RESUMO
BACKGROUND: Percutaneous axillary artery access is increasingly used for large-bore access during interventional vascular and cardiac procedures. The aim of this study was to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (fenestrated and branched endovascular aneurysm repair [FBEVAR]) requiring large-bore upper extremity access and to discuss best practices for technique and complication management. METHODS: One-hundred forty-six patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption 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) were predeployed before 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 computed tomography angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. RESULTS: One-hundred 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 14 F in 4 patients (2.8%), 12F in 133 patients (91.7%), and 8F in 8 patients (5.5%). Ten patients (6.9%) required covered stent placement (Viabahn, W. L. Gore & Associates) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in two patients (1.3%) and transient upper extremity paresthesias in two patients (1.3%). Three patients (2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and two possibly access-related embolic strokes. On follow-up, axillary artery patency was 100%. There was a trend toward decreased closure failure over time, with seven patients (10%) in the early cohort and three (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 >90% of patients with a low incidence of access-related complications. There was a trend toward 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.
Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Cateterismo Periférico , Procedimentos Endovasculares , Humanos , Cateterismo Periférico/métodos , Aneurisma da Aorta Abdominal/cirurgia , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/cirurgia , Estudos Prospectivos , Curva de Aprendizado , Resultado do Tratamento , Estudos Retrospectivos , Artéria Femoral/cirurgiaRESUMO
Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.
El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.
Assuntos
Braço/irrigação sanguínea , Hemorragia/terapia , Perna (Membro)/irrigação sanguínea , Lesões do Sistema Vascular/cirurgia , Artéria Axilar/lesões , Artéria Axilar/cirurgia , Artéria Braquial/lesões , Artéria Braquial/cirurgia , Síndromes Compartimentais/diagnóstico , Consenso , Artéria Femoral/lesões , Artéria Femoral/cirurgia , Técnicas Hemostáticas , Humanos , Ilustração Médica , Artéria Poplítea/lesões , Artéria Poplítea/cirurgia , Complicações Pós-Operatórias/etiologia , Avaliação de Sintomas , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/classificação , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/epidemiologiaRESUMO
INTRODUCTION: Ductus arteriosus stenting is a palliative alternative for neonates with ductal-dependent pulmonary flow. OBJECTIVE: To present an alternative of arterial access for percutaneous coronary intervention in neonates. CLINICAL CASE: A term neonate with low weight diagnosed with pulmonary atresia with intact ventricular septum and severe hypoplasia of the tricuspid valve with dependent coronary circu lation. Due to the surgical risk and femoral artery damage and the anatomy of the ductus arteriosus, a left axillary arterial puncture was decided where a 3.5-millimeter coronary stent was successfully placed. The patient developed an axillary spasm that resolved spontaneously. CONCLUSION: Alternati ve arterial access other than the femoral artery route is an option for neonates with high surgical risk and low birth weight.
Assuntos
Artéria Axilar/cirurgia , Stents Farmacológicos , Canal Arterial , Implantação de Prótese/métodos , Atresia Pulmonar/complicações , Circulação Pulmonar , Aorta Torácica/diagnóstico por imagem , Cateterismo Cardíaco/métodos , Circulação Coronária , Canal Arterial/diagnóstico por imagem , Humanos , Recém-Nascido de Baixo Peso , Recém-Nascido , Masculino , Implantação de Prótese/efeitos adversos , Punções , Valva Tricúspide/anormalidadesRESUMO
Abstract With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.
Assuntos
Humanos , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Artéria Axilar/cirurgia , Cateterismo Cardíaco , Resultado do Tratamento , Artéria Femoral/cirurgiaRESUMO
With transcatheter aortic valve implantation (TAVI) technology expanding its indications for low-risk patients, the number of TAVI-eligible patients will globally grow, requiring a better understanding about the second-best access choice. Regarding the potential access sites, the transfemoral retrograde route is recognized as the standard approach and first choice according to current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access is required. Among the alternative non-femoral routes, the transaxillary approach has received increasing recognition due to its proximity and relatively straight course from the axillary artery to the aortic annulus, which provides a more accurate device deployment. Here we discuss some particular aspects of the transaxillary access, either percutaneously performed or by cutdown dissection.
Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Artéria Axilar/cirurgia , Cateterismo Cardíaco , Artéria Femoral/cirurgia , Humanos , Resultado do TratamentoRESUMO
OBJECTIVE: This study aimed to develop risk predictive models of 30-day mortality, morbidity, and major adverse limb events (MALE) after bypass surgery for aortoiliac occlusive disease (AIOD) and to compare their performances with a 5-Factor Frailty Index. METHODS: The American College of Surgeons National Surgical Quality Improvement Program 2012-2017 Procedure Targeted Aortoiliac (Open) Participant Use Data Files were queried to identify all patients who had elective bypass for AIOD: femorofemoral bypass, aortofemoral bypass, and axillofemoral bypass (AXB). Outcomes assessed included mortality, major morbidity, and MALE within 30 days postoperatively. Major morbidity was defined as pneumonia, unplanned intubation, ventilator support for >48 hours, progressive or acute renal failure, cerebrovascular accident, cardiac arrest, or myocardial infarction. Demographics, comorbidities, procedure type, and laboratory values were considered for inclusion in the risk predictive models. Logistic regression models for mortality, major morbidity and MALE were developed. The discriminative ability of these models (C-indices) were compared with that of the 5-Factor Modified Frailty Index (mFI-5): a general frailty tool determined from diabetes, functional status, history of chronic obstructive pulmonary disease, history of congestive heart failure, and hypertension. Calculators were derived using the most significant variables for each of the three risk predictive models. RESULTS: A total of 2612 cases (mean age 65.0, 60% male) were identified, of which 1149 (44.0%) were femorofemoral bypass, 1138 (43.6%) were aortofemoral bypass, and 325 (12.4%) were axillofemoral bypass. Overall, the rates of mortality, major morbidity, and MALE were 2.0%, 8.5%, and 4.9%, respectively. Twenty preoperative risk factors were considered for incorporation in the risk tools. Apart from procedure type, age was the most statistically significant predictor of both mortality and morbidity. Preoperative anemia and critical limb ischemia were the most significant predictors of MALE. All three constructed models demonstrated significantly better discriminative ability (P < .001) on the outcomes of interest as compared with the mFI-5. CONCLUSIONS: Our models outperformed the mFI-5 in predicting 30-day mortality, major morbidity, and adverse limb events in patients with AIOD undergoing elective bypass surgery. Calculators were created using the most statistically significant variables to help calculate individual patient's postoperative risks and allow for better informed consent and risk-adjusted comparison of provider outcomes.
Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Fragilidade/diagnóstico , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aorta/patologia , Aorta/cirurgia , Artéria Axilar/cirurgia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Artéria Femoral/cirurgia , Fragilidade/complicações , Mortalidade Hospitalar , Humanos , Artéria Ilíaca/patologia , Extremidade Inferior/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/etiologia , Doença Arterial Periférica/mortalidade , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
INTRODUCTION: One of the most important points of the acute type A aortic dissection surgery is how to perform cannulation regarding cerebral protection concerns and the conditions of arterial structures as a pathophysiological consequence of the disease. OBJECTIVE: In this study, femoral and axillary cannulation methods were compared in acute type A aortic dissection operations. METHODS: The study retrospectively evaluated 52 patients who underwent emergency surgery for acute type A aortic dissection. Patients without malperfusion according to Penn Aa classification were chosen for preoperative standardization of the study groups. The femoral arterial cannulation group was group 1 (n=22) and the axillary arterial cannulation group was group 2 (n=30). The groups were compared in terms of perioperative and postoperative results. RESULTS: There was no statistically significant difference in terms of preoperative data. In terms of postoperative parameters, especially early mortality and new-onset cerebrovascular event, there was no statistically significant difference. Mortality rates in group 1 and group 2 were 13.6% (n=3) and 10% (n=3), respectively (P=0.685). Postoperative new-onset cerebral events ratio was found in 5 (22.7%) in the femoral cannulation group and 6 (20%) in the axillary cannulation group (P=0.812). CONCLUSION: Both femoral and axillary arterial cannulation methods can be safely performed in patients with acute type A aortic dissection, provided that cerebral protection strategies should be considered in the first place. The method to be performed may vary depending on the patient's current medical condition or the surgeon's preference.
