A systematic review of outcomes of upper extremity access for fenestrated and branched endovascular aortic repair

Malgor, Rafael D.; Marino, Pablo Marqués de; Verhoeven, Eric L.G.; Katsargyris, Αthanasios

doi:10.1016/j.jvs.2019.09.028

Cited by 34 publications

(22 citation statements)

References 64 publications

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“…Other centers have shown low stroke rates with the right-side approach. 11,12 Fiorucci et al 12 reported a 3% stroke rate among 61 patients treated with multibranched endografts using RUE access. In that series, patients who sustained stroke had hostile arch anatomy, including left carotid-subclavian bypasses in 2 patients and innominate artery thrombus in 1 patient.…”

Section: Discussionmentioning

confidence: 99%

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Comparison of Cerebral Embolic Events Between Right and Left Upper Extremity Access During Fenestrated/Branched Endovascular Aortic Repair

et al. 2020

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Purpose: To evaluate the incidence and outcomes of cerebral embolic events when using right (RUE) vs left upper extremity (LUE) access for fenestrated/branched endovascular aneurysm repair (f/bEVAR). Materials and Methods: A retrospective review was conducted of 290 consecutive patients enrolled in a physician-sponsored Investigational Device Exemption study to evaluate f/bEVAR between 2013 and 2018. Of these, 270 patients (93%) had an upper extremity access with 12-F sheaths, including 205 patients (mean age 75±8 years; 147 men) with LUE and 65 patients (mean age 73±8 years; 42 men) with RUE access. Outcome measures were technical success, procedural metrics, major adverse events (MAEs), any stroke or transient ischemic attack (TIA), and mortality. Results: Technical success was higher (p=0.04) for LUE (99.6%) vs RUE access (98.4%). Patients treated via RUE access more often had extent I-III thoracoabdominal aortic aneurysms (57% vs 39%, p=0.03). Procedural metrics were similar for LUE vs RUE sides, including endovascular time (255±80 vs 246±83 minutes, respectively; p=0.23), fluoroscopy time (84±32 vs 90±35 minutes, respectively; p=0.80), and contrast volume (156±57 vs 153±56 mL, respectively; p=0.82). Total radiation exposure was significantly higher for LUE vs RUE access (2463±1912 vs 1757±1494 mGy, respectively; p=0.02). There were 2 deaths (1%) at 30 days or during hospital admission, both unrelated to access site complications. MAEs occurred in 32% of patients who had LUE and 26% of those who had RUE access (p=0.44). Five patients (2%) had embolic stroke and none had TIA. Embolic strokes were ipsilateral to the access side in 4 patients and affected the posterior circulation in 3. Two patients (1%) had hemorrhagic strokes. The incidence of stroke was 3% for LUE and 2% for RUE access (p>0.99). Conclusion: Fenestrated/branched stent-graft repair was associated with low rates of cerebral embolic events and no significant difference between the right vs left upper extremity approach.

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Section: Discussionmentioning

confidence: 99%

“…Since this initial report, several centers have shown favorable results with right upper extremity (RUE) access. 11,12 The aim of this study was to evaluate the incidence and outcomes of cerebral embolic events during f/bEVAR via RUE vs LUE access.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Cerebral Embolic Events Between Right and Left Upper Extremity Access During Fenestrated/Branched Endovascular Aortic Repair

et al. 2020

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“…In branched stent grafts, downward-oriented branches usually require an upper extremity access via brachial, axillary or subclavian artery. Even with stabilizing the access sheath with a through-and-through wire and maintaining ACT>250 s, there is a significant risk of cerebral embolization and stroke [1,2]. Steerable sheaths have been successfully used as a secondary option after failed standard cannulation in fenestrated and branched endovascular repair [4].…”

Section: Discussionmentioning

confidence: 99%

“…Endovascular repair of thoraco-abdominal aortic aneurysms frequently involves the use of downward facing, antegrade branches. Upper extremity access (brachial, axillary or subclavian artery) has been used regularly for catheterization of these branches and the target vessels and has been proven to be save and feasible [ 1 ]. One of the major drawbacks of placing large diameter sheaths across the arch is the risk of perioperative stroke [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

