Stern Jordan R, Ellozy Sharif H, Connolly Peter H, Meltzer Andrew J, Schneider Darren B
New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY.
New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY.
J Vasc Surg. 2017 Sep;66(3):705-710. doi: 10.1016/j.jvs.2016.12.107. Epub 2017 Mar 1.
Endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs) with branched and fenestrated stent grafts often requires upper extremity arterial access for antegrade delivery of bridging covered stents into the visceral arteries. Axillary, brachial, and radial artery approaches have been described, but data on the safety and utility of the different approaches remain limited. We have preferentially used axillary artery conduits for upper extremity arterial access during endovascular repair of TAAA and describe our technique and report our experience herein.
Thirty-two patients were treated within an investigator-sponsored investigational device exemption clinical trial of endovascular repair of TAAAs using custom-manufactured stent grafts. In 29 of these cases, the axillary artery was exposed through an infraclavicular incision, and an axillary conduit was used for antegrade delivery of bridging visceral artery stent components. In all cases, a 12F sheath was placed through the conduit for delivery of stent graft components. The left axillary artery was used in 27 of these 29 cases, and the right axillary artery was used in 2 patients. Proximal brachial artery access was used in two patients, and one patient did not require upper extremity access. Aneurysms treated included pararenal (n = 3) and Crawford TAAA extent I (n = 1), extent II (n = 3), extent III (n = 10), and extent IV (n = 15). Patients have been followed up to 2 years after the procedure, with a mean follow-up of 226 days.
Axillary conduits were used to deliver a total of 170 stent components placed into 81 branches and 27 fenestrations with 99.1% technical success (one accessory renal branch could not be cannulated). There were no intraoperative complications related to the construction or use of the conduit. There were two postoperative complications (6.9%) potentially attributable to the conduit; one patient experienced ipsilateral hand weakness and one patient had postoperative minor stroke, which resolved by the first postoperative visit. There were no cases of arm ischemia, wound hematoma, or reoperation related to the conduit.
The use of an axillary conduit during endovascular repair of complex aortic aneurysms provides safe and effective upper extremity access for delivery of visceral branches. Moreover, axillary conduits facilitate delivery of 12F sheaths without interrupting upper extremity perfusion and provide a shorter working distance compared with brachial artery approaches.
使用分支型和开窗型支架移植物对胸腹主动脉瘤（TAAA）进行血管内治疗时，通常需要通过上肢动脉入路将桥接覆膜支架顺行输送至内脏动脉。已描述了腋动脉、肱动脉和桡动脉入路，但关于不同入路的安全性和实用性的数据仍然有限。在TAAA血管内修复过程中，我们优先使用腋动脉导管进行上肢动脉入路，并在此描述我们的技术并报告我们的经验。
32例患者在一项由研究者发起的使用定制支架移植物进行TAAA血管内修复的研究器械豁免临床试验中接受治疗。在其中29例病例中，通过锁骨下切口暴露腋动脉，并使用腋动脉导管顺行输送桥接内脏动脉支架组件。在所有病例中，通过导管置入一个12F鞘管以输送支架移植物组件。这29例病例中有27例使用左腋动脉，2例使用右腋动脉。2例患者使用近端肱动脉入路，1例患者不需要上肢入路。治疗的动脉瘤包括肾旁动脉瘤（n = 3）和克劳福德I型TAAA（n = 1）、II型（n = 3）、III型（n = 10）和IV型（n = 15）。术后对患者进行了长达2年的随访，平均随访时间为226天。
腋动脉导管共输送了170个支架组件，置入81个分支和27个开窗，技术成功率为99.1%（一个副肾分支未能成功插管）。没有与导管构建或使用相关的术中并发症。有2例术后并发症（6.9%）可能归因于导管；1例患者出现同侧手部无力，1例患者术后发生轻微中风，在术后首次就诊时症状缓解。没有与导管相关的手臂缺血、伤口血肿或再次手术病例。
在复杂主动脉瘤血管内修复过程中使用腋动脉导管可为内脏分支的输送提供安全有效的上肢入路。此外，与肱动脉入路相比，腋动脉导管便于置入12F鞘管，且不中断上肢灌注，并提供更短的工作距离。
