Brachial Plexus Injuries from Overhead Arm Positioning During F/BEVAR: A Case Series and Call for Standardized Technique

Overhead arm positioning during fenestrated and branched endovascular aortic repair (F/BEVAR) may improve imaging quality and reduce procedural radiation dose. Elevated arm positioning during general anesthesia, however, may result in risk for nerve symptoms. The aim of this study was to assess the occurrence of upper extremity symptoms (UES) after overhead arm positioning during F/BEVAR.

Single-center, retrospective, cohort.

All consecutive patients undergoing F/BEVAR performed with bilateral overhead arm positioning at *our* Hospital between 2023 and 2025 were included. Neutral head position, padded overhead support, and abduction limited to ≤90° were used in accordance with standardized positioning protocols. Demographic, comorbidity, and procedural data were accessed from the clinical records. The primary aim was to evaluate the rate of post-operative UES and brachial plexus injury (BPI). In cases with BPI, neurological consultation and rehabilitation outcomes were assessed.

Among 67 patients who underwent F/BEVAR with bilateral overhead arm position, six patients (9.0%) developed postoperative UES. Two patients (3.0%) had neurologist-confirmed BPI; one developed bilateral palsy with partial recovery after 8 weeks, while the other developed unilateral palsy with complete recovery by 3 months. Neither patient required surgical intervention, The remaining four patients (6.0%) experienced minor transient UES. There was no difference in baseline parameters between patients with and without UES. Urgent repair was more frequent among patients experiencing any UES than among those without UES (50.0% vs 9.8%; p = 0.028). Both patients with BPI underwent procedures lasting >180 minutes. Procedural technical success was 98.5%, and in-hospital mortality 1.5%.

Bilateral overhead arm positioning during F/BEVAR was associated with a measurable incidence of UES. Although most symptoms were transient and resolved without intervention, clinically significant BPI occurred in a small proportion of patients despite standardized positioning. These findings support cautious and selective use of prolonged overhead arm positioning and warrant prospective evaluation of safe positioning duration and patient-related susceptibility.