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  • Percutaneous Axillary Artery

    Access For Branch Grafting for

    complex TAAAs and pararenal

    AAAs: How to do it safely

    Daniela Branzan, MD,

    Department of Vascular Surgery

    University Hospital Leipzig

  • Disclosure

    I do not have any potential conflict of interest.

  • Upper Extremity Access

    3

    required during endovascular TAAA repair to deliver

    • bridging stent components through branches and parallel visceral stents during chimney procedures.

    Fenestrated stentgrafts Branched devices

    Parallel stenting approaches

    („chimney“, „sandwich“, etc.)

  • Upper Extremity Access

    4

  • 98 pts treated with FEVAR with upper extremity access during

    5 years

    Access

    • Open: – 86 pts with two local complication and one cerebrovascular accident

    – Sheath size >7Fr via high brachial open

    • Percutaneous access: – 12 Pts with two local complications

    – one pt.: 12 Fr sheath via axillary artery

    – 11 pts: 7 Fr sheath

    The mean sheath size: 10.59±2.51 Fr 5

    Upper Extremity Access is safe

  • Axillary Artery Access

    Benefits over brachial access:

    • Accommodate sheath sizes larger than 7Fr even up to 18Fr

    • Shorten the working distance to the visceral arteries

    • Enhanced pushability

    Approaches:

    6

    surgical cut-down percutaneous punctureaxillary conduit construction

    M. Knowles, J Vasc Surg 2015;61:80-7. M Wooster, Ann Vasc Surg 2015; 29: 1543–1547

  • Leiziger Experience:

    October 2013 - December 2017

    Patients‘ Characteristics

    Variables No. %

    Total 40

    Sex Male 27 67.5

    Female 13 32.5

    Age(y) Mean ± SD 72.7 ± 7.4

    Median (Range) 75 (56 - 84)

    History of Hypertension 40 100

    COPD 13 32.5

    Smoker 26 35

    CAD 16 40

    Diabetes mellitus 15 27.5

    Renal Insufficiency 24 60

    CHF 4 10

    BMI(kg/m2) Mean ± SD 26.7±4.4

    Median (Range) 25.8 (18.7 -35.3)

    7

    Largest cohort of patients treated for TAAA using a

    percutaneous axillary access with a 12 Fr sheath

  • Characteristics of Aneurysma

    Aneurysm Characteristics

    No. %

    Acute 9 22.5

    Rupture 4 10

    PAU 3 7.5

    Symtomatic (Pain) 2 5

    Chronic 31 77.5

    Crawford Classification

    Type II 15 37.5

    Type III 20 50

    Type IV 3 7.5

    Type V 2 5

    Maximal Aortic Diameter (mm)

    Mean ± SD 67.2±12.16

    Median (Range) 65 (50 -102)

    Previous Repair of the Aorta 14 35

    thoracic 9 22.5

    abdominal 5 12.5

    Previous Coil of SA 17 42.5

    TAAA atherosclerotic 36 90

    dissection 4 10

    8

  • Procedural Details

    Procedure

    No %

    Total 40

    FEVAR 1 2.5

    Fenestrations (Mean±SD) 4±0

    BEVAR 27 67.5

    Branches (Mean±SD) 3,6±0.9

    FBEVAR 3 7.5

    Fenestrations/Branches

    (Mean±SD) 4±0

    ChEVAR 9 22.5

    Branches (Mean±SD) 3,77±0,66

    General Anesthesia 30 100

    Left Axillary access 30 100

    CSF 6 20,00

    Operative time 219.5±49.7

    9

    Very complex cases!

  • 10

    Percutaneous Axillary Artery Access

    Technique 1

  • 11

    US guided puncture of the axillary

    artery

    5 Fr sheath into the axillary artery

    Small incision at the puncture site

    Percutaneous Axillary Artery Access

    Technique 2

  • 12

    Placement of a 9 Fr sheath

    Deployment of two Perclose Proglide closure devices at a 90° angle

    Percutaneous Axillary Artery Access

    Technique 3

  • Establish a through-and-through brachio-femoral access with a 0.035-inch

    300 cm stiff wire (Lunderquist)

    13

    Advance a 12F hydrophilic flexor

    sheath to the mid-descending

    thoracic aorta via the stiff wire

    Percutaneous Axillary Artery Access

    Technique 4

  • Catheterize, wire, and stent sequentially each branch and its corresponding

    target vessel with a covered bridging stent via a coaxial 55 cm 7F sheath

    placed in the 12 Fr sheath

    14

    CT SMA RRA LRA

    Percutaneous Axillary Artery Access

    Technique 5

  • Sheath Rendez-vous in Axillary artery

    15

    Balloon Assited Sheath removal

    Percutaneous Axillary Artery Access –

    Closure of the Puncture Site

    7 Fr sheath, 90cm

    12 Fr sheath, 45cm

  • tide down the Proglide sutures

    16

    control angiography

    Percutaneous Axillary Artery Access

    Technique 7

  • Intra-operative Results

    Procedure success (percutaneous closure of the

    axillary artery):

    • 40 patients (100%)

    Device success:

    • 33 patients (82.5 %)

    3 stenosis, 3 occlusions and one bleeding of the

    axillary artery after Proglide failure:

    • endovascular stent implantation.

    17

  • 18

    Percutaneous Axillary Artery Access

    Troubleshooting

    persistent bleedingocclusionflow limiting dissection

    Viabahn 8/50Epic 8/40Smart 6/30 + ++

  • 30-Days Results

    19

    Death: 3 Pts. (7.5%)

    Pseudoaneurysma: 1 Pt. (2.5%) (Treated conservatively)

    Arm ischemia: 0 Pts.

    Stroke: 2 Pts. (5%)(minor)

  • Conclusion

    Direct puncture of the axillary artery for the total

    percutaneous treatment of complex thoraco-abdominal

    aortic aneurysms is feasible and safe.

    A balloon should be placed into the subclavian artery via

    the common femoral artery before closing the axillary

    puncture site to facilitate the endovascular treatment in

    the case of failure of the vessel’s closure.

    20

  • Thank you!

    21

    Daniela.Branzan@medizin.uni-leipzig.de

  • Percutaneous Axillary Artery

    Access For Branch Grafting for

    complex TAAAs and pararenal

    AAAs: How to do it safely

    Daniela Branzan, MD,

    Department of Vascular Surgery

    University Hospital Leipzig

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