The brachial artery: a critical access for endovascular procedures

Axillary compared to brachial access for endovascular procedures

OBJECTIVES

Limited knowledge exists regarding access site complication rates between trans-axillary and trans-brachial approaches with sheath sizes ≥6Fr. We retrospectively reviewed our institution experience with access site complications for percutaneous trans-axillary and trans-brachial arterial interventions using sheath sizes ranging from 6Fr to 10Fr.

METHODS

We examined 67 endovascular interventions performed over 18 months, restricted to sheath sizes of 6Fr to 10Fr. Procedures utilizing trans-brachial (41 cases) and trans-axillary (26 cases) approaches under sonographic guidance were included. Cases involving hemodialysis accesses and those requiring surgical cut-down were excluded. The primary outcome measure was the occurrence of major access site complications (SIR grade-II/III) within 30 days, with data collected on hemostasis method, sheath size, and complications. Statistical analysis involved ANCOVA and Fisher's exact tests, with significance set at p < .05.

RESULTS

Successful percutaneous arterial access was achieved in all cases using either approach (trans-axillary or trans-brachial). Closure devices were employed in all axillary punctures and in 71% of brachial punctures. Major access site complications occurred in 7 out of 41 cases (17%) in the trans-brachial group and in 4 out of 26 cases (15%) in the trans-axillary group. However, there was no statistically significant difference in complication rates between the two groups, regardless of access site or sheath size.

CONCLUSION

Trans-axillary access serves as a safe and effective upper limb access method for percutaneous endovascular procedures requiring sheath size of 7Fr or larger when compared to trans-brachial approach.

Challenging the Controversy Surrounding Percutaneous Brachial Artery Access Related Complications: A Systematic Review and Meta-Analysis

BACKGROUND

Endovascular therapy has become increasingly preferred in the diagnosis and treatment of various conditions. The choice of arterial access usually depends on the type of procedure being performed with most via the common femoral artery and increasingly via the radial artery. Percutaneous access via the brachial artery has however been approached with caution due to the perceived increased risk for development of complications. Percutaneous brachial artery access (pBAA) has insufficient evidence when compared to femoral and radial access, with no large-scale studies available. The objective of this study is to review the literature and report the clinical and radiological complications associated with pBAA.

METHODS

EMBASE, EMCARE, CINAHL and Medline were searched for existing data on the complications associated with pBAA. Systematic review and meta-analysis were carried out on the data of 31 studies.

RESULTS

The results of this systematic review and meta-analysis indicates that the probability of post procedural haematoma was 4.76%, haemorrhage 1.43%, perforation 1.11% pseudoaneurysm 1.06%, spasm 0.9%, thrombus 0.55%, neuropathy 0.53%, occlusion 0.51%, ischaemia 0.37% and infection 0.24 %. Non-target vessel puncture, stenosis and stroke had a 0% incidence among the assessed population.

CONCLUSION

This study provides evidence to support clinical decision making when it comes to the utility of pBAA in endovascular diagnosis or therapy. The results demonstrate that pBAA is relatively safe with a low incidence of serious complications and thereby provide the clinician with the option of an alternate access point when planning treatment.

Adverse Events in Open Surgical vs. Ultrasound-Guided Percutaneous Brachial Access for Endovascular Interventions

Background: Advances in endovascular interventions have made endovascular approaches the first option for treating peripheral arterial diseases. Although radial artery access is commonly used for coronary procedures, the common femoral artery remains the most frequent site for endovascular treatments due to better ergonomics and proven technical success. Meanwhile, data on using upper extremity access via the brachial artery during complex endovascular aortic interventions are lacking. This study aimed to compare the incidence of access site complications between ultrasound-guided percutaneous brachial access (UPA) and open surgical incisional brachial access (OSA) in the management of peripheral arterial diseases. Methods: Patients who underwent treatment for peripheral arterial and aortic disease using brachial access from 2019 to 2023 were included in this study. The primary endpoint was the complication rate at the access site 30 days postoperatively. Access-related complications included bleeding requiring re-exploration, acute upper limb ischemia, thrombosis, pseudoaneurysm, arteriovenous fistula, and nerve injury associated with the brachial access. Results: Brachial access was performed on 485 patients (UPA, n = 320; OSA, n = 165). The mean operation time was 164.5 ± 45.4 min for the percutaneous procedure and 289.2 ± 79.4 min for the cutdown procedure (p = 0.003). Postprocedural hematoma occurred in 15 patients in the UPA group and 2 patients in the OSA group (p = 0.004). Thromboembolic events were observed in 9 patients in the percutaneous group and 3 patients in the OSA group. Reoperation was required for 23 patients in the percutaneous group and 8 patients in the cutdown group. Conclusions: The findings indicate that patients undergoing endovascular arterial interventions have a higher rate of brachial access complications in the UPA group compared to the OSA group.

Single Tract Aortic Revascularization Technique in the Treatment of Aortoiliac Occlusive Disease

Endovascular treatment is an acceptable option for patients with aortoiliac occlusive disease. However, bilateral passage of guidewires through the aortoiliac occlusion can be a challenging step in achieving successful revascularization. The aim of this article is to present a novel strategy for successfully passing bilateral guidewires through long aortoiliac occlusive lesions. After one guidewire is passed through the aortic and iliac lesions via one side of the femoral artery, the other guidewire is passed using the up-and-over technique and pulled out from the ipsilateral side of the body. This contralateral guidewire is then inserted into the ipsilateral angiographic catheter along with the ipsilateral guidewire. Subsequently, the angiographic catheter is removed in a manner similar to a peel-away sheath. Eventually, bilateral guidewires can be passed through the lesion via a single aortic tract.

Anemia to Median Nerve Palsy

Mesenteric angina has a high mortality rate. Occlusion of the superior mesenteric artery is the most common cause. Increasingly, it is managed endovascularly instead of by open revascularization. Despite the lower risk of complications in minimally invasive procedures, it is important to be mindful of long-term sequelae of minor complications. Patient education regarding risks and complications is paramount for better clinical outcomes. The risks of transbrachial angiography procedures are low. Postprocedural vigilance for interventionists and written educational advice to patients are paramount in all minimally invasive endovascular procedures, especially because most of these patients with a complication require urgent operative correction.

