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Upper Extremity Access for Fenestrated Endovascular Aortic Aneurysm Repair is not Associated with Increased Morbidity
Martyn Knowles, David A. Nation, David E. Timaran, Luis F. Gomez, M. Shadman Baig, R. James Valentine, Carlos H. Timaran
University of Texas - Southwestern, Dallas, TX

Background: Fenestrated endovascular aortic aneurysm repair (FEVAR) is an alternative to open repair in patients with complex abdominal aortic aneurysms, who are neither fit nor suitable for standard open or endovascular repair. Chimney and snorkel grafts are other endovascular alternatives, but require upper extremity access that has been associated to a 3.2-9.5% risk of stroke. However, because of the caudal orientation of the visceral vessels, upper extremity access is also frequently required for FEVAR. The purpose of this study was to assess the use of upper extremity access for FEVAR and associated morbidity.
Methods: During a 5-year period, 148 patients underwent FEVAR. Upper extremity access for FEVAR was used in 98 (66.2%) patients. The median number of vessels fenestrated was 3 (IQR: 2-4), with a total of 457 vessels stented. Twelve were percutaneous (12.2%) and 86 (87.8%) were open. All patients that required a sheath size>7F underwent high brachial open access, with the exception of 1 patient who underwent percutaneous axillary access with a 12F sheath. The median sheath size was 12F (IQR: 10-12), which was advanced into the descending thoracic aorta allowing multiple wire and catheter exchanges.
Results: One (1/98; 1.0%) hemorrhagic stroke in the upper extremity access group and 1 (1/54; 1.9%) ischemic stroke in the femoral-only access group occurred (P=0.67). The stroke in the upper extremity access group occurred 5 days after FEVAR and was related to uncontrolled hypertension, whereas the stroke in the femoral group occurred on postoperative day 3. Neither patient had signs or symptoms of a stroke immediately after FEVAR. The right upper extremity was accessed 6 times without a stroke (0/6; 0%), compared to the left being accessed 92 times with 1 stroke (1/92; 1.1%) (P=0.8). Four (4.1%) patients had complications related to upper extremity access; 1 (1.0%) required exploration for an expanding hematoma after manual compression for a 7F sheath, 1(1.0%) required exploration for hematoma and neurologic symptoms after open access for a 12F sheath; 2 (2.0%) patients with small hematomas did not require intervention. Two (2/12; 16.7%) of these complications were in the percutaneous access group, which were significantly more frequent than in the open group (2/86; 2.3%) (P=0.02).
Conclusion: Upper extremity access appears to be a safe and feasible approach for patients undergoing FEVAR. Open exposure in the upper extremity may be safer than percutaneous access during FEVAR. Unlike chimney and snorkel grafts, upper extremity access during FEVAR is not associated with an increased risk of stroke, despite the need for multiple visceral vessel stenting.


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