Percutaneous access and closure of the axillary artery during complex aortic endovascular procedures
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1 Percutaneous access and closure of the axillary artery during complex aortic endovascular procedures Luca Bertoglio, Andrea Melloni, Maria Katsarou, Alessandra Fittipaldi, Simone Salvati, Andrea Kahlberg, Germano Melissano, Roberto Chiesa Vascular Surgery, Vita-Salute - San Raffaele University Scientific Institute Ospedale San Raffaele, Milan Italy Chief: Prof. Roberto Chiesa
2 Disclosure Speaker name: Andrea Melloni X I do not have any potential conflict of interest
3 TAAA unfit for surgery Jan Oct. 2018: 139 cases Hybrid surgery 55 cases present CHIM PS 8 cases High-risk patients BEVAR / FEVAR 76 cases
4 Upper extremity accesses for B/FEVAR San Raffaele experience ( ): 72/76 cases (94.7%) OPEN 22 cases (32%) High-brachial Brachial Illustration modified from David Factor (Mayo Clinic) in Oderich GS edition. Springer 2017
5 Percutaneous Axillary Access (paxa) San Raffaele experience (Dec present) ENDO 50 cases (68%) Axillary Illustration modified from David Factor (Mayo Clinic) in Oderich GS edition. Springer 2017
6 Large sheaths puncture site 1 st Segment Pectoralis minor
7 Axillary ecoguided puncture All cases Bertoglio et al. J Vasc Surg 2018 Online video
8 Standard double Proglide implant According to IFU Bertoglio et al. J Vasc Surg 2018 Online video
9 Percutaneous femoral downsizing Early limb reperfusion one femoral access available
10 AXA closure 1 st step In-graft through-and-through wire and sheath rendez-vous
11 AXA closure 2 nd step Sheaths unlink and disassemble the through-and-through
12 AXA closure 3 rd step Sheaths unlink and balloon-assisted sheath removal
13 paxa study ClinicalTrials.gov Identifier: NCT currently enrolling Population: 60 patients treated with F/BEVAR requiring UEA - 20 patients retrospective [14 cases already published in J Vasc Surg 2018] - 40 patients prospective [30 patients enrolled] Inclusion: paxa access closed with double Proglide technique Primary endpoint: Primary technical success Bertoglio et al. J Vasc Surg 2018
14 paxa study: Access details 50 cases (Dec Oct. 2018) Left access side 42 (84%) Median AXA diameter (mm) 8.9 mm ( ) Median AXA tortuosity index 1.5 ( ) Sheath size (ID) 10F 6 (12%) 12F 38 (76%) 14F 4 (8%) 16F 2 (4%) Hostile accesses Pacemaker 6 (12%) Scars (Previous cannulation) 2 (6%) Relative controindication Previous LIMA-CABG or Dyalisis fistulas 1 (2%)
15 paxa study: 30-day outcomes Postoperative US and CT scan assessment Primary technical success 46 (92%) Any 30-day open conversion 0 Assisted technical success 50 (100%) Need for bare stents for dissection 1 (2%) Need for covered stents for bleeding 3 (6%) Access site hematoma (any) Clinically evident 1 (2%) Radiological (US or CT assessment) 4 (8%) Access site false aneurysm (any) 0 Access artery thrombosis (any) 0 Peripheral neurological complications Permanent 0 Temporary paraesthesia < 48 hours 2 (4%)
16 Discussion
17 Discussion A) Axillary puncture site: 1 st segment vs 3 rd segment 1 st segment Mean Ø 8.9 mm Proximal No brachial plexus 3 rd segment Mean Ø 7.7 mm Distal Brachial plexus Bertoglio et al. J Vasc Surg 2018 Harris et al. J Vasc Surg 2018 Schäfer et al. Int J Cardiol 2017 Puippe et al. Vasa 2018 Branzan et al. ESVS annual meeting 2017 Pratesi et al. Veith symposium 2017
18 Discussion B) Decreased X-ray exposure? Standard: Working from the left New: Working from the right Illustration from David Factor (Mayo Clinic) in Oderich GS edition. Springer 2017
19 Discussion C) Enhanced pushability from upper extermities access 12F 7 Fr x 90 mm 12 Fr x 45 mm 7F
20 Discussion D) More Extensive use of upper extremities access SM A RR A LR A Indwelling catheter One vessel from above 14Fr (2 vessels)
21 Discussion E) Total percutaneous approach (univariate analysis) Total PF/BEVAR (n=46) Cutdown F/BEVAR (n=27) p value Local anaesthesia 22 (56%) 10 (37%) ns Procedural time (min) OR occupation time (min) 290 ( ) 327 ( ) 340 ( ) 434 ( ) Fluroscopy time (min) 80 (69-96) 90 (57-114) ns DAP (cgycm 2 ) 593 ( ) 500 ( ) Contrast media (ml) ns Estimated blood loss (ml) 250 ( ) ns 450 (0-600) ns Mean n. of RBC transfusions 2 (0-3) 3 (1-5).05
22 Conclusions TECHNIQUE paxa study 1 st segment of axillary artery Ecoguided puncture Balloon-assisted removal RESULTS Feasible and safe Potential advantages over brachial and cutdown Ongoing study
23 Percutaneous access and closure of the axillary artery during complex aortic endovascular procedures Luca Bertoglio, Andrea Melloni, Maria Katsarou, Alessandra Fittipaldi, Simone Salvati, Andrea Kahlberg, Germano Melissano, Roberto Chiesa Vascular Surgery, Vita-Salute - San Raffaele University Scientific Institute Ospedale San Raffaele, Milan Italy Chief: Prof. Roberto Chiesa
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