The Clinical Impact of Access Site Selection for Successful Thrombolysis and Intervention in Acute Critical Lower Limb Ischaemia (RAD-ALI Registry)

Background: Acute limb ischaemia (ALI) is of great clinical importance due to its consequent serious complications and high comorbidity and mortality rates. The purpose of this study was to compare the acute success and complication rates of CDT performed via transradial, transbrachial, and transfemoral access sites in patients with acute lower limb vascular occlusion and to investigate the 1-year outcomes of CDT and MT for ALI. Methods: Between 2008 and 2019, 84 consecutive patients with ALI were treated with CDT in a large community hospital. Data were collected and retrospectively analysed. The primary ("safety") endpoints encompassed major adverse events (MAEs), major adverse limb events (MALEs), and the occurrence of complications related to the access site. Secondary ("efficacy") endpoints included both technical and clinical achievements, treatment success, fluoroscopy time, radiation dose, procedure time, and the crossover rate to an alternative puncture site. Results: CDT was started with radial (n = 17), brachial (n = 9), or femoral (n = 58) access. CDT was technically successful in 74/84 patients (88%), but additional MT and angioplasty and/or stent implantation was necessary in 17 (20.2%) and 45 cases (53.6%), respectively. Clinical success was achieved in 74/84 cases (88%). The mortality rate at 1 year was 14.3%. The cumulative incidence of MAEs and MALEs at 12 months was 50% and 40.5%, respectively. After conducting multivariate analysis, history of Rutherford stage IIB (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.58-8.41; p = 0.0025), occlusion of the external iliac artery (HR, 27.52; 95% CI, 2.83-267.33; p = 0.0043), being a case of clinically unsuccessful thrombolysis (HR, 7.72; 95% CI, 2.48-23.10; p = 0.0004), and the presence of diabetes mellitus (HR, 2.18; 95% CI, 1.01-4.71; p = 0.047) were independent predictors of a high MAE mortality rate at 12 months. For MALEs, statistically significant differences were detected with the variables history of Rutherford stage IIB (HR, 4.30; 95% CI, 1.99-9.31; p = 0.0002) and external iliac artery occlusion (HR, 31.27; 95% CI, 3.47-282.23; p = 0.0022). Conclusions: Based on the short-term results of CDT, acute limb ischaemia can be successfully, safely, and effectively treated with catheter-directed thrombolytic therapy with radial, brachial, or femoral access. However, radial access is associated with fewer access site complications. A history of Rutherford stage IIB, occlusion of external iliac artery, unsuccessful thrombolysis, and the presence of diabetes mellitus were independently associated with an increased risk of MAEs. A history of Rutherford stage IIB and external iliac artery occlusion are independent predictors of MALEs.

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

BACKGROUND

There are many percutaneous coronary approaches. The most commonly used one is the radial artery because of its lowest risk of adverse vascular events. However, it could not be an option in some situations as congenital radial artery hypoplasia and spasm. In these cases, the second most common access is the femoral artery. The current literature over the brachial artery access is controversial. Thus, the aim of this study was to verify the brachial artery approach's effectiveness and safety.

RESULTS

We studied 300 patients who underwent elective coronary angiography and angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients with brachial access and 150 with femoral access. Access, procedural and fluoroscopy times were recorded. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, P = 0.05), but no significant difference noted regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not significantly differ (P = 0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ± 1.1 vs. 3.4 ± 0.7 min, P = 0.05) and hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, P < 0.001). Regarding major and minor complications (especially hematomas), they were significantly less in the brachial arm (P = 0.04 and P = 0.05, respectively).

CONCLUSIONS

Brachial access is a safe, efficient and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

Safety and learning curve of percutaneous axillary artery access for complex endovascular aortic procedures

BACKGROUND

Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management.

METHODS

One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular) were predeployed before the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed.

RESULTS

One-hundred forty-five patients underwent successful percutaneous axillary artery access; 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience.

CONCLUSIONS

Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in >90% of patients with a low incidence of access-related complications. There was a trend toward better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.

Alternative access for peripheral vascular interventions

Percutaneous endovascular interventions for advanced lower extremity peripheral arterial disease are becoming increasingly used, often as first-line treatment of chronic limb threatening ischemia. Advancements in endovascular techniques have provided safe and effective alternative revascularization options, especially for high-risk surgical patients. Although the classic transfemoral approach results in high technical success and patency rates, an estimated 20% of lesions remain challenging to access via an antegrade approach. As such, alternative access sites are important in the endovascular armamentarium for the management of chronic limb threatening ischemia. The goal of this review is to discuss alternative access sites, specifically the transradial, transpopliteal, and transpedal approaches, in addition to transbrachial and transaxillary access, and their outcomes in peripheral arterial disease and limb salvage.

Advanced Endovascular Treatment of Complex Aortic Pathology

Endovascular aortic aneurysm repair and thoracic endovascular aortic repair have been shown to reduce blood loss, operative time, length of hospital stay, mortality, and morbidity compared with open surgical repair for abdominal aortic aneurysms and thoracic aortic aneurysms. However, there are anatomical constraints that limit the application of the endovascular approach in 30% to 40% of patients, including those with short necks, excessive angulation, or aneurysms with the involvement of aortic side branches such as supra-aortic trunks, arch aneurysms, visceral arteries, or internal iliac arteries.

Single Primary Retrograde Access to Treat Femoro-Popliteal Occlusive Lesions

INTRODUCTION

The retrograde puncture of a distal artery is considered a bailout procedure in case of anterograde approach failure for peripheral artery disease (PAD) treatment. A single primary retrograde access has been suggested as an efficient and safe option. As scant data are available, we present our results using this approach.

MATERIAL AND METHODS

Between August 2019 and October 2022, we performed this technique in selected patients with femoro-popliteal PAD. Chronic total occlusions (CTOs) were selected on the basis of the CTOP classification. An ultrasound-guided retrograde puncture of a tibial artery at the ankle level was performed, followed by the preferential use of 4F materials. Hemostasis of the puncture site was obtained using manual compression. Postoperative duplex scan examination systematically included an evaluation of the punctured artery. Demographics, intraoperative, and follow-up data were collected retrospectively. The results are expressed as means with standard deviations and numbers with percentages when appropriate.

RESULTS

In total, 55 procedures were performed in 46 patients (9 bilateral). Of these, 57% (N=26) were considered at risk for femoral puncture (obesity, history of groin surgery, challenging crossover approach) and 54% (N=25) presented with critical limb-threatening ischemia (CLTI). The TASC-II femoro-popliteal classification was generally B (60%) and also C (33%) or D (7%). Mean lesion length was 105.6±49.4 mm and 65% were CTOs. Most patients were operated in an outpatient setting (N=25; 54%) under potentialized local anesthesia (N=41, 89%). The punctured site was the posterior tibial artery in 73% (N=40). The procedure time was 65.1±25.7 minutes, and the fluoroscopy time was 10.7±8.5 minutes. The technical success rate was 100%. There were no intraoperative complications. All patients could walk the same day. One CLTI patient presented an erysipelas related to the puncture in postoperative period. At 30 days, the primary patency of the treated and the punctured arteries were 98% and 100%, respectively.

CONCLUSION

A single primary retrograde access can be used safely to treat femoro-popliteal PAD. It represents a valuable alternative to the femoral puncture and allows fast ambulation. Prospective and long-term studies on larger populations are necessary to confirm our results.

CLINICAL IMPACT

This study demonstrates that a single primary retrograde access can be used safely without damaging the punctured artery to treat femoro-popliteal lesions, especially in claudicant patients. Chronic total occlusions can be treated successfully using this technique. This approach represents a valuable alternative to the femoral puncture and allows fast ambulation without risk of major bleeding.

Multicentre International Registry of Open Surgical Versus Percutaneous Upper Extremity Access During Endovascular Aortic Procedures

OBJECTIVE

To investigate access failure (AF) and stroke rates of aortic procedures performed with upper extremity access (UEA), and compare results of open surgical vs. percutaneous UEA techniques with closure devices.

