Safety and Learning Curve of Percutaneous Axillary Artery Access for Complex Endovascular Aortic Procedures.

Overview

abstract

BACKGROUND: Percutaneous axillary artery access is increasingly utilized for large-bore access during interventional vascular and cardiac procedures. The aim of this study is to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (FBEVAR) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. METHODS: One-hundred and forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption (IDE) study between September 2017 and January 2023 were analyzed. Ultrasound guidance and micropuncture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular, Santa Clara, CA) were pre-deployed prior to the insertion of the large-bore sheath. Completion angiography was performed in all patients to verify hemostatic closure. Axillary artery patency was also assessed on follow-up CT angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. RESULTS: One-hundred and forty-five patients underwent successful percutaneous axillary artery access, 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 115 patients (79%), and the right axillary artery was accessed in 30 patients (21%). The largest profile sheath was 14Fr in 4 patients (2.8%), 12rF in 133 patients (91.7%), and 8Fr in 8 patients (5.5%). 10 patients (6.9%) required covered-stent placement (Viabahn, W.L. Gore, Flagstaff, AZ) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in 2 patients (1.3%) and transient upper extremity paresthesias in 2 patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and 2 possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend towards decreased closure failure over time, with 7 patients (10%) in the early cohort, and 3 patients (4%) in the late cohort. There was a significant negative correlation between the cumulative complication rate and the cumulative experience. CONCLUSIONS: Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, achieving successful closure in over 90% of patients with a low incidence of access-related complications. There was a trend towards better closure rates with increasing experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography may ensure safe application of the technique of percutaneous large-bore axillary artery access.