Right-sided Upper Extremity Access for Patients Undergoing Parallel Graft Placement during Endovascular Aortic Repair is Not Associated with Increased Neurologic Events When Compared with Left Upper Extremity Access.

Background: The safety and efficacy of right axillary cannulation during complex aortic aneurysm repair for the deployment of chimney grafts is controversial; however, there are few studies that compare right and left upper extremity access. We favor the right axillary approach because of the relative ease of access to the visceral branches and the ability of surgeons and nursing staff to work on the same side of the patient, while avoiding the left sided image intensifier. We aim to demonstrate that right-sided access is equivalent or safer than left-sided access in terms of technical success and complication rates, with a focus on neurologic outcomes.

Methods: This is a single-institution retrospective study with a review of patients who underwent aortic intervention from January 2012 through December 2018. A total of 398 aortic interventions were performed, and 97 of these required brachial, axillary, or subclavian arterial access for attempted ChEVAR or thoracic endovascular aortic repair with parallel chimney grafts. Primary end points that were analyzed were site or sites of upper extremity access, technical success, 30-day mortality, cerebrovascular events, and subclavian/axillary artery injury. The number of parallel grafts, age, mean hospital length of stay, prior aortic intervention, emergent or elective status were also analyzed.

Results: Ninety-seven endovascular aortic operations required upper extremity access, with 67 using access from the right upper extremity, 26 using access from the left upper extremity, and 4 using bilateral upper extremity access. A total of 68.0% of patients had undergone prior aortic surgery. Technical success was achieved in 85 cases (87.6%). Five total patients suffered cerebrovascular accidents, with 2 occurring in left-sided access (7.7%), 2 in right-sided access (3.0%), and 1 in bilateral access (25%).

Conclusions: Right upper extremity access for patients undergoing parallel graft placement during endovascular aortic aneurysm repair is a safe and feasible approach that is not associated with an increased risk of stroke or neurological events as compared with left upper extremity access.