Percutaneous Axillary Artery Access For Branch Grafting for complex TAAAs and pararenal AAAs: How to do it safely
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1 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
2 Disclosure I do not have any potential conflict of interest.
3 Upper Extremity Access 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.) 3
4 Upper Extremity Access 4
5 Upper Extremity Access is safe 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 Fr 5
6 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: surgical cut-down axillary conduit construction percutaneous puncture M. Knowles, J Vasc Surg 2015;61:80-7. M Wooster, Ann Vasc Surg 2015; 29:
7 Leiziger Experience: October December 2017 Patients Characteristics Largest cohort of patients treated for TAAA using a percutaneous axillary access with a 12 Fr sheath Variables No. % Total 40 Sex Male Female Age(y) Mean ± SD 72.7 ± 7.4 Median (Range) 75 (56-84) History of Hypertension COPD Smoker CAD Diabetes mellitus Renal Insufficiency CHF 4 10 BMI(kg/m2) Mean ± SD 26.7±4.4 Median (Range) 25.8 ( ) 7
8 Characteristics of Aneurysma Aneurysm Characteristics No. % Acute Rupture 4 10 PAU Symtomatic (Pain) 2 5 Chronic Crawford Classification Type II Type III Type IV Type V 2 5 Maximal Aortic Diameter (mm) Mean ± SD 67.2±12.16 Median (Range) 65 (50-102) Previous Repair of the Aorta thoracic abdominal Previous Coil of SA TAAA atherosclerotic dissection
9 Procedural Details Procedure No % Total 40 FEVAR Fenestrations (Mean±SD) 4±0 BEVAR Branches (Mean±SD) 3,6±0.9 FBEVAR Fenestrations/Branches (Mean±SD) 4±0 ChEVAR Branches (Mean±SD) 3,77±0,66 General Anesthesia Left Axillary access CSF 6 20,00 Operative time 219.5±49.7 Very complex cases! 9
10 Percutaneous Axillary Artery Access Technique 1 10
11 Percutaneous Axillary Artery Access Technique 2 US guided puncture of the axillary artery 5 Fr sheath into the axillary artery Small incision at the puncture site 11
12 Percutaneous Axillary Artery Access Technique 3 Deployment of two Perclose Proglide closure devices at a 90 angle Placement of a 9 Fr sheath 12
13 Percutaneous Axillary Artery Access Technique 4 Advance a 12F hydrophilic flexor sheath to the mid-descending thoracic aorta via the stiff wire Establish a through-and-through brachio-femoral access with a inch 300 cm stiff wire (Lunderquist) 13
14 Percutaneous Axillary Artery Access Technique 5 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 CT SMA RRA LRA 14
15 Percutaneous Axillary Artery Access Closure of the Puncture Site Sheath Rendez-vous in Axillary artery 7 Fr sheath, 90cm 12 Fr sheath, 45cm Balloon Assited Sheath removal 15
16 Percutaneous Axillary Artery Access Technique 7 tide down the Proglide sutures control angiography 16
17 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. 17
18 Percutaneous Axillary Artery Access Troubleshooting flow limiting dissection occlusion persistent bleeding Smart 6/30 Epic 8/40 Viabahn 8/50 18
19 30-Days Results Death: 3 Pts. (7.5%) Pseudoaneurysma: 1 Pt. (2.5%) (Treated conservatively) Arm ischemia: 0 Pts. Stroke: 2 Pts. (5%)(minor) 19
20 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. 20
21 Thank you! 21
22 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
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