METHODS

A physician initiated, multicentre, ambispective, observational registry (SUPERAXA - NCT04589962) was carried out of patients undergoing aortic procedures requiring UEA, including transcatheter aortic valve replacement, aortic arch, and thoraco-abdominal aortic endovascular repair, pararenal parallel grafts, renovisceral and iliac vessel repair. Only vascular procedures performed with an open surgical or percutaneous (with a suture mediated vessel closure device) UEA were analysed. Risk factors and endpoints were classified according to the Society for Vascular Surgery and VARC-3 (Valve Academic Research Consortium) reporting standards. A logistic regression model was used to identify AF and stroke risk predictors, and propensity matching was employed to compare the UEA closure techniques.

RESULTS

Sixteen centres registered 1 098 patients (806 men [73.4%]; median age 74 years, interquartile range 69 - 79 years) undergoing vascular procedures using open surgical (76%) or percutaneous (24%) UEA. Overall AF and stroke rates were 6.8% and 3.0%, respectively. Independent predictors of AF by multivariable analysis included pacemaker ipsilateral to the access (odds ratio [OR] 3.8, 95% confidence interval [CI] 1.2 - 12.1; p = .026), branched and fenestrated procedure (OR 3.4, 95% CI 1.2 - 9.6; p = .019) and introducer internal diameter ≥ 14 F (OR 6.6, 95% CI 2.1 - 20.7; p = .001). Stroke was associated with female sex (OR 3.4, 95% CI 1.3 - 9.0; p = .013), vessel diameter > 7 mm (OR 3.9, 95% CI 1.1 - 13.8; p = .037), and aortic arch procedure (OR 7.3, 95% CI 1.7 - 31.1; p = .007). After 1:1 propensity matching, there was no difference between open surgical and percutaneous cohorts. However, a statistically significantly higher number of adjunctive endovascular procedures was recorded in the percutaneous cohort (p < .001).

CONCLUSION

AF and stroke rates during complex aortic procedures employing UEA are non-negligible. Therefore, selective use of UEA is warranted. Percutaneous access with vessel closure devices is associated with similar complication rates, but more adjunctive endovascular procedures are required to avoid surgical exposure.

Perioperative adverse events in percutaneous versus open brachial access

OBJECTIVE

The objective of the present study was to compare the incidence of complications at the access site after percutaneous brachial access (PBA) and open brachial access (OBA) in the treatment of peripheral arterial disease.

METHODS

From November 2016 to November 2021, all patients who had undergone peripheral artery revascularization with brachial access were included. The primary outcome was the 30-day rate of postoperative complications at the access site. The complications included hematoma, arteriovenous fistula, and pseudoaneurysms that had resulted in prolonged hospitalization and/or reintervention.

RESULTS

Overall, 259 procedures with brachial access had been performed (PBA, n = 101; OBA, n = 158). The baseline clinical and demographic characteristics were well-balanced between the two groups. The sheath size was larger for the OBA procedures. Complications had occurred in 11 of 101 patients (11.1%) in the PBA group and 5 of 158 patients (3.2%) in the OBA group (P = .01). The mean duration of the procedure was significantly shorter for the PBA group (73.5 ± 46.5 minutes vs 101.2 ± 60.8 minutes; P = .0001).

CONCLUSIONS

For patients who had undergone brachial access for peripheral vascular disease, the rate of access site-related complications was significantly lower for the patients who had undergone open access compared with that for the patients who had undergone percutaneous access.

Comparing Outcomes of Transfemoral Versus Transbrachial or Transradial Approach in Carotid Artery Stenting (CAS)

BACKGROUND

While Transfemoral Carotid Artery Stenting (TFCAS) is a valid minimally invasive option for patients who also might be suitable for carotid endarterectomy (CEA) or transcarotid artery revascularization (TCAR), alternative access sites such as transbrachial (TB) or transradial (TR) are only utilized when anatomic factors preclude direct carotid or transfemoral access. In this study, we aimed to evaluate the outcomes of TR/TB access in comparison to TF for percutaneous carotid artery revascularization.

METHODS

All patients undergoing non-TCAR carotid artery stenting (CAS) from January 2012 to June 2021 in the Vascular Quality Initiative (VQI) Database were included. Patients were divided into 2 groups based on the access site for CAS: TF or TR/TB. Primary outcomes included stroke/death, technical failure and access site complications (hematoma, stenosis, infection, pseudoaneurysm and AV fistula). Secondary outcomes included stroke, TIA, MI, death, non-home discharge, extended length of postoperative stay (LOS) (>1 day), and composite endpoints of stroke/MI and stroke/death/MI. Univariable and multivariable logistic regression models were used to assess postoperative outcomes, and results were adjusted for relevant potential confounders including age, gender, race, degree of stenosis, symptomatic status, anesthesia, comorbidities, and preoperative medications.

RESULTS

Out of the 23,965 patients, TR/TB approach was employed in 819 (3.4%) while TF was used in 23,146 (96.6%). Baseline characteristics found men were more likely to undergo revascularization using TR/TB approach (69.4% vs. 64.9%, P = 0.009). Patients undergoing TR/TB approach were also more likely to be symptomatic (49.9% vs. 28.6%, P < 0.001). Guideline directed medications were more frequently used with TR/TB including P2Y12 inhibitor (80.3% vs. 74.7%, P < 0.01), statin (83.8% vs. 80.6%), and aspirin (88.3% vs. 84.5%, P = 0.003) preoperatively. On univariate analysis, patients with TB/TR approach experienced higher rates of adverse outcomes. After adjusting for potential confounders, TR/TB patients had no significant increase in the risk of stroke/death [aOR 1.10 (0.69-1.76), P = 0.675]; however, the use of TR/TB access was associated with a more than 2-fold increase in risk for in-hospital MI [aOR 2.39 (1.32-4.30), P = 0.004] and 2-fold increase in risk of technical failure [aOR 2.21 (1.31-3.73) P = 0.003]. The use of TR/TB access was also associated with a 50% reduction in the risk of access site complications [aOR 0.53 (0.32-0.85), P = 0.009].

CONCLUSIONS

This study confirms that although technically more challenging, TR or TB approach serves as a reasonable alternative with lower access site complications for CAS particularly in patients where anatomic factors preclude revascularization by TFCAS or TCAR. However, TR/TB is associated with an increased risk of technical failure and myocardial infarction, which requires further study.

Contralateral brachial arterial access for endovascular treatment of recurrent axillofemoral bypass graft stump syndrome: A case report

Axillofemoral bypass graft stump syndrome is an uncommon complication of axillofemoral bypass graft surgery. The traditional treatment is open surgical repair; however, endovascular recanalization can be achieved. Interventional treatment by approaching the brachial artery contralateral to the lesion site has rarely been reported in acute upper extremity ischemia. We report a case of recanalization through the left brachial artery due to embolic occlusion of the right brachial and axillary arteries and suspected axillofemoral bypass graft stump syndrome in a 71-year-old man. Access through the common femoral artery was impossible because the patient underwent reoperation of the left axillofemoral bypass and femorofemoral bypass due to occlusion of the right axillofemoral bypass and femorofemoral bypass surgery. Furthermore, bilateral radial arteries were occluded, allowing access to the left brachial artery. Two self-expandable stents were inserted into the occlusion of the right brachial and axillary arteries, and the stump area was covered. Aspiration thrombectomy was performed for embolism in the ulnar artery. Axillofemoral bypass graft stump syndrome can also be treated with interventional management. If access to the bilateral common femoral and radial arteries is not possible, an upper extremity arterial procedure through the contralateral brachial artery may be considered in cases of steno-occlusion of the upper extremities.

