Percutaneous Axillary Artery Access for Endovascular Treatment of Complex Thoraco-abdominal Aortic Aneurysms.

The aim of this study was to determine the feasibility and safety of percutaneous axillary artery (AxA) access using vascular closure devices (VCD) for endovascular repair (ER) of thoraco-abdominal aortic aneurysms (TAAA) using fenestrated, branched, and chimney stent grafts. Between September 2013 and December 2017, 40 high risk patients (27 men; mean age: 72.7 ± 7.4 years) with TAAA underwent total percutaneous endovascular aortic repair by percutaneous puncture of the third segment of the left AxA, using a 12F sheath for delivery of the bridging visceral stent grafts. Percutaneous closure was performed using ultrasound guidance and two Perclose ProGlide VCDs per puncture site. Endpoints were device success defined as successful haemostasis of the axillary puncture site by VCD, procedure success defined as endovascularly assisted haemostasis of the AxA, major cerebrovascular and peripheral neurological complications, and 30 day mortality. The median diameter of the AxA in the third segment was 6.5 mm (range 4.4-10.4 mm). The procedure success was 100%. Device success was achieved in 33 patients (82.5%). Device success in patients with AxA diameter >5 mm was 97%. All patients with diameter of the AxA <5 mm developed stenosis or occlusions of the vessel (n = 6), which were treated by percutaneous stent implantation. One bleeding at the AxA puncture site was treated with trans-femoral implantation of a covered stent. No secondary open procedures were required. No neurological deficit of the left upper limb was seen at discharge. Overall mortality at 30 days was 10%. Direct puncture of the AxA in the third segment and its use as an access vessel for large sheaths during total percutaneous treatment of complex endovascular aortic procedures appear to be feasible and safe in arteries with a diameter >5 mm. Complications can be managed using endovascular techniques.

Branzan D ，Steiner S ，Haensig M ，Scheinert D ，Schmidt A ... -  《-》

Percutaneous axillary artery access for fenestrated and branched thoracoabdominal endovascular repair.

The aim of this study was to assess the safety and effectiveness of upper extremity access (UEA) with percutaneous closure of the axillary artery (AxA) during endovascular treatment of thoracoabdominal aortic aneurysms with fenestrated and branched endografts. Between January 2014 and 2017, 34 out of 37 patients (92%) required UEA during a staged branched and fenestrated endovascular approach. A percutaneous AxA (pAxA) approach was used in 14 consecutive patients (41%) with the off-label use of two Perclose ProGlide (Abbott Vascular, Santa Clara, Calif) devices. The results of patients who had received a pAxA access were analyzed; technical success was defined as successful arterial closure with no evidence of persistent bleeding or arterial occlusion requiring secondary interventions. Early (30 days) and short-term (6 months) success rates were recorded. The anatomic characteristics of the AxA of the entire cohort (34 cases) were studied. Primary technical success of pAxA was 100%; in one case, an adjunctive Perclose ProGlide device was used to achieve complete closure. No secondary open or endovascular procedures were required. At predischarge computed tomography, no intimal defects, pseudoaneurysms, or signs of bleeding were observed, and all patients were discharged without neurologic deficits related to the AxA puncture site. All 14 patients are alive at follow-up, and 9 of 14 patients completed a 6-month clinical follow-up with computed tomography examination; no late complications were observed at the site of UEA percutaneous repair. With regard to the anatomic characteristics of the AxA, the vessel diameters in the first and third segments were statistically different (P < .001) with a median difference of 1.5 mm (1.0-2.0 mm), with no differences between the right and left sides. The distance between the end of the first segment of the AxA and the origin from the aortic arch was statistically different between the right and left sides, with a median difference of 36 mm (17-50 mm). A positive linear correlation was found between the diameter of the AxA and the height of the patients. AxA is adequate in terms of both caliber and lack of calcifications as an access vessel for large-sheath catheterizations, and it might be considered an alternative UEA for complex aortic endovascular procedures thanks to its proximity to visceral target vessels. In this preliminary experience, percutaneous closure of AxA access with the Perclose ProGlide device is clinically safe and technically feasible with high rates of success.

Bertoglio L ，Mascia D ，Cambiaghi T ，Kahlberg A ，Melissano G ，Chiesa R ... -  《-》

Percutaneous AXillary Artery (PAXA) Access at the First Segment During Fenestrated and Branched Endovascular Aortic Procedures.

The aim of this study was to assess the feasibility and safety of percutaneous axillary access with vessel closure device closure after puncturing the first segment during endovascular treatment of complex aneurysms with fenestrated and branched endografts (F/BEVAR). The PAXA (Percutaneous AXillary Access) study is a physician initiated, single centre, ambispective, non-randomised study (clinicaltrials.gov: NCT03223311). The primary endpoint was the closure success rate defined as the absence of any vascular injury to achieve haemostasis at the puncture site, requiring any treatment other than manual compression or adjunctive endovascular ballooning. The secondary endpoints were minor access complications, cerebrovascular complication rate, short term access vessel patency, and study cohort anatomical evaluation of the axillary artery. Sixty-four patients required an upper extremity access during F/BEVAR procedure during study period (November 2016 to July 2019) and were screened for the PAXA study: 59 patients (47 males; median age: 75 years, IQR 69-78) met the study inclusion criteria and were enrolled (one patient had bilateral access). Closure success was obtained in 54 cases (90%) with no open conversion required: five patients received a bare or covered stenting to the AXA and in one patient mechanical failure of the delivery system was recorded. No 30 day permanent peripheral nerve injuries and two non-ipsilateral ischaemic strokes (3.4%) were recorded. Seven patients (12%) had access haematomas managed conservatively associated with closure failure (p = .002), oral anticoagulants therapy (p = .005) and procedure length (p = .028). At short term follow up (6 months), no late complications were observed, and all access vessels were patent. PAXA on the first segment using a large sheath (10-16F) is technically feasible, relatively safe with no need for open conversion but it may require access related secondary endovascular procedures. Further prospective studies are needed to modify the device instruction for use and to put the procedure on label.

Bertoglio L ，Grandi A ，Melloni A ，Kahlberg A ，Melissano G ，Chiesa R ... -  《-》

Outcomes of Percutaneous Access to the First Versus Third Segment of Axillary Artery During Aortic Procedures.

Melloni A ，Bertoglio L ，Van den Eynde W ，Agrusa CJ ，Parlani G ，Howard DPJ ，Rio J ，Fazzini S ，Mansour W ，Dias NV ，Ronchey S ，Branzan D ，SUPERAXA and PAXA Registry Collaborators * ... -  《-》

Feasibility and Safety of Percutaneous Axillary Artery Access in a Prospective Series of 100 Complex Aortic and Aortoiliac Interventions.

Wittig T ，Sabanov A ，Schmidt A ，Scheinert D ，Steiner S ，Branzan D ... -  《Journal of Clinical Medicine》