Alternative Aortic Access: Translumbar, Transapical, Subclavian, Conduit, and Transvenous Access to the Aorta

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.

Trans-Iliac Aortic Valve Replacement: Feasibility, Safety, and Medium-Term Follow-up

Background

Transcatheter aortic valve replacement (TAVR) is nowadays generally accepted as the treatment of choice for high- to intermediate-risk patients with severe aortic stenosis not suitable for the standard surgical replacement. Many vascular accesses have been described for the valve delivery, comprising the common iliac artery as the arterial site of access.

Methods

From September 2008 to June 2014, 440 patients underwent TAVR at our institution. We report a series of 12 patients that have undergone TAVR via a trans-iliac (TI) retroperitoneal surgical approach and also discuss its feasibility, security, and medium-term follow-up.

Results

The 30-day survival rate was 92%. Only 1 local vascular access major complication occurred requiring an iliac-femoral bypass grafting with a vascular graft. Two patients experienced transient neurological ischemic attack. At 3-year follow-up, all the 11 patients were alive and well and the echocardiographic evaluation revealed good function of the prosthesis.

Conclusions

The TI route seems to be feasible with a low profile of local complications. It may be a reasonable access alternative to the femoral artery and to the trans-apical approach. A broader, prospective study is advisable to gain general consensus on this approach.

Unconventional Endovascular Access for Symptomatic Thoracic Aortic Ulcer with Infrarenal Aortic Occlusion-A Case Report

BACKGROUND

A man in very poor general condition was admitted for acute thrombosis of the infrarenal aorta associated to a penetrating aortic ulcer (PAU) of the distal thoracic aorta.

METHODS

We planned a two-stage procedure: an axillobifemoral revascularization to be followed by thoracic endovascular aortic repair (TEVAR) after rehabilitation. Before the second stage, the patient presented with acute respiratory failure secondary to an abrupt PAU evolution.

RESULTS

A properly selected stent graft was successfully deployed in an antegrade manner through a left axillary artery access with the nose of the delivery system pushed over a guidewire deep into the aortic thrombosis.

CONCLUSIONS

Inadequate access and paraplegia are the major challenges hampering clinical success of TEVAR. Off-the-shelf stent graft can be used outside its primary use in an unconventional setting. Careful planning, consideration of all comorbidities and vascular anatomy, as well as correct choice of the device are crucial for the successful treatment.

Impact of sheath diameter of different sheath types on vascular complications and mortality in transfemoral TAVI approaches using the Proglide closure device

OBJECTIVE

Evaluation of the impact of the sheath diameter on vascular complications and mortality in transfemoral aortic valve implantation.

METHOD

Between 2012 and 2014, 183 patients underwent the procedure using a sheath diameter of 18-24 F. This collective was divided into two groups: group 1, with a sheath diameter of 18F (G1, n = 94), consisted of patients with 18F Medtronic Sentrant and 18 F Direct Flow sheaths, and group 2 with a sheath diameter of 19-24 F (G2, n = 89) consisted of patients with Edwards expandable e-sheath and Solopath sheaths. Perclose-Proglide® was used as a closure device in all patients.

RESULTS

G1 had significantly more female patients (64.9% vs. 46.1% in G2, p = 0.01) and the average BMI was lower (26 ± 4.5% vs. 27.4 ± 4.7%, p = 0.03). There was no significant difference in the incidence of major and minor vascular complications (G1: 12.8% vs. G2: 12.4%, p = 0.9). 30-day mortality was similar in both groups (G1: 6.4 ± 2.5% [95% CI: 0.88-0.98], G2: 3.7 ± 1.9% [95% CI: 0.92-0.99]. The Kaplan Meier analysis of survival revealed no significant differences either.

CONCLUSION

The difference in sheath diameter had no effect on either incidence or severity of vascular complications. There was no impact on mortality either.

Superficial femoral artery access for transcatheter aortic valve replacement

Different vascular accesses have been described for the delivery of a transcatheter aortic bioprosthesis. We report the use of the superficial femoral artery (SFA) as the arterial site of puncture with surgical cut-down. It may be a reasonable access alternative to the other classical routes, especially in the setting of either obese patients with elevated body mass index or in the presence of high femoral artery bifurcation. This route seems to be feasible with a low-profile risk.