Study of course and termination of brachial artery by dissection and computed tomography angiography methods with clinical importance

The Brachial artery is a continuation of the axillary artery, from the inferior border of the tendon of teres major to the neck of the radius, terminating into radial and ulnar arteries just a cm distal to the elbow joint. Unlike veins, variations in the arteries are comparatively less common. Anatomical variations of the brachial artery occur in almost 20% of the cases and are commonly found during routine dissection or clinical practice. To observe the variations in the course and termination of brachial artery by dissection and computed tomography (CT) angiography methods. The present study was conducted on 40 upper limbs each in the department of Anatomy & Radiology of JSS Medical College and Hospital, Mysuru. The brachial artery was traced from origin to termination and variations were noted and photographed. Patients who were undergoing CT angiography of the upper limbs in JSS Hospital were included in the study. Variations noted and compared with the dissection method. In the present study, normal patterns of the brachial arterial course and termination were observed in 31 specimens. The remaining 9 specimens showed variant course and termination in the brachial artery like an unusually tortuous superficial brachial artery, superficial brachio-ulnar artery and brachio-radial artery. CT angiography showed 6 variations and a tortuous brachial artery. A detailed description of the vascular pattern of upper limbs especially variations in their origin and termination is of extreme importance in clinical practice. The knowledge of these variations is important for catheterization, graft harvesting, arteriovenous fistula creation, shunt application and astrup examination.

Multicenter Experience of Upper Extremity Access in Complex Endovascular Aortic Aneurysm Repair

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.

Transbrachial Access Site Complications in Endovascular Interventions: A Systematic Review of the Literature

The transfemoral approach (TFA) or transradial approach (TRA) serves as the primary technique for most endovascular cases; however, the transbrachial (TBA) route is an alternative access site used when TFA and TRA are contraindicated. Although TBA has advantages over TRA, such as the ability to accommodate large guide catheters and devices, there is some apprehension in implementing TBA due to perceived access site complication rates. This article aims to glean the rate of access site complication from current literature. Relevant studies were identified using the following search terms: ((access site complications) AND ((endovascular AND brachial) OR (percutaneous brachial access) OR (brachial))) OR (endovascular AND (percutaneous brachial access)); endovascular + brachial artery; endovascular + brachial artery + access site; and endovascular + brachial artery + access site complications. Articles published after 2008 addressing major complication rates from percutaneous TBA interventions were included. Fifteen studies out of 992 total articles met the inclusion criteria. The major access site complication rate was 75/1,424 (5.27%). Patients who underwent hemostasis with a vascular closure device (VCD) had a major complication rate of 13/309 (4.21%) compared to a major complication rate of 65/1122 (5.79%) for patients who underwent hemostasis with manual compression (MC). The major access site complication rate associated with TBA was 5.27%, which is relatively high compared to the complication rate in TFA or TRA. More prospective trials are needed to fully understand the access site complication rate in TBA interventions.

Percutaneous proximal axillary artery versus femoral artery access for endovascular interventions

OBJECTIVE

The primary objective of this study is to describe and illustrate the technique of ultrasound-guided percutaneous proximal axillary artery (PAA) access, and secondarily to evaluate the versatility and safety of this approach in peripheral, visceral, and aortic endovascular interventions.

METHODS

This is a single-center retrospective review of all peripheral, visceral, and aortic endovascular cases using percutaneous PAA access from February 2019 to March 2021 compared with a sample of an equivalent number of consecutive cases completed via percutaneous common femoral artery (CFA) access during the same time period. Access entry success, minor and major access site complications within 30 days, major adverse events within 30 days, demographics, and procedural details were analyzed using standard statistical analyses.

RESULTS

A total of 115 accesses-59 PAA and 56 CFA-were reviewed during the study period. Group demographics were not significantly different. Access entry success was achieved in 58 (98.3%) and 56 (100%) of PAA and CFA accesses, respectively, with no statistically significant difference. There were no significant differences in minor access-site complications (13.6% vs 5.4%; P = .21) major access site complications (3.4% vs 7.1%; P = .43), or major adverse events (6.8% vs 5.4%). between the PAA and CFA groups. With respect to versatility, PAA cases had a significantly greater mean number of vessels intervened on per procedure compared with CFA access (2.59 ± 1.31 vs 1.95 ± 0.98; P < .01). A wide range of target vessels were intervened on in both groups. PAA cases had significantly more bilateral lower leg interventions (28.8% vs 12.5%; P = .04). PAA access had a significantly longer mean procedure time (103.2 minutes vs 58.63 minutes; P < .001) and fluoroscopy time (18.21 minutes vs 12.87 minutes; P = .02).

CONCLUSIONS

The PAA is a feasible, versatile, and safe percutaneous access option for endovascular intervention. The in-line trajectory from this site facilitates visceral, renal, aortic, and bilateral lower extremity interventions with ease. Outcomes, complications, and major adverse events are similar to those of conventional CFA access in the short term.

Technical note: An alternative use of a steerable homemade for the treatment of chronic total occlusion of an iliac artery

INTRODUCTION

The complexity of the peripheral recanalization comes from the difficulty to cross the lesion or get into the subintimal space and its re-entry afterward, with a high risk of complications like artery dissection and/or rupture, which are life-threatening complications. To our knowledge, we report the first case of the use of a homemade steerable sheath for the successful revascularization of a heavy chronic total occlusion in a patient with unsuitable upper vascular access.

TECHNIQUE

By contralateral vascular access and the use of a 6Fr 55-cm Cook Flexor sheath and a pre-looped 0.014" choice guidewire, a steerable homemade sheath was used to achieve the support, pushability, and steer needed to access the subintimal space at the origin of a heavy occluded common iliac artery, thus giving us the ability to cross the lesion.

CONCLUSIONS

The homemade steerable sheath is feasible, quick, cheap, and easy to use, sparing the use of re-entry systems and catheters for the attempts of subintimal navigation. In addition, this technique gives the advantage to steer the catheters and wires as needed, avoiding non-desired re-entry points with secondary collaterals lumen compromise or extensive dissections.

Perioperative neurologic outcomes of right versus left upper extremity access for fenestrated-branched endovascular aortic aneurysm repair

OBJECTIVE

Upper extremity (UE) access is frequently used for fenestrated-branched endovascular aortic aneurysm repair (F-BEVAR), particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right- vs left-side UE access.

METHODS

During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs left UE access. End points included cerebrovascular events, perioperative mortality, technical success, and local access-related complications.

RESULTS

UE access was used in 361 (80%) patients. The right side was used in 232 (64%) and the left side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal, and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which three were ischemic and two were hemorrhagic. No transient ischemic attacks occurred perioperatively. Two hemorrhagic strokes were associated with permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P = .16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P = .99). Arm access-related complications occurred in 15 (5%) patients, 11 (4.8%) on the right side and 4 (6%) on the left side (P = .74).

CONCLUSIONS

Right UE access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or transient ischemic attacks. In general, UE access is not associated with an increased risk of perioperative stroke compared with femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.

