The right brachial access is safe for branched EVAR in complex aortic disease
Nikolaos Tsilimparis, MD,MD, Beatrice Fiorucci, MD, E. Sebastian Debus, MD, PhD, Fiona Rohlffs, MD, Fabio Verzini, MD, PhD, Tilo Kölbel, MD, PhD.
Heart Center Hamburg, Hamburg, Germany.
Introduction: The risk of peri-operative cerebrovascular events in endovascular repair of thoracic and thoracoabdominal aneurysms is reported from 2-15%. The unavoidable use of an upper extremity access during branched EVAR (bEVAR) may play a role in embolic brain injuries. For this reason, some advocate the use of a left-sided upper access to avoid crossing the origin of supra-aortic vessels. However, this assumption has not yet been confirmed in the literature. Methods: Retrospective single-center analysis of all consecutive patients treated by bEVAR. A through-and-through right-brachio-femoral 0.014i wire was used to stabilize the sheath across the arch in all cases. Endpoint of the study was the incidence of cerebrovascular events. Results: 53 patients with bEVAR were identified during a 4-year period. Mean age at time of surgery was 70.4 years (range 53-87 years, 65.6% male). The most common indication for treatment was type II (32.8%), followed by type IV thoracoabdominal aneurysms (23%). There were 20 urgent (32.8%) and 41 elective (67.2%) procedures. Two perioperative strokes occurred in the first postoperative day in two male patients (2/61; 3.3%). There was no statistically significant association between the occurrence of postoperative stroke and any of the perioperative characteristics (p=ns). No significant association was found between the duration of the procedure and our endpoint(p=ns).. In both cases with embolic events, the use of a left arm approach would not have been easily possible due to overstenting of the left subclavian artery. Conclusion: The postoperative stroke rate in our experience with bEVAR with the use of a right brachial access was in line with the literature for the treatment of thoracic and thoraco-abdominal disease. We conclude that the right-brachial access with the use of a stabilizing through-and-through buddy-wire is a safe approach during bEVAR.
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