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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

Percutaneous Axillary Artery Access For Branch Grafting ... · – Sheath size >7Fr via high brachial open ... target vessel with a covered bridging stent via a coaxial 55 cm 7F sheath

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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

Disclosure

I do not have any potential conflict of interest.

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.)

Upper Extremity Access

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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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Percutaneous Axillary Artery Access

Technique 1

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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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Thank you!

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[email protected]

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