The Transaxillary Approach via Prosthetic Conduit for Transcatheter Aortic Valve Replacement With the New-Generation Balloon-Expandable Valves in Patients With Severe Peripheral Artery Disease

Background: The left subclavian artery (LSA) is an infrequently used alternative access route for patients with severe peripheral artery disease (PAD) in patients who underwent transcatheter aortic valve replacement (TAVR). We report a new endovascular approach for TAVR combining an axillary prosthetic conduit-based access technique with new-generation balloon-expandable TAVR prostheses.

Methods and Results: Between January 2020 and December 2020, 251 patients underwent TAVR at the West German Heart and Vascular Center. Of these, 10 patients (3.9%) were deemed to be treated optimally by direct surgical exposure of the left or right axillary artery via a surgically adapted prosthetic conduit. All procedures were performed under general anesthesia. One procedural stroke occurred due to severe calcification of the aortic arch. No specific complications of the subclavian access site (vessel rupture, vertebral, or internal mammary ischemia) were reported. Two minor bleedings from the access site could be treated conservatively. No surgical revision was necessary.

Conclusion: The axillary prosthetic conduit-based access technique using new-generation balloon-expandable valves allows safe and successful TAVR in a subgroup of patients with a high risk of procedural complications due to severe peripheral vascular disease. Considering the increasing number of patients referred for TAVR, this approach could represent an alternative for patients with limited access sites.

Percutaneous Axillary Artery Access for Peripheral and Complex Endovascular Interventions: Clinical Outcomes and Cost Benefits

OBJECTIVES

The aim of this study was to determine the safety, efficacy, and applicability of percutaneous axillary artery (pAxA) access in patients requiring upper extremity large sheath access during complex aortic, cardiac, and peripheral endovascular procedures. We also take this opportunity to address the potential cost-benefits offered by pAxA access compared to open upper extremity access.

METHODS

A total of 26 consecutive patients, between June 2018 and October 2020, underwent endovascular intervention, requiring upper extremity access (UEA). Ultrasound-guided, percutaneous access of the axillary artery was used in all 26 patients with off-label use of pre-close technique with Perclose ProGlide closure devices. Access sites accommodated sheath sizes that ranged from 6 to 14 French (F). End points were technical success and access site-related complications including isolated neuropathies, hematoma, distal embolization, access-site thrombosis, and post-operative bleeding requiring secondary interventions. Technical success was defined as successful arterial closure intraoperatively with no evidence of stenosis, occlusion, or persistent bleeding, requiring additional intervention.

RESULTS

Of the 26 patients requiring pAxA access, 15 underwent complex endovascular aortic aneurysm repairs (EVAR) with branched, fenestrated, snorkel, or parallel endografts, 6 underwent peripheral vascular interventions, and 5 underwent cardiac interventions. Fifty-three percent accommodated sheath sizes of 12F or higher. Technical success was achieved in 100% of cases with no major perioperative access complications requiring additional open or endovascular procedures. In our series, we had one post-operative mortality secondary to myocardial infarction in a patient with significant coronary artery disease.

CONCLUSIONS

Our data again demonstrated the proposed safety and efficacy attributable to pAxA access, while extending its application to wide spectrum of endovascular interventions which included peripheral or coronary vascular in addition to complex EVAR.

Transradial versus transfemoral access for acute stroke endovascular thrombectomy: a 4-year experience in a high-volume center

PURPOSE

To compare clinical outcomes and safety of transradial (TRA) versus transfemoral access (TFA) for endovascular mechanical thrombectomy in acute stroke patients.

METHODS

Retrospective analysis of 832 consecutive patients with acute stroke undergoing interventional thrombectomy using TRA (n = 64) or TFA (n = 768).

RESULTS

Direct TFA failures occurred in 36 patients, 18 of which underwent crossover TFA to TRA, while direct TRA failures occurred in 2 patients having both crossovers to TFA. Successful catheterization was achieved in 96.8% (62/64) and 95.3% (732/768) of patients undergoing direct TRA and direct TFA, respectively, without significant differences. The median (IQR) catheterization time was 10 (8-16) min in the direct TRA group and 15 (10-20) in the direct TFA group (P < 0.001). This difference was also significant in the subgroup of anterior circulation strokes and in patients younger and older than 80 years of age. The majority of procedures yielded thrombolysis in cerebral infarction grade 2b/2c/3 revascularization in patients undergoing direct TRA (88.5%) and direct TFA (90.8%), without statistically significant differences. The median (IQR) puncture to recanalization time was 37 (24-58) min for the direct TRA group and 42 (28-70) min for the direct TFA group. Significant differences in access site complications, symptomatic ICH, and mRS score 0-2 at 90 days between both TRA and TFA accesses were not found.

CONCLUSIONS

TRA is not inferior to TFA in the probability of catheterization, times of catheterization and revascularization, and other clinical outcomes for mechanical thrombectomy in acute stroke.

Brachial and axillary artery vascular access for endovascular interventions

OBJECTIVES

Endovascular access is usually achieved through the common femoral artery due to its large size and accessibility. Access through the upper extremity can however be necessary due to anatomic reasons, obesity, or peripheral arterial disease. The two main methods of access are surgical cutdown and percutaneous puncture. In this single-centre retrospective cohort study we compared complication risks for both surgical cutdown and percutaneous puncture of an upper arm approach.

MATERIALS AND METHODS

Data was obtained from patients receiving endovascular access through the brachial or axillary artery between 2005 and 2018. A total of 109 patients were included. Patient demographics including age, sex, medical history, smoking status, and actual medication were registered, as well as postoperative complications including hematoma, thrombosis, dissection, infection, pseudoaneurysm, nerve injury, reoperation, and readmission.

RESULTS

Access was achieved through surgical cutdown in 53% (n=58) and through percutaneous puncture in 47% (n=51) of patients. Fifty-eight percent (n=63) received access via the brachial artery and 42% (n=46) via the axillary artery. Complication rate was 25.0% (3 of 12) for surgical cutdown via the brachial artery, 29.4% (15 of 51) for percutaneous puncture via the brachial artery, and 10.9% (5 of 46) for surgical cutdown via the axillary artery. Major complication rate was 8.3% (1 of 12) for surgical cutdown via the brachial artery, 13.7% (7 of 51) for percutaneous puncture via the brachial artery, and 4.3% (2 of 46) for surgical cutdown via the axillary artery. There was no association between baseline patient characteristics and complication rate.

CONCLUSIONS

In this non-randomized retrospective study, surgical cutdown via the axillary artery was the safest option with fewest complications, but selection of patients may have blurred the results. Surgical cutdown and percutaneous puncture seem equally safe in terms of complication rate in the brachial artery.

Complication rates of percutaneous brachial artery puncture: effect of live ultrasound guidance

Purpose

The current literature on the use of brachial artery access is controversial. Some studies found increased puncture site complications. Others found no higher complication rates than in patients with femoral or radial access. The purpose of this study was to determine the impact of ultrasound (US)-guidance on access site complications.

Materials and methods

This is a single-center retrospective study of all consecutive patients with brachial arterial access for interventional procedures. Complications were classified into minor complications (conservative treatment only) and major complications (requiring surgical intervention). The brachial artery was cannulated in the antecubital fossa under US-guidance. After the intervention, manual compression or closure devices, both followed by a compression bandage for 3 h, either achieved hemostasis.

