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

Abstract

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.

Evaluation of Safety of Overhead Upper Extremity Positioning During Fenestrated–Branched Endovascular Repair of Thoracoabdominal Aortic Aneurysms

“…Proper preoperative assessment by the surgical and anesthesia team is critical to identify patients with limited mobility, and in these cases, the standard position is recommended. When needed, the use of right-side brachial access provides better operator ergonomics and potentially reduces radiation exposure [16].…”

Multicenter experience of upper extremity access in complex endovascular aortic aneurysm repair

“…Traditionally, left UEA has been favored because of the theory that right UEA is more likely to cause ischemic cerebrovascular events as both carotid arteries have to be passed instead of none. 18 This traditional opinion is reflected in our cohort, as most procedures were performed through left-sided UEA. Right-sided access can offer advantages such as ergonomics and lower radiation exposure to the operator.…”

“…One has to consider though that the studies published merely evaluated a small number of patients. 6,[15][16][17][18] The aim of this real-world multicenter study was to evaluate the outcome and complications of different UEA strategies used during complex endovascular aortic procedures.…”

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

“…Given the greater number of implanted stent-grafts/materials, it is proposed that this is likely to be more widespread with unclear implications [ 101 ]. Whether the use of a percutaneous approach to the axillary artery will lead to improved clinical outcomes as compared with conventional brachial artery cutdown, or any significant differences exist with use of the right-side upper arm access vs. the left-side approach also remain areas of ongoing research efforts [ 102 , 103 , 104 ]. In addition, many of the perioperative factors discussed in the preceding chapters (such as procedural staging and risk for death during waiting time, optimal patient selection, type of BSs and use of ancillary materials, application of CSFD, or treatment for particular cases, such as post-dissection aneurysms, connective tissue diseases, or failures after prior infrarenal procedures) are only partially understood and represent unmet critical issues needing further study [ 105 , 106 ].…”