UC San Diego

Objective

Physician modified endografts (PMEG) and custom manufactured devices (CMD) use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity access from a transfemoral approach. Single institution studies have demonstrated increased risks of access site complications and stroke when upper extremity access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed upper extremity (UEM) access.

Methods

This study is an analysis of the Vascular Quality Initiate for all patients who underwent F/BEVAR from 2014-2021. Patients were stratified based on a TTF delivery of all devices versus any UEM access for deployment of target vessel stents. Primary outcomes included stroke, myocardial infarction and perioperative death. Secondary outcomes included access site hematoma, occlusion, or embolization, operative time, fluoroscopy time, and technical success. Multivariable linear and logistic regression analyses were performed.

Results

3146 patients underwent a F/BEVAR; 2309 (73.4%) TTF and 837 (26.6%) UEM. Logistic regression analysis indicated a two-fold increased risk of death and MI and a three-fold increased risk of stroke in the UEM group. Furthermore, there is decreased operative time (221 versus 297 minutes, p<0.001) and fluoroscopy time (62 versus 80 minutes, p<0.001) in the TTF group and no difference in technical success between groups (96% versus 97%, p=0.159). Finally, there was a decrease in access site hematoma 2.54% versus 4.31% (p=0.013), access site occlusion 0.61% versus 1.91% (p=0.001) and extremity embolization 2.17% versus 3.58% (p=0.026) in the TTF versus UEM group.

Conclusion

This study using VQI data demonstrates that patients who undergo a F/BEVAR utilizing UEM access have an increased risk of perioperative MI, death and stroke compared to TTF access.