Results

Seventy-five procedures in seventy-one patients were performed in the study period using brachial access. Access was successful in all cases (100%). Procedures in different vascular territories were performed: neurovascular (10/13.5%), upper extremity (32/43.2%), visceral (20/27.0%), and lower extremity (12/16.3%). Sheath size ranged from 3.2F to 8F (mean: 5F). Closure devices were used in 17 cases (22.7%). In total, six complications were observed (8.0%), four minor complications (5.3%, mostly puncture site hematomas), and two major complications, that needed surgical treatment (2.7%). No brachial artery thrombosis or upper extremity ischemia occurred.

Conclusion

Exclusive use of US-guidance resulted in a low risk of brachial artery access site complications in our study compared to the literature. US-guidance has been proven to reduce the risk of access site complications in several studies in femoral access. In addition, brachial artery access yields a high technical success rate and requires no additional injection of spasmolytic medication. Sheath size was the single significant predictor for complications.

Management of Postoperative Complications Following Endovascular Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) is a minimally invasive therapeutic approach to manage abdominal aortic pathologies (eg, aneurysm and dissection). EVAR was first introduced in 1991. In 1994, endovascular technique was also applied for thoracic aorta, thoracic endovascular aortic repair (TEVAR). In recent decades, EVAR has become an acceptable first-line treatment with 50% utilization rate across most practices, especially in high-risk patients. The safety profile of EVAR is comparable to the open approach, with superiority in terms of perioperative mortality and morbidity. This article summarizes the most common complications following EVAR/TEVAR and the most current treatment modalities across practices.

TRIACCESS Study: Randomized Comparison Between Radial, Femoral, and Pedal Access for Percutaneous Femoro-popliteal Artery Angioplasty

BACKGROUND

The aim of this randomized study was to compare the success and complication rates of different access sites for the treatment of superficial artery stenosis.

METHODS AND RESULTS

A total of 180 consecutive patients were randomized in a prospective study to treat symptomatic superficial femoral artery stenosis via radial (RA), femoral (FA), or pedal artery (PA) access. Technical success was achieved in 96.7%, 100%, and 100% of the patients in the RA, FA, and PA groups, respectively (p=0.33). Secondary access sites were used in 30%, 3.3%, and 30% of the patients in the RA, FA, and PA access groups, respectively (p=0.0002). Recanalization for chronic total occlusion was performed in 34/36 (94.4%), 30/30 (100%), and 46/46 (100%) patients in the RA, FA, and PA groups, respectively (p=0.17). The X-ray dose was significantly lower in the PA group than that in the RA and FA access groups (63.1 vs 162 vs 153 Dyn, p=0.0004). The cumulative rates of access site complications in the RA, FA, and PA groups were 3.3% (0% major and 3.3% minor), 16.7% (3.3% major and 13.3% minor), and 3.3% (3.3% major and 0% minor) (p=0.0085), respectively. The cumulative incidence of MACEs at 6 months in the RA, FA, and PA groups was 5%, 6.7%, and 1.7%, respectively. The cumulative incidence of MALEs at 6 months in the RA, FA, and PA groups was 20%, 16.7%, and 9.2%, respectively (p=0.54).

CONCLUSION

Femoral artery intervention can be safely and effectively performed using radial, femoral, and pedal access, but radial and pedal access is associated with a lower access site complication rate and hospitalization. Pedal access is associated with a lower X-ray dose than that with radial and femoral access.

Comparison of Access Site-Related Complications and Quality of Life in Patients after Invasive Cardiology Procedures According to the Use of Radial, Femoral, or Brachial Approach

The radial approach (RA) is the most common in invasive cardiology, but depending on the clinical situation, the femoral approach (FA) and brachial approach (BA) are also used. The BA is associated with the highest odds of complications so it is used mainly if a first-choice approach fails. The aim of the study was to assess clinical outcomes after invasive cardiology procedures stratified by the use of the RA, FA, and BA, with a focus on access site-related complications, quality of life (QoL), and patients' perspective. A total of 250 procedures (RA: 98; FA: 99; BA: 53) performed between 2013 and 2020 were retrospectively analyzed. Puncture site-related complications, vascular events, patient preferences, and QoL were assessed by the analysis of medical records and telephone follow-up using a proprietary questionnaire and the modified EQ-5D-3L questionnaire. Patients from the RA group received the smallest volume of contrast during a percutaneous coronary interventions (PCI) procedure (RA vs. FA vs. BA: 180 (150-240) mL vs. 200 (180-270) mL vs. 190 (100-200) mL, p = 0.045). The access site was changed most frequently in the procedures initiated from the RA (p < 0.04). Overall puncture site-related complications, especially local hematomas, occurred most commonly in the BA group (7.1, 14.1, and 24.5% for RA, FA, and BA, respectively, p = 0.01). During the index procedure, the access site was changed most frequently in procedures initiated from the RA (19.7, 8.5 and 0%, p = 0.04). The RA was indicated as an approach preferred by the patient for a hypothetical next procedure (87.9, 55.4, and 70.0% for subjects preferring the same approach out of patients who underwent a procedure by the RA, FA, and BA, respectively, p < 0.001). For the RA and FA, the prevalence of moderate or extreme access site-related problems in self-care decreased significantly (RA: p < 0.01, FA: p < 0.05) within 1 month after the index procedure (RA: 18.1, 4.2, and 1.4%; FA: 20.7, 11.1, and 9.6% periprocedurally, after 1 and 6 months, respectively). In contrast, for the BA these percentages were higher and a significant improvement (p < 0.05) was delayed until 6 months (54.6, 36.4, and 18.2% periprocedurally, after 1 and 6 months, respectively). In conclusion, compared to the BA and FA, the RA appears to be not only the safest, mainly due to the lowest risk of puncture site-related complications after coronary procedures but also represents a preferable approach from the patient's perspective. Although overall post-procedural QoL outcomes did not differ significantly according to the access site, nevertheless, the BA was associated with more frequent self-care problems whose improvement was delayed until more than one month after the index procedure.

Periprocedural Outcomes of Popliteal vs Upper Extremity Access in the Treatment of Superficial Femoral Artery Occlusive Disease

PURPOSE

Percutaneous lower extremity revascularization is being performed via upper extremity, pedal, or popliteal access with increasing frequency. This study aimed to compare periprocedural outcomes of popliteal (POA) and upper extremity (UEA) access for the treatment of isolated superficial femoral artery (SFA) occlusive disease.

MATERIALS AND METHODS

A retrospective cohort study compared the outcomes of patients undergoing primary percutaneous intervention of SFA occlusive disease with POA or UEA using the Vascular Quality Initiative database from December 2010 to June 2019. Our primary endpoint was technical success. Secondary endpoints included factors associated with perioperative complications.

