Vascular Surgery Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain -
Vascular Surgery Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain.
Int Angiol. 2024 Aug;43(4):404-410. doi: 10.23736/S0392-9590.24.05258-1. Epub 2024 Sep 20.
Endovascular treatment of aortic diseases with complex anatomy may require an additional upper extremity arterial access (like axillary access) for support during aortic navigation and allowing the use of larger sheaths for thoracoabdominal antegrade access. The objective of this study is to evaluate the safety of the open axillary approach as adjuvant access in complex thoracoabdominal aortic endovascular interventions.
A monocentric retrospective study was performed, including all patients with a complex aortic endovascular procedure (fEVAR, bEVAR, chEVAR or TEVAR), elective or urgent, with open surgical exposure of the axillary artery as adjuvant access, between 2012 and 2022. Demographic data, diagnosis and urgency criteria, type of aortic intervention, size of axillary sheath, use of through-and-through maneuver, and features by computed tomography angiography (CTA) of the axillary artery and aortic arch were recorded. The appearance of local and aortic postoperative complications were described, and possible prognostic factors were analyzed.
Forty-eight patients (38 men) were included, median age 78 years (range 50-87), 33 with intact thoracoabdominal aneurysms, eight previous EVAR endoleaks and seven aortic aneurysm ruptures. 28 fEVAR/bEVAR, 17 chEVAR and three TEVAR procedures with axillary access were performed. Left infraclavicular axillary access was the most common approach (94%), along with a 12 French (F) median sheath (range 7-20). Eight (16.7%) local complications were identified: three bleedings, one hematoma, three focal dissections in the subclavian artery, and one brachial embolism, all successfully resolved. The only factor related to local complications was small axillary diameter (median 10.7 vs. 14.6 mm; P<0.001), a subclavian/sheath ratio less than one was associated to more local complications (P=0.02). Regarding aortic complications, two (4.1%) type B asymptomatic aortic dissections with left juxta-subclavian tear were found, attributed to local manipulation, occurring only in urgent procedures (P=0.032).
The use of open axillary access as an adjuvant approach in complex aortic endovascular surgery, although it is very useful and usually safe, can be associated with subclavian or even aortic complications (not reported until now), especially in cases with small subclavian diameters and urgent cases.
对于解剖结构复杂的主动脉疾病，血管内治疗可能需要额外的上肢动脉入路（如腋动脉入路）来支持主动脉导航，并允许使用更大的鞘管进行胸腹主动脉顺行入路。本研究的目的是评估腋动脉开放入路作为复杂胸腹主动脉血管内介入治疗辅助入路的安全性。
这是一项单中心回顾性研究，纳入了 2012 年至 2022 年间所有接受复杂主动脉血管内手术（fEVAR、bEVAR、chEVAR 或 TEVAR）的患者，包括择期或急诊手术，手术中腋动脉开放暴露作为辅助入路。记录患者的人口统计学数据、诊断和紧急标准、主动脉介入类型、腋动脉鞘管大小、使用贯穿技术、腋动脉和主动脉弓的 CT 血管造影（CTA）特征。描述局部和主动脉术后并发症的出现情况，并分析可能的预后因素。
共纳入 48 例患者（38 例男性），中位年龄 78 岁（50-87 岁），33 例患者为完整的胸腹主动脉瘤，8 例为既往 EVAR 内漏，7 例为主动脉瘤破裂。28 例 fEVAR/bEVAR、17 例 chEVAR 和 3 例 TEVAR 手术采用腋动脉入路。最常见的入路是左锁骨下腋动脉入路（94%），腋动脉鞘管大小中位数为 12 French（F）（范围 7-20）。发现 8 例（16.7%）局部并发症：3 例出血，1 例血肿，3 例锁骨下动脉局灶性夹层，1 例肱动脉栓塞，均成功解决。唯一与局部并发症相关的因素是腋动脉直径小（中位数 10.7 比 14.6mm；P<0.001），锁骨下动脉/鞘管比值小于 1 与更多的局部并发症相关（P=0.02）。关于主动脉并发症，发现 2 例（4.1%）无症状 B 型主动脉夹层，伴左侧近锁骨下撕裂，归因于局部操作，仅在急诊手术中发生（P=0.032）。
腋动脉开放入路作为复杂主动脉血管内手术的辅助入路虽然非常有用且通常安全，但可能与锁骨下动脉甚至主动脉并发症相关（直到现在还没有报道过），尤其是在锁骨下动脉直径较小和急诊手术的情况下。
