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BACKGROUND: Endovascular treatment of aortic diseases with complex anatomy may require an additional upper extremity arterial access (like axillary access) for support during aortic navigation and allowing the use of larger sheaths for thoracoabdominal antegrade access. The objective of this study is to evaluate the safety of the open axillary approach as adjuvant access in complex thoracoabdominal aortic endovascular interventions. METHODS: A monocentric retrospective study was performed, including all patients with a complex aortic endovascular procedure (fEVAR, bEVAR, chEVAR or TEVAR), elective or urgent, with open surgical exposure of the axillary artery as adjuvant access, between 2012 and 2022. Demographic data, diagnosis and urgency criteria, type of aortic intervention, size of axillary sheath, use of through-and-through maneuver, and features by computed tomography angiography (CTA) of the axillary artery and aortic arch were recorded. The appearance of local and aortic postoperative complications were described, and possible prognostic factors were analyzed. RESULTS: Forty-eight patients (38 men) were included, median age 78 years (range 50-87), 33 with intact thoracoabdominal aneurysms, eight previous EVAR endoleaks and seven aortic aneurysm ruptures. 28 fEVAR/bEVAR, 17 chEVAR and three TEVAR procedures with axillary access were performed. Left infraclavicular axillary access was the most common approach (94%), along with a 12 French (F) median sheath (range 7-20). Eight (16.7%) local complications were identified: three bleedings, one hematoma, three focal dissections in the subclavian artery, and one brachial embolism, all successfully resolved. The only factor related to local complications was small axillary diameter (median 10.7 vs. 14.6 mm; P<0.001), a subclavian/sheath ratio less than one was associated to more local complications (P=0.02). Regarding aortic complications, two (4.1%) type B asymptomatic aortic dissections with left juxta-subclavian tear were found, attributed to local manipulation, occurring only in urgent procedures (P=0.032). CONCLUSIONS: The use of open axillary access as an adjuvant approach in complex aortic endovascular surgery, although it is very useful and usually safe, can be associated with subclavian or even aortic complications (not reported until now), especially in cases with small subclavian diameters and urgent cases.
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BACKGROUND: Autologous arteriovenous fistula is usually the vascular access of choice for hemodialysis in patients with chronic kidney disease. Autologous forearm loops with cephalic or basilic vein are an alternative in those cases with a suitable forearm vein but with an unsuitable radial artery; however they are rarely used and there is little reported evidence of their usefulness. Our objective is to report our results on the creation of autogenous forearm loops as vascular access for hemodialysis. METHODS: We present a prospective cohort study of autogenous forearm loop arteriovenous fistula created between 2010 and 2022, in patients with stage 4-5 chronic kidney disease. Demographic data, surgical details, vein used, follow up to 24 months, maturation, utilization, primary, assisted, and secondary patency estimations with Kaplan-Meier curves, as well as complications during follow-up, were recorded. RESULTS: During the study period, 22 autologous forearm loops were created, 14 of them with cephalic, and 8 with basilic vein. Most (59%) of the patients were men, 19 were already on dialysis and the rest started during follow-up. Sixteen patients had previous vascular accesses. One patient was lost during follow-up. Six-week maturation rate was 61.9% and utilization rate was 57.1%. 6, 12, and 24 months primary and secondary patencies were 75.4%, 59.2%, 41.5% and 85.0%, 69.5%, 56.9% respectively. In five patients an access-induced distal ischemia was diagnosed, four successfully treated and only one patient lost the access. No cases of infection or other major complications were reported. CONCLUSION: Autologous forearm loops have acceptable maturation (61.9%) and patency rates at follow-up (56.9% 2-years secondary patency). Although rarely used, they are a vascular access alternative that should be considered to preserve the proximal vasculature of the arm for future accesses.
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OBJECTIVE: Inflow arterial aneurysms are a rare but serious complication after long term arteriovenous fistulae (AVF), probably due to arterial wall remodelling after an increase in flow and shear stress, and kidney transplantation with immunosuppressive therapy. This study aimed to describe the outcomes of surgical treatment and long term follow up in a large cohort. METHODS: This prospective cohort study collected data from patients with a true inflow artery aneurysm after AVF creation that was surgically repaired between 2010 and 2022. Anastomotic and infected aneurysms or post-puncture pseudoaneurysms were excluded. Demographic data, access characteristics, symptoms, treatment strategies, and long term follow up were recorded; patency was estimated using Kaplan-Meier survival analysis. RESULTS: During the study period, 28 patients (64% men, mean age 60.1 years) were treated surgically for aneurysmal degeneration of the axillary or brachial (n = 23) or radial (n = 5) artery after an AVF (10 distal, 18 proximal) performed a mean of 18.3 ± SD 7.9 years previously. Most AVFs were ligated or thrombosed, while all patients except one had previously received kidney transplants. Most of the cases (n = 18) were symptomatic: 13 with pain or swelling, four with distal embolisation, and one rupture. They were repaired by aneurysm partial excision and graft interposition (11 great saphenous vein, six ipsilateral basilic vein, three cephalic vein, and two PTFE graft), ligation (n = 3), or direct end to end anastomosis (n = 3). No major complications occurred before discharge, after a mean hospital stay of 2.4 days. After a mean follow up of 4.8 ± 3.3 years, three cases presented complications: two recurrent proximal brachial aneurysms were repaired with an additional proximal interposition graft (one with further late infected pseudoaneurysm) and an asymptomatic post-traumatic graft thrombosis. Five year primary and secondary patency was 84% and 96%, respectively. CONCLUSION: Aneurysmal degeneration of the inflow artery is an unusual complication during long term follow up of AVFs. Aneurysm excision and, in general, autogenous graft interposition using the saphenous or ipsilateral arm vein is a safe and effective strategy.