percutaneous axillary artery access for branch grafting ... · – sheath size >7fr via high...
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Percutaneous Axillary Artery
Access For Branch Grafting for
complex TAAAs and pararenal
AAAs: How to do it safely
Daniela Branzan, MD,
Department of Vascular Surgery
University Hospital Leipzig
Upper Extremity Access
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required during endovascular TAAA repair to deliver
• bridging stent components through branches and parallel visceral stents during chimney
procedures.
Fenestrated stentgrafts Branched devices
Parallel stenting approaches
(„chimney“, „sandwich“, etc.)
98 pts treated with FEVAR with upper extremity access during
5 years
Access
• Open:
– 86 pts with two local complication and one cerebrovascular accident
– Sheath size >7Fr via high brachial open
• Percutaneous access:
– 12 Pts with two local complications
– one pt.: 12 Fr sheath via axillary artery
– 11 pts: 7 Fr sheath
The mean sheath size: 10.59±2.51 Fr5
Upper Extremity Access is safe
Axillary Artery Access
Benefits over brachial access:
• Accommodate sheath sizes larger than 7Fr even up to 18Fr
• Shorten the working distance to the visceral arteries
• Enhanced pushability
Approaches:
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surgical cut-down percutaneous punctureaxillary conduit construction
M. Knowles, J Vasc Surg 2015;61:80-7. M Wooster, Ann Vasc Surg 2015; 29: 1543–1547
Leiziger Experience:
October 2013 - December 2017
Patients‘ Characteristics
Variables No. %
Total 40
Sex Male 27 67.5
Female 13 32.5
Age(y) Mean ± SD 72.7 ± 7.4
Median (Range) 75 (56 - 84)
History of Hypertension 40 100
COPD 13 32.5
Smoker 26 35
CAD 16 40
Diabetes mellitus 15 27.5
Renal Insufficiency 24 60
CHF 4 10
BMI(kg/m2) Mean ± SD 26.7±4.4
Median (Range) 25.8 (18.7 -35.3)
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Largest cohort of patients treated for TAAA using a
percutaneous axillary access with a 12 Fr sheath
Characteristics of Aneurysma
Aneurysm Characteristics
No. %
Acute 9 22.5
Rupture 4 10
PAU 3 7.5
Symtomatic (Pain) 2 5
Chronic 31 77.5
Crawford Classification
Type II 15 37.5
Type III 20 50
Type IV 3 7.5
Type V 2 5
Maximal Aortic Diameter (mm)
Mean ± SD 67.2±12.16
Median (Range) 65 (50 -102)
Previous Repair of the Aorta 14 35
thoracic 9 22.5
abdominal 5 12.5
Previous Coil of SA 17 42.5
TAAA atherosclerotic 36 90
dissection 4 10
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Procedural Details
Procedure
No %
Total 40
FEVAR 1 2.5
Fenestrations (Mean±SD) 4±0
BEVAR 27 67.5
Branches (Mean±SD) 3,6±0.9
FBEVAR 3 7.5
Fenestrations/Branches
(Mean±SD) 4±0
ChEVAR 9 22.5
Branches (Mean±SD) 3,77±0,66
General Anesthesia 30 100
Left Axillary access 30 100
CSF 6 20,00
Operative time 219.5±49.7
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Very complex cases!
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US guided puncture of the axillary
artery
5 Fr sheath into the axillary artery
Small incision at the puncture site
Percutaneous Axillary Artery Access
Technique 2
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Placement of a 9 Fr sheath
Deployment of two Perclose Proglide closure devices at a 90° angle
Percutaneous Axillary Artery Access
Technique 3
Establish a through-and-through brachio-femoral access with a 0.035-inch
300 cm stiff wire (Lunderquist)
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Advance a 12F hydrophilic flexor
sheath to the mid-descending
thoracic aorta via the stiff wire
Percutaneous Axillary Artery Access
Technique 4
Catheterize, wire, and stent sequentially each branch and its corresponding
target vessel with a covered bridging stent via a coaxial 55 cm 7F sheath
placed in the 12 Fr sheath
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CT SMA RRA LRA
Percutaneous Axillary Artery Access
Technique 5
Sheath Rendez-vous in Axillary artery
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Balloon Assited Sheath removal
Percutaneous Axillary Artery Access –
Closure of the Puncture Site
7 Fr sheath, 90cm
12 Fr sheath, 45cm
tide down the Proglide sutures
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control angiography
Percutaneous Axillary Artery Access
Technique 7
Intra-operative Results
Procedure success (percutaneous closure of the
axillary artery):
• 40 patients (100%)
Device success:
• 33 patients (82.5 %)
3 stenosis, 3 occlusions and one bleeding of the
axillary artery after Proglide failure:
• endovascular stent implantation.
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Percutaneous Axillary Artery Access
Troubleshooting
persistent bleedingocclusionflow limiting dissection
Viabahn 8/50Epic 8/40Smart 6/30+ ++
30-Days Results
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Death: 3 Pts. (7.5%)
Pseudoaneurysma: 1 Pt. (2.5%) (Treated conservatively)
Arm ischemia: 0 Pts.
Stroke: 2 Pts. (5%)(minor)
Conclusion
Direct puncture of the axillary artery for the total
percutaneous treatment of complex thoraco-abdominal
aortic aneurysms is feasible and safe.
A balloon should be placed into the subclavian artery via
the common femoral artery before closing the axillary
puncture site to facilitate the endovascular treatment in
the case of failure of the vessel’s closure.
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