Association of upper extremity and neck access with stroke in endovascular aortic repair

Objective: Upper extremity and neck access is commonly used for complex endovascular aortic repairs. We sought to compare perioperative stroke and other complications of (1) arm/neck (AN) and femoral or iliac access versus femoral/iliac (FI) access alone, (2) right- versus left-sided AN, and (3) specific arm versus neck access sites. Methods: Patients entered in the thoracic endovascular aortic repair/complex endovascular aortic repair registry in the Vascular Quality Initiative from 2009 to 2018 were analyzed. Patients with a missing access variable and aortic arch proximal landing zone were excluded. The primary outcome was perioperative in-hospital stroke. Secondary outcomes were other postoperative complications and 1-year survival. Kaplan-Meier curves and log-rank test were used for survival analysis. Results: Of 11,621 patients with 11,774 recorded operations, 6691 operations in 6602 patients met criteria for analysis (1418 AN, 5273 FI). AN patients had a higher rate of smoking history (83.6% vs 76.1%; P < .0001), and prior stroke (12.6% vs 10.1%; P = .01). Operative time (280 ± 124 minutes vs 157 ± 102 minutes; P < .0001), contrast load (141 ± 82 mL vs 103 ± 67 mL; P < .0001), and estimated blood loss (300 mL vs 100 mL; P < .0001) were larger in the AN group, indicative of greater complexity cases. Overall, AN had a higher rate of stroke (3.1% vs 1.8%; P = .003) compared with FI and on multivariable analysis AN access was found to be an independent risk factor for stroke (odds ratio, 1.97; P = .0003). There was no difference in stroke when comparing right- and left-sided AN access (2.8% vs 3.2%; P = .71). Stroke rates were similar between arm, axillary, and multiple access sites, but were significantly higher in patients with carotid access (2.6% vs 3.5% vs 13% vs 3.7%; P = .04). AN also had higher rates of puncture site hematoma, access site occlusion, arm ischemia, and in-hospital mortality (7.1% vs 4.2%; P < .0001). At 1 year, AN had a lower survival rate (85.1% vs 88.1%; P = .03). Conclusions: Upper extremity and neck access for complex aortic repairs has a higher risk of stroke compared with femoral and iliac access alone. Right-sided access does not have a higher stroke rate than left-sided access. Carotid access has a higher stroke rate than axillary, arm, and multiple arm/neck access sites.