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The axillary artery a new approach for endovascular treatment of thoracic aortic diseases Eduardo Keller Saadi, Luiz Henrique Dussin, Leandro Moura and AndréSevero Machado Interact CardioVasc Thorac Surg 2010;11:617-619; originally published online Aug 5, 2010; DOI: 10.1510/icvts.2010.245274

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://icvts.ctsnetjournals.org/cgi/content/full/11/5/617

Interactive Cardiovascular and Thoracic Surgery is the official journal of the European Association for Cardio-thoracic Surgery (EACTS) and the European Society for Cardiovascular Surgery (ESCVS). Copyright © 2010 by European Association for Cardio-thoracic Surgery. Print ISSN: 1569-9293.

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ARTICLE IN PRESS doi:10.1510/icvts.2010.245274 Editorial

www.icvts.org

Proposal for bail-out procedures - Aortic and aneurysmal

Department of Cardiovascular and Endovascular Surgery, Federal University of Rio Grande do SulyHospital de Clı´nicas de Porto Alegre, Rua Ramiro Barcellos 2350 Zip 90035-004, Porto Alegre, RS, Brazil

Abstract


Brief Case Report Communication

䊚 2010 Published by European Association for Cardio-Thoracic Surgery

Historical Pages

The feasibility of endovascular surgery depends on many anatomical factors, including the diameter and the disease state of the access vessels w4x. Stenosis, calcifications, tortuosity, small sizes or dissection of both femoral and iliac arteries can make introduction of large sheath hazard-

Nomenclature

*Corresponding author. Tel.: q55 51 3333 7887yq55 51 9982 5379 (Mobile); fax: q55 51 3346 5818. E-mail address: [email protected] (E.K. Saadi).

3. Discussion

Best Evidence Topic

Between April 2008 and June 2010, we treated five patients with TAD in which transfemoral access was contraindicated because of occlusive disease, small vessels or extreme calcification. The demographic characteristics of the patients and the contraindications to use the femoral artery are presented in Table 1. In two cases, the right axillary artery was used and in the other three we used the left axillary artery. The axillary artery was exposed through an incision in the deltopeitoral groove. The pectoralis major muscle was

State-of-the-art

2. Case reports and technique

Follow-up Paper