RESULTS

A total of 349 patients underwent isolated SFA intervention through the popliteal, radial, or brachial artery. UEA was performed in 188 (53.9%) patients and POA in 161 (46.1%). Technical success with TASC A lesions was 95.8% and with TASC D lesions, 65.0%. POA had a higher proportion of TASC D lesions (24.8% vs 10.6%, p<0.001), and larger (≥7 Fr) sheath size (14.3% vs 2.7%, p<0.001). UEA had a higher proportion of no calcification (27.1% vs 11.2%, p<0.001), and smaller (4-5 Fr) sheath size (46.8% vs 34.8%, p=0.023). There was no difference in technical success between UEA and POA (88.8% vs 84.5%, p=0.230), which was also seen on multivariable analysis (p=0.985). Univariate analysis revealed technical failure was associated with TASC D lesions (45.7% vs 12.9%, p<0.001) and the presence of severe calcifications (39.1% vs 17.5%, p=0.002). Multivariable analysis confirmed technical failure was associated with degree of calcification (OR, 2.4; 95% CI, 1.18 to 4.89; p=0.016) and TASC D lesions (OR, 5.01; 95% CI, 2.45 to 10.24; p<0.001). Postoperative complications were associated with UEA on univariate (p=0.041) and multivariate analysis (OR, 2.08; 95% CI, 0.80 to 5.37; p=0.016). Access site complications were also associated with UEA compared to POA (4.3% vs 0.0%, p=0.027).

CONCLUSIONS

There is no difference in technical success between UEA and POA when treating isolated SFA occlusive disease, and UEA is associated with a higher complication rate. Technical success is dependent on calcification and TASC II classification. Based on similar technical success rates and low complication rates, POA should be considered as a viable alternative to UEA when planning endovascular interventions.

Lateral Axillary Exposure for Antegrade Access during Endovascular Repair of Complex Abdominal Aortic and Thoracoabdominal Aneurysms

BACKGROUND

During endovascular treatment of pararenal aortic aneurysms (PAA) and thoracoabdominal aortic aneurysms (TAAA), our antegrade vascular access of choice is a lateral axillary exposure (LAE). We directly access the axillary artery with multiple sheaths followed by primary closure of the axillary artery at case completion. The aim of this study is to describe our technique and to report our results with this approach.

METHODS

This study is a single-institution, retrospective review of 53 patients who were treated with parallel grafts for endovascular repair of PAA and TAAA from 2006 to 2018. The aortic repairs requiring LAE included: 9 cases of endo-leaks from prior endovascular repair, 20 TAAAs, and 24 PAAs. The axillary artery was exposed with a vertical axillary skin incision followed by retraction of the lateral border of the pectoralis major to expose the axillary artery distal to the pectoralis minor. A 5-French (F) through 12F sheaths were used to directly access the axillary artery for delivery of endovascular devices.

RESULTS

Two hundred and sixty reno-visceral stents were delivered through 125 axillary sheaths in an antegrade fashion to 114 arteries without intraoperative complications or technical failures. Two postoperative complications included an access-site hematoma managed conservatively (1.9%) and a left brachial vein thrombosis treated with anticoagulation (1.9%). There were no cases of cerebrovascular or peripheral neurologic events, upper extremity ischemia, or reoperation related to LAE.

CONCLUSIONS

LAE is a valid approach for upper extremity access during the endovascular repair of complex aortic aneurysms requiring simultaneous delivery of multiple reno-visceral devices. It does not require the use of a prosthetic conduit. There were no neurologic events or upper extremity ischemia in our series.

Transradial artery access for percutaneous cardiovascular procedures: state of the art and future directions

The transradial access (TRA) for cardiac catheterization and percutaneous coronary intervention (PCI) has been widely adopted in the last decades since its first description in the late 40s. The transradial approach has been associated with favorable outcomes as compared with transfemoral access (TFA) in several registries and randomized clinical trials, mainly due to the lower incidence of access-site bleedings, vascular complications and improved patient comfort. This review aimed to summarize the body of evidence supporting the use of TRA, to discuss clinical implications, possible technical limitations and future directions, such as the implementation of TRA as the primary access for complex procedures and structural interventions.

[Endovascular repair of a descending thoracic aortic aneurysm: one-year follow-up results]

The article deals with the results of successful surgical management of a male patient with a ruptured thoracic aortic aneurysm, posing particular problems as to deciding upon the scope and stages of surgical reconstruction, accompanied by describing the dynamics of clinical and diagnostic parameters, as well as the main events of the postoperative period. This clinical case report was characterized by additional difficulties due to the occurrence of subtotal haemothorax. Also presented herein is a set of comprehensive measures making it possible to successfully complete open reconstruction of the thoracic portion of the aorta and to achieve a satisfactory outcome both during the in-hospital period and within one-year follow up. Besides, elucidated is the state-of-the-art of this problem in the world literature.

A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair

BACKGROUND

Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score.

METHODS

Elective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed.

RESULTS

Overall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset.

CONCLUSIONS

This novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

Distal Radial Artery Access for Superficial Femoral Artery Interventions

PURPOSE

To compare the acute success and complication rates of distal radial (DR) vs proximal radial (PR) artery access for superficial femoral artery (SFA) interventions.

MATERIALS AND METHODS

Between 2016 and 2019, 195 consecutive patients with symptomatic SFA stenosis were treated via DR (n=38) or PR (n=157) access using a sheathless guide. Secondary access was achieved through the pedal artery when necessary. The main outcomes were technical success, major adverse events (MAEs), and access site complications. Secondary outcomes were treatment success, fluoroscopy time, radiation dose, procedure time, and crossover rate to another puncture site.

RESULTS

Overall technical success was achieved in 188 patients (96.4%): 37 of 38 patients (97.3%) in the DR group and 151 of 157 patients (96.2%) in the PR group (p=0.9). Dual (transradial and transpedal) access was used in 14 patients (36.8%) in the DR group and 28 patients (18.9%) in the PR group (p<0.01). Chronic total occlusions were recanalized in 25 of 26 DR patients (96.1%) and in 79 of 81 PR patients (92.6%) (p=0.57). The crossover rate to femoral access was 0% in the DR group vs 3.2% in the PR group (p=0.59). Stents were implanted in the SFA in 15 DR patients (39.4%) and in 39 patients (24.8%) in the PR group (p=0.1). The contrast volume, fluoroscopy time, radiation dose, and procedure time were not statistically different between the DR and PR groups, nor were the rates of access site complications (2.6% and 7.0%, respectively). The cumulative incidences of MAE at 6 months in the DR and PR groups were 15.7% vs 14.6%, respectively (p=0.8).

CONCLUSION

SFA interventions can be safely and effectively performed using PR or DR access with acceptable morbidity and a high technical success rate. DR access is associated with few access site complications.

Distal Radial Artery Access for Superficial Femoral Artery Interventions

Purpose:

To compare the acute success and complication rates of distal radial (DR) vs proximal radial (PR) artery access for superficial femoral artery (SFA) interventions.

Materials and Methods:

Between 2016 and 2019, 195 consecutive patients with symptomatic SFA stenosis were treated via DR (n=38) or PR (n=157) access using a sheathless guide. Secondary access was achieved through the pedal artery when necessary. The main outcomes were technical success, major adverse events (MAEs), and access site complications. Secondary outcomes were treatment success, fluoroscopy time, radiation dose, procedure time, and crossover rate to another puncture site.

