Outcomes Of Upper Extremity Vs. Transfemoral Access For Fenestrated-branched Endovascular Aortic Repair (FB-EVAR)
Khalil H. Chamseddin, MD1, Carlos H. Timaran, MD1, Carla K. Scott, MD1, Oderich S. Gustavo, MD2, Andres Schanzer, MD3, Farber Mark, MD4, Schneider Darren, MD5, Matthew J. Eagleton, MD6, Matthew P. Sweet, MD7, Adam W. Beck, MD8.
1UT Southwestern, Dallas, TX, USA, 2UT Health Science Center at Houston, Houston, TX, USA, 3UMass Memorial, Worcester, MA, USA, 4University of North Carolina Chapel Hill, North Carolina, NC, USA, 5University of Pennsylvania School of Medicine, Philadelphia, PA, USA, 6Massachusetts Medical Hospital, Boston, MA, USA, 7UW Medical Center, Seattle, WA, USA, 8University of Alabama at Birmingham, Birmingham, AL, USA.
Objective: Upper extremity (UE) access is frequently used for FB-EVARs. The advent of steerable sheaths has enabled FB-EVAR to be performed using total transfemoral approach without UE access, potentially decreasing risks of cerebral embolic events. The purpose of this study was to assess outcomes of FB-EVAR using UE vs. transfemoral (TF) access.Methods: Prospectively collected data from nine physician-sponsored investigational device exemption studies at US centers was analyzed using a standardized database. All patients were treated for complex (CAAA) and thoracoabdominal aortic aneurysms (TAAA) using manufactured fenestrated and branched stent-grafts between 2005 and 2020. Outcomes were compared between patients undergoing UE vs. TF access. The primary composite outcome was strokes and transient ischemia attacks (TIAs) during the perioperative period. Secondary outcomes included technical success, local access related complications, and perioperative mortality. Results: 1681 patients (71% men, mean age 73.43±7.8 years) underwent FB-EVAR for 502 CAAAs (30%), 535 Extent IV TAAAs (32%) and 644 Extent I-III TAAAs (38%). UE access was used in 1103 patients (67%). The right-side was used in 395 patients (24%) and the left-side in 705 patients (42%). UE access was preferentially used for TAAAs (74% vs. 47%, P<.001), whereas TF access was used more frequently for CAAAs (53% vs. 26%; P<.01). There were 38 (2.5%) perioperative cerebrovascular events, 32 strokes (1.9%) and six TIAs (0.4%). Perioperative cerebrovascular events occurred more frequently with UE access compared to TF access (2.8% vs.1.2%; P=.036). Individual component analysis of the primary outcome revealed trends for more frequent strokes (2.3% vs. 1.2%; P=.13) and TIAs (0.54% vs. 0%; P=.10) in the UE access group. Total TF access was associated with a 60% reduction in perioperative cerebrovascular events by multivariate analysis (odds ratio, 0.39; P=.029). No significant differences were observed between UE and TF access in technical success (96.5% vs. 96.8%; P=.72), perioperative mortality (2.9% vs. 2.6% P=.72) or local access related complications (6.5% vs. 5.5%; P=.43).Conclusions A total transfemoral approach for F-BEVAR is associated with a lower rate of perioperative cerebrovascular events compared to UE access. Although the cerebrovascular event rate was low with UE access in appropriately selected patients, a total femoral approach offers a lower risk of stroke and TIAs. UE access may be justified, however, for more complex repairs.
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