“…One of the major drawbacks of placing large diameter sheaths across the arch is the risk of perioperative stroke [ 2 ]. In some cases, arterial access from the arm can be challenging and dangerous due to low arterial diameter, arteriosclerotic lesions, thrombus or tortuosity [ 1 ]. Previous endovascular procedures or elongation and kinking of the aorta proximal to the target vessels might increase embolic risk or make access impossible.…”

Section: Introductionmentioning

confidence: 99%

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Improved stability of steerable sheath access by femoro-femoral crossover wire in branched stent graft repair of complex thoraco-abdominal aortic aneurysms

Töpel

Betz

Steinbauer

et al. 2020

Innovative Surgical Sciences

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PurposeThe purpose of this study was to describe a technique to catheterize antegrade branches of a branched aortic endograft by using a steerable sheath stabilized by a through-and-through wire via a femoral access.TechniqueAfter implantation of a branched endovascular graft, a steerable 8.5 F sheath is advanced from the femoral access. After placing the sheath proximal to the branches, a 0.014″ through-and-through wire is established to the contralateral femoral access which is held under slight traction after the curved tip of the sheath is brought into the 180° position. Then catheterization, wire exchange and deployment of the bridging stent is done in standard fashion.ConclusionThe use of a through-and-through wire with a steerable sheath for retrograde femoral access adds stability and precision to this technique. It has the potential to reduce the risk of preoperative stroke in complex aortic endovascular repair by avoiding upper extremity access.

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Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta‐analysis

Goyal,

Fatima,

Mushtaq

et al. 2024

Cathet Cardio Intervent

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Endovascular aortic repair is an emerging novel intervention for the management of abdominal aortic aneurysms. It is crucial to compare the effectiveness of different access sites, such as transfemoral access (TFA) and upper extremity access (UEA). An electronic literature search was conducted using PubMed, EMBASE, and Google Scholar databases. The primary endpoint was the incidence of stroke/transient ischemic attack (TIA), while the secondary endpoints included technical success, access‐site complications, mortality, myocardial infarction (MI), spinal cord ischemia, among others. Forest plots were constructed for the pooled analysis of data using the random‐effects model in Review Manager, version 5.4. Statistical significance was set at p < 0.05. Our findings in 9403 study participants (6228 in the TFA group and 3175 in the UEA group) indicate that TFA is associated with a lower risk of stroke/TIA [RR: 0.55; 95% CI: 0.40–0.75; p = 0.0002], MI [RR: 0.51; 95% CI: 0.38–0.69; p < 0.0001], spinal cord ischemia [RR: 0.41; 95% CI: 0.32–0.53, p < 0.00001], and shortens fluoroscopy time [SMD: −0.62; 95% CI: −1.00 to −0.24; p = 0.001]. Moreover, TFA required less contrast agent [SMD: −0.33; 95% CI: −0.61 to −0.06; p = 0.02], contributing to its appeal. However, no significant differences emerged in technical success [p = 0.23], 30‐day mortality [p = 0.48], ICU stay duration [p = 0.09], or overall hospital stay length [p = 0.22]. Patients with TFA had a lower risk of stroke, MI, and spinal cord ischemia, shorter fluoroscopy time, and lower use of contrast agents. Future large‐scale randomized controlled trials are warranted to confirm and strengthen these findings.

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A systematic review of outcomes of upper extremity access for fenestrated and branched endovascular aortic repair

Cited by 34 publications

References 64 publications

Comparison of Cerebral Embolic Events Between Right and Left Upper Extremity Access During Fenestrated/Branched Endovascular Aortic Repair

Comparison of Cerebral Embolic Events Between Right and Left Upper Extremity Access During Fenestrated/Branched Endovascular Aortic Repair

Improved stability of steerable sheath access by femoro-femoral crossover wire in branched stent graft repair of complex thoraco-abdominal aortic aneurysms

Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta‐analysis

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