RS22 - Safety and Learning Curve of Percutaneous Axillary Artery Access for Complex Endovascular Aortic Procedures

Objectives: Percutaneous axillary artery access is increasingly utilized for large-bore access during vascular and interventional cardiology procedures. The aim of this study is to evaluate the safety and learning curve of percutaneous axillary artery access in patients undergoing complex endovascular aortic repair (FBEVAR) requiring large-bore upper extremity access and to discuss best practices for technique and complication management.

Methods: Ninety-three patients undergoing large-bore percutaneous axillary artery access during FBEVAR in a prospective, nonrandomized, Investigational Device Exemption (IDE) study between September 2017 and December 2021 were analyzed. Ultrasound guidance and micropunture were used to access the second portion of the axillary artery and 2 Perclose Proglide or Prostyle devices (Abbott Vascular, Santa Clara, CA) were pre-deployed prior to 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 CT angiography. Patient-related, procedural, and postoperative variables were collected and analyzed. The experience was divided into early, middle and late cohorts to evaluate learning curve effects on access site complications.

Results: Ninety-two patients underwent successful axillary access, 1 patient failed axillary access and alternative access was established. The left axillary artery was accessed in 79 patients(86%), and the right axillary artery was accessed in 13(14%). The largest sheath profile was 14Fr in 4 patients(4.3%), 12rF in 83 patients(90.2%), and 8Fr in 5 patients(5.4%). Seven patients(7.6%) required covered-stent placement (Viabahn, W.L. Gore, Flagstaff, AZ) for failure to achieve hemostasis; there were no conversions to open surgical repair. Additional adverse events included transient upper extremity weakness in 1 patient(1.1%) and transient paresthesias in 2 patients(2.2%). Two patients(2.2%) suffered postoperative strokes, including one unrelated hemorrhagic stroke and one possibly access-related embolic stroke. On follow-up, axillary artery patency was 100%. There was a trend towards decreased closure failure over time, with 4 patients(13%) in the early cohort, 2 patients(6%) in the middle cohort, and 1(3%) patient in the late cohort, but this failed to reach statistical significance (P=0.17 comparing early and late cohorts).

Conclusions: Large-bore percutaneous axillary artery access provides safe upper extremity large-bore access during FBEVAR, providing successful closure in over 90% of patients with a low incidence of access-related complications. There was a trend towards better closure rates with more experience, suggesting a learning curve effect. Application of best practices including ultrasound guidance and angiography will help to ensure safe dissemination of the technique of percutaneous large-bore axillary artery access.