Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair
An upper extremity access (UEA) is necessary for complex endovascular aortic repairs, especially for branched and fenestrated endografts to successfully catheterize target vessels with a caudal orientation.
The subclavian artery and axillary artery (AxA) have largely been described as UEA sites for different endovascular aortic and cardiac interventions with large sheaths, despite requiring surgical cutdown. At present, percutaneous vessel closure devices (VCDs) are employed during complex aortic repair to close the femoral access site, but no specific device has been designed to perform percutaneous closure of UEAs, thus allowing a totally percutaneous procedure.In our practice, a minimum size of 6 mm was deemed appropriate for a percutaneous AxA closure and to allow nonocclusive passage of large sheaths. Ultrasound guidance allows the user to safely puncture the artery identifying the correct spot to avoid accessing of the AxA through the vein, nerves, or pectoralis minor muscle. Furthermore, it helps identify postoperative complications, such as flow limiting lesions, as well as pseudoaneurysms or active bleeding.
The AxA first segment is punctured, and two VCDs are deployed according to the device’s instructions for use. A femoral access is maintained during the procedure as a safety net to endoclamp the artery during the closure to avoid any bleeding and to perform any bail-out technique if needed. After the axillary closure step, an angiographic check is performed and if no other procedures have to be performed, the femoral access is completely closed.
Primary technical success of pAxA closure was 100%; in one case, an adjunctive Perclose ProGlide device was used to achieve complete closure, but no secondary procedures were required. Completion angiography performed at the end of the closure did not reveal any flow-limiting dissection or stenosis, and the brachial and radial pulses were palpable. No upper limb ischemia was noticed at the end of the procedure. The completion and postoperative day 1 ultrasound assessment did not reveal any complications. In one case, we observed that the puncture site had been made through the pectoralis minor muscle; and in two cases, a hematoma <15 mm in thickness was noticed surrounding the AxA, without clinically relevant consequences. All patients were discharged without neurologic deficits related to the AxA puncture site. No late complications were observed at the site of UEA percutaneous repair.
Interestingly, we analized the AxA anatomy and we found out that the median diameters of the AxA in the first and third segments were statistically different (P < .001) with a median difference of 1.5 mm (1.0-2.0 mm). Moreover, the distance between the end of the first segment of the AxA and its origin from the arch was statistically different with a median difference of 36 mm (17-50 mm). Positive linear correlation was found between the height of the patients and the diameter of the AxA.
This transaxillary percutaneous approach offers different advantages. The increased working length achieved with this access allows the operator to work from the right side of the patient, which has been proved to decrease the operator’s radiation dose exposure. Performing a total percutaneous procedure, we are able to use only local anesthesia. This allows us to perform an early neuromonitoring of the patient at the end of the procedure, it shortens the operative time and reduces the need for postoperative transfusions.
In our experience, the AxA is a suitable site for large-sheath catheterization in terms of both diameter and wall quality and that a percutaneous closure with off-label use of currently available VCDs is safe and feasible if performed by experienced percutaneous operators.
Luca Bertoglio, Alessandro Grandi, Roberto Chiesa
Division of Vascular Surgery, “Vita – Salute” University, Scientific Institute H. San Raffaele, Milan, Italy
Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair.
Bertoglio L, Mascia D, Cambiaghi T, Kahlberg A, Melissano G, Chiesa R
J Vasc Surg. 2018 Jul