Right brachial access is safe for branched endovascular aneurysm repair in complex aortic disease

The risk of perioperative cerebrovascular events in endovascular repair of thoracic and thoracoabdominal aneurysms is reported from 2% to 15%. The unavoidable use of an upper extremity access during branched endovascular aneurysm repair (b-EVAR) 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, the assumption that right brachial access has a higher risk for stroke during b-EVAR has not been confirmed in the literature.

This study retrospectively analyzed all consecutive patients treated by b-EVAR with right brachial access at a single institution. A through-and-through right-brachiofemoral 0.014-inch wire was used to stabilize the sheath across the arch in all cases. End point of the study was the incidence of cerebrovascular events.

We identified 61 patients (65.6% male) during a 4-year period. Mean age at the time of surgery was 70.4 years (range, 53-87 years). The most common indication for treatment was type II (32.8%), followed by type IV thoracoabdominal aortic aneurysms (23%). There were 20 urgent (32.8%) and 41 elective (67.2%) procedures. Two perioperative ischemic strokes occurred in the first postoperative day in two men (3.3%; 95% confidence interval, 0.397-11.84). No further ischemic strokes occurred perioperatively. There was no statistically significant association between the occurrence of postoperative stroke and any of the perioperative characteristics. No significant association was found between the duration of the procedure and the end point. In both patients with embolic events, the use of a left arm approach would not have been feasible due to coverage of the left subclavian artery ostium.

The postoperative stroke rate in b-EVAR with the use of a right brachial access in our experience was in line with the literature for treatment of thoracic and thoracoabdominal aortic aneurysms. We conclude that the right brachial access with the use of a stabilizing through-and-through wire is a safe approach during b-EVAR.