Assuntos
Dissecção Aórtica , Artéria Axilar , Artéria Femoral , Fêmur , Adulto , Idoso , Artéria Axilar/cirurgia , Cateterismo , Feminino , Fêmur/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos VascularesRESUMO
Abstract Introduction: One of the most important points of the acute type A aortic dissection surgery is how to perform cannulation regarding cerebral protection concerns and the conditions of arterial structures as a pathophysiological consequence of the disease. Objective: In this study, femoral and axillary cannulation methods were compared in acute type A aortic dissection operations. Methods: The study retrospectively evaluated 52 patients who underwent emergency surgery for acute type A aortic dissection. Patients without malperfusion according to Penn Aa classification were chosen for preoperative standardization of the study groups. The femoral arterial cannulation group was group 1 (n=22) and the axillary arterial cannulation group was group 2 (n=30). The groups were compared in terms of perioperative and postoperative results. Results: There was no statistically significant difference in terms of preoperative data. In terms of postoperative parameters, especially early mortality and new-onset cerebrovascular event, there was no statistically significant difference. Mortality rates in group 1 and group 2 were 13.6% (n=3) and 10% (n=3), respectively (P=0.685). Postoperative new-onset cerebral events ratio was found in 5 (22.7%) in the femoral cannulation group and 6 (20%) in the axillary cannulation group (P=0.812). Conclusion: Both femoral and axillary arterial cannulation methods can be safely performed in patients with acute type A aortic dissection, provided that cerebral protection strategies should be considered in the first place. The method to be performed may vary depending on the patient's current medical condition or the surgeon's preference.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Artéria Axilar/cirurgia , Artéria Femoral , Fêmur/cirurgia , Dissecção Aórtica , Procedimentos Cirúrgicos Vasculares , Cateterismo , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of this study was to compare two complex vascular access techniques that utilize the axillary artery as inflow and accesses were created with early cannulation grafts: the axillary-atrial arteriovenous graft versus axillary-iliac arteriovenous graft. METHODS: This is a retrospective study of end-stage renal disease patients with occluded intrathoracic central veins that underwent complex hemodialysis access creation in our institution after failed endovascular recanalization attempts. Patients' demographics, comorbidities, number and types of previous accesses, intraoperative variables, and clinical outcomes were collected and compared. RESULTS: Four patients underwent axillary-atrial arteriovenous graft creation with Flixene™ (Atrium™, Hudson, NH, USA) grafts, through a midline sternotomy to expose the right atrium; all were successfully implanted and used for hemodialysis within the first 72 h; one patient developed a pseudoaneurysm in the mid-graft portion, requiring surgical repair, and it is currently functional. Eight axillary-iliac arteriovenous grafts were created; all grafts were patent and were utilized within 96 h after placement. At 6 months of follow-up period, five (62 %) of our patients underwent graft thrombectomy, one (12 %) balloon angioplasty at the vein anastomosis secondary to stenosis, and two (25 %) grafts were removed due to infectious complications. Axillary-atrial arteriovenous graft and axillary-iliac arteriovenous graft primary patency rates at 6 months were 75% and 48%, respectively; 6-month secondary patency of the axillary-atrial arteriovenous graft compares favorably against that of axillary-iliac arteriovenous graft (100% vs 75%, respectively). CONCLUSION: Despite the invasiveness, direct atrial outflow procedures remain a valid alternative in carefully selected patients with adequate cardiopulmonary reserve.
Assuntos
Derivação Arteriovenosa Cirúrgica , Apêndice Atrial/cirurgia , Artéria Axilar/cirurgia , Implante de Prótese Vascular , Veia Ilíaca/cirurgia , Falência Renal Crônica/terapia , Diálise Renal , Adulto , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/instrumentação , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
Abstract Objective: To investigate whether axillary artery cannulation has supremacy over innominate artery cannulation in thoracic aortic surgery. Methods: A comprehensive search was undertaken among the four major databases (PubMed, Excerpta Medica dataBASE [EMBASE], Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing axillary to innominate artery cannulation in thoracic aortic surgery. Databases were evaluated and assessed up to March 2017. Results: Only three studies fulfilled the criteria for this meta-analysis, including 534 patients. Cardiopulmonary bypass time was significantly shorter in the innominate group (P=0.004). However, the innominate group had significantly higher risk of prolonged intubation > 48 hours (P=0.04) than the axillary group. Further analysis revealed no significant difference between the innominate and axillary groups for deep hypothermic circulatory arrest time (P=0.06). The relative risks for temporary and permanent neurological deficits as well as in-hospital mortality were not significantly different for both groups (P=0.90, P=0.49, and P=0.55, respectively). Length of hospital stay was similar for both groups. Conclusion: There is no superiority of axillary over innominate artery cannulation in thoracic aortic surgery in terms of perioperative outcomes; however, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing optimal arterial cannulation site.