Perioperative Neurologic Outcomes of Right vs. Left Upper Extremity Access for Fenestrated-Branched Endovascular Aortic Aneurysm Repair (F-BEVAR)

Objective Upper extremity (UE) access is frequently used for F-BEVAR, particularly for complex repairs. Traditionally, left-side UE access has been used to avoid crossing the arch and the origin of the supra-aortic vessels, which could potentially result in cerebral embolization and an increased risk of perioperative cerebrovascular events. More recently, right UE has been more frequently used as it is more convenient and ergonomic. The purpose of this study was to assess the outcomes and cerebrovascular events after F-BEVAR with the use of right vs. left-side upper extremity access. Methods During an 8-year period, 453 patients (71% male) underwent F-BEVAR at a single institution. UE access was used in more complex repairs. Left UE access was favored in the past, whereas right UE access is currently the preferred UE access side. Brachial artery cutdown was used in all patients for the placement of a 12F sheath. Outcomes were compared between patients undergoing right vs. left UE access. Endpoints included cerebrovascular events, perioperative mortality, technical success and local access related complications. Results UE access was used in 361 (80%) patients. The right-side was used in 232 (64%) and the left-side in 129 (36%) patients for the treatment of 88 (25%) juxtarenal, 135 (38%) suprarenal and 137 (38%) thoracoabdominal aortic aneurysms. Most procedures were elective (94%). Technical success was achieved in 354 patients (98%). In-patient or 30-day mortality was 3.3%. Five (1%) perioperative strokes occurred in patients undergoing right UE access, of which 3 were ischemic and 2 were hemorrhagic. No transient ischemic attacks (TIAs) occurred perioperatively. Two hemorrhagic strokes were associated to permissive hypertension to prevent spinal cord ischemia. No perioperative strokes occurred in patients undergoing left UE access (P=.16). Overall, perioperative strokes occurred with similar frequency in patients undergoing UE (5, 1%) and femoral access only (1, 1%) (P=.99). Arm access related complications occurred in 15 (5%) patients, 11 (4.8%) on the right-side and 4 (6%) on the left-side (P=.74). Conclusions Right upper extremity access can be used for F-BEVAR with low morbidity and minimal risk of perioperative ischemic stroke or TIAs. In general, upper extremity access is not associated with an increased risk of perioperative stroke compared to femoral access only. Tight blood pressure control is, however, critical to avoid intracranial bleeding related to uncontrolled hypertension.