Axillary Artery Access as an Adjunct for Complex Endovascular Aortic Repair

The aim of this study was to review and compare our experience with 3 upper extremity access techniques (percutaneous single-sheath brachial, multi-sheath brachial cutdown, and axillary cutdown with conduit construction) in the setting of complex endovascular repair of paravisceral aneurysms.

We performed a retrospective review of a prospectively collected endovascular aneurysm repair database. All patients who underwent parallel stent grafting or fenestrated repair with upper extremity arterial access were included. End points included the following: (1) local access complications, (2) number of vessels successfully snorkeled, and (3) technical success.

Fifty patients underwent treatment for paravisceral aneurysms using a combination of snorkel and fenestration techniques. All cases used one of the 3 upper extremity arterial access techniques--percutaneous single-sheath brachial, multi-sheath brachial cutdown, and axillary cutdown with conduit construction. Eighteen patients underwent open brachial exposure (15 for single vessel snorkel, 2 for two vessel snorkel, 1 for 4 vessel snorkel) with zero access site complications. Five patients underwent percutaneous brachial access (all for single vessel snorkel) with 2 brachial artery injuries and 1 median nerve injury. Twenty-seven patients underwent open axillary exposure with the conduit/sheath technique (1 for single vessel, 15 for two vessel, 6 for three vessel, and 5 for four vessel snorkel) with 2 access site hematomas requiring surgical evacuation. Successful cannulation of 95 of the 97 vessels was achieved.

Upper extremity arterial access is required to snorkel one or more of the visceral vessels during complex endovascular pararenal aortic aneurysm repair. There are several techniques of arm access that can be used. Brachial access is appropriate when a single visceral vessel must be cannulated, and by utilizing the conduit/sheath combination presented here, it is possible to safely approach multiple visceral vessels from an axillary access. Further evolution of this technique will expand our ability to treat complex paravisceral aneurysms.