number of cases. This can be necessary in specific clinical scenarios such as hostile aortic arch and descending thoracic aortic anatomy, or in the case of previous aortic arch and supra-aortic vessels surgery complicating the conventional approach with ULA in BEVAR. Taking inspiration from the prior description of a precursory technique, we report the application of our technique in BEVAR procedures, using standard introducer sheaths as a directional stable platform to facilitate an "All Femoral Access" (AFA) approach without the need for ULA, snaring or commercial steerable sheaths. Our concept is based on utilizing a wire loop to form a directional sheath (WILD sheath technique).
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Affiliation(s)
- Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Tommaso Donati
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Panos Gkoutzios
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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