Results:

Overall technical success was achieved in 188 patients (96.4%): 37 of 38 patients (97.3%) in the DR group and 151 of 157 patients (96.2%) in the PR group (p=0.9). Dual (transradial and transpedal) access was used in 14 patients (36.8%) in the DR group and 28 patients (18.9%) in the PR group (p<0.01). Chronic total occlusions were recanalized in 25 of 26 DR patients (96.1%) and in 79 of 81 PR patients (92.6%) (p=0.57). The crossover rate to femoral access was 0% in the DR group vs 3.2% in the PR group (p=0.59). Stents were implanted in the SFA in 15 DR patients (39.4%) and in 39 patients (24.8%) in the PR group (p=0.1). The contrast volume, fluoroscopy time, radiation dose, and procedure time were not statistically different between the DR and PR groups, nor were the rates of access site complications (2.6% and 7.0%, respectively). The cumulative incidences of MAE at 6 months in the DR and PR groups were 15.7% vs 14.6%, respectively (p=0.8).

Conclusion:

SFA interventions can be safely and effectively performed using PR or DR access with acceptable morbidity and a high technical success rate. DR access is associated with few access site complications.

Percutaneous brachial access associated with increased incidence of complications compared with open exposure for peripheral vascular interventions in a contemporary series

OBJECTIVE

Although percutaneous brachial access has been used more often for peripheral vascular interventions (PVIs), previous studies have suggested that open brachial artery exposure for access is associated with fewer complications than percutaneous access. The present study sought to determine the incidence of complications for each access method and identify the predictors of access site complications after brachial access.

METHODS

The Vascular Quality Initiative national database was queried for all patients who had undergone PVI with brachial artery access from 2016 to 2019. Procedures with simultaneous thrombolysis or open procedures were excluded. The primary outcome was any perioperative brachial artery access complications. Multivariable logistic regression was used to identify any associated predictors.

RESULTS

A total of 1400 procedures had been performed for 1242 patients; 189 procedures (13.5%) had used an open exposure. The mean patient age was 67.3 ± 9.5 years, and 55.7% of the procedures were on men. No significant demographic differences were found between the open and percutaneous groups. Open exposure procedures were more likely to have used sheaths >5F (79.4% vs 59.0%; P < .001) and treated more arteries (2.0 ± 1.8 vs 1.7 ± 0.9; P < .001) but less likely to have used multiple access sites (8.5% vs 20.1%; P < .001). Access complications occurred in 7.5% of the percutaneous procedures and 1.6% of the open exposures (P = .003). Percutaneous access was independently associated with the occurrence of brachial access complications (odds ratio [OR], 5.92; 95% confidence interval [CI], 1.76-19.9; P = .004). Other associated factors included female sex (OR, 2.23; 95% CI, 1.44-3.44; P < .001), congestive heart failure (OR, 2.02; 95% CI, 1.26-3.24; P = .003), and increasing sheath size (OR, 1.36 per each 1F increase in size; 95% CI, 1.07-1.72; P = .011); diabetes was protective (OR, 0.53; 95% CI, 0.33-0.83; P = .006).

CONCLUSIONS

Open exposure might be advantageous compared with percutaneous access for preventing complications after brachial access. However, the difference in complications was driven by hematomas that were managed nonoperatively. Operative complications were more common in the percutaneous group, although this did not reach statistical significance. Percutaneous access should be used cautiously in women, patients with a history of congestive heart failure, those without diabetes, and interventions in which larger sheaths are required.

Percutaneous Endovascular Aneurysm Repair: Current Status and Future Trends

Endovascular aneurysm repair (EVAR) is a common, safe, and effective method of treating abdominal aortic aneurysms. Traditionally treated via surgical cutdown over the common femoral arteries, many recent studies demonstrate percutaneous access techniques to avoid the surgical cutdown. Developing familiarity with these percutaneous techniques, including risks, complications, adjuncts, and alternative accesses, can help improve the outcomes and availability of EVAR. As these techniques become increasingly common, it is not unlikely that they can be practiced safely in select patients in an outpatient setting.

Delayed severe median nerve palsy due to undiagnosed brachial pseudoaneurysm

Post-catheterization pseudoaneurysms are a well-known complication of many endovascular procedures at the site of arterial puncture. However, long-term neurological complications due to undiagnosed compression are rare. A 60-year-old man presented to our unit for round, non-pulsatile, painless swelling in the inner side of his upper arm. Clinical examination showed finger paralysis, associated with amyotrophy of the forearm. Large brachial pseudoaneurysm with median nerve compression was diagnosed. The patient underwent autologous vein bypass, with poor 6-month neurological recovery. Early diagnosis of pseudoaneurysms is paramount because, when associated with nerve compression, the longer the diagnostic delay, the poorer the neurological prognosis.

Safety and Efficacy of Transbrachial Access for Endovascular Procedures: A Single-Center Retrospective Analysis

BACKGROUND

Endovascular procedures nowadays are generally performed via the femoral and radial artery. Although not routinely used by many, there is still an essential role for vascular interventions via brachial access. The technological advancement of endovascular devices leads to a significant increase of the variety of percutaneously treatable vascular pathology. The brachial artery approach nowadays is becoming crucial for complex procedures either as single access or in the context of mandatory double vascular approach for many complex interventions.

OBJECTIVE

To evaluate the safety and efficacy of brachial artery access for diagnostic arteriography and endovascular interventions in different vascular territories in a single-center setting on the basis of a retrospective analysis of prospectively collected data in a large patient cohort.

METHODS

Between 01/2013 and 09/2016, 11,274 endovascular procedures were performed in our hospital, 847 (7.5%) of them via brachial access, presenting the database for this study. All demographic, clinical, and periprocedural data were obtained prospectively and included in the computerized hospital records, and on this basis, a retrospective analysis was performed.

RESULTS

While the radial access was the most used and constant for coronary and noncoronary interventions in our center (71%) in this period, the use of brachial access increased (from 4% to 12%) causing the femoral to decrease (from 27% to 16%). We used the brachial approach for diagnostic purposes in 162 patients (19%) and for head to toe endovascular interventions (including angioplasty, stenting, thrombolysis, or as adjunctive access) in 685 patients (81%). For 53 patients (6.2%), this was the only possible access for endovascular intervention. Overall access site-related complications occurred in 25 patients (2.9%), in 19 of them (2.2%) required surgical correction, for brachial artery thrombosis or pseudoaneurysm. The other six were managed conservatively. No permanent neurological deficits of the arm or severe bleeding were observed. Minor complications, mostly hematomas, occurred in 62 patients (7.3%), but they required no further treatment.

CONCLUSION

Brachial artery access expands our capability to perform complex procedures by allowing us to reach arterial targets in all territories. Complications of brachial vascular access are gradually decreasing together with the decrease of the crossing profile of the devices used in practice. However, when they occur, they often require surgical treatment. The growing experience of the team not only while obtaining the access but also while achieving adequate hemostasis ("patent hemostasis") is of great importance for minimizing the complications.

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

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 69-78) 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 = .002), oral anticoagulants therapy (p = .005) and procedure length (p = .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 (10-16F) 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.

Avoiding peripheral nerve injury in arterial interventions

Although peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or by manual compression with incidence in literature ranging from as low as 0.04% for femoral access in a large retrospective study to 9% for brachial and axillary access. Given the increasing frequency of endovascular arterial procedures and the increasing use of nontraditional access points, it is important that the interventionalist have a working knowledge of peripheral nerve anatomy and function as it relates to relevant arterial access sites to avoid injury.