TY - JOUR
T1 - Association of upper extremity and neck access with stroke in endovascular aortic repair
AU - Plotkin, Anastasia
AU - Ding, Li
AU - Han, Sukgu M.
AU - Oderich, Gustavo S.
AU - Starnes, Benjamin W.
AU - Lee, Jason T.
AU - Malas, Mahmoud B.
AU - Weaver, Fred A.
AU - Magee, Gregory A.
N1 - Publisher Copyright:
© 2020 Society for Vascular Surgery
PY - 2020/11
Y1 - 2020/11
N2 - 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.
AB - 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.
KW - Access
KW - Arm
KW - Complex EVAR
KW - Neck
KW - Stroke
KW - Tevar
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U2 - 10.1016/j.jvs.2020.02.017
DO - 10.1016/j.jvs.2020.02.017
M3 - Article
C2 - 32273227
AN - SCOPUS:85082797445
VL - 72
SP - 1602
EP - 1609
JO - Journal of Vascular Surgery
JF - Journal of Vascular Surgery
SN - 0741-5214
IS - 5
ER -