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

Abstract

The paper reports anatomical and intra-operative data on the percutaneous use of the axillary artery first segment for upper extremity access during complex endovascular aortic procedures. This prospective study offers new data supporting a technically feasible and relatively safe percutaneous access to deliver bridging stents during endovascular treatment of thoraco-abdominal or complex abdominal aortic aneurysms, increasing the treatment options at physician's disposal.Objective: 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). Methods: 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. Results: 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 69e78) 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 a bare or covered stenting to the AXA and in one patient mechanical failure of the delivery system was recorded. 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 ¼ .002), oral anticoagulants therapy (p ¼ .005) and procedure length (p ¼ .028). At short term follow up (6 months), no late complications were observed, and all access vessels were patent. Conclusion: PAXA on the first segment using a large sheath (10e16F) is technically feasible, relatively safe with no 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.

Sex-Related Anatomical Feasibility Differences in Endovascular Repair of Thoracoabdominal Aortic Aneurysms With a Multibranched Stent-Graft

“…In the entire cohort, vascular access feasibility (Table 5) alone excluded 48 patients (18%) from potential transfemoral repair: an iliac axis <8.5 mm was present in 46 patients (17%), and 2 patients (1%) had no upper extremity access (bilateral occlusion of the subclavian arteries). 29 An inadequate iliac axis was more frequent in women than men [27 (39%) vs 19 (9%); p<0.001). If the custom-made low-profile t-Branch (18-F sheath outer diameter vs 23-F) were made available off-the-shelf, it would increase the vascular access feasibility from 82% to 94% (91% women vs 95% men, p=0.381).…”

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

“…The rate of overall access complications of 10.2% in our cohort aligns with prior results. 15,17,20,21 In our multicenter cohort, the AA strategy was least frequently used; this might be due to the fact that the surgical approach of the axillary artery can be more challenging and possible access complications include pneumothorax and hemothorax. Although no differences in the overall access complication were seen between the four locations, there were significant more peripheral neuropathies seen after PBA.…”

“…The literature also offers data on percutaneous access of the axillary artery, which has been reported to have a low conversion and reintervention rate, using even larger sheath sizes. 10,20,[25][26][27] However, the above-mentioned meta-analysis by Malgor et al 17 also found percutaneous AA to be inferior to a surgical approach regarding the access complication rate.…”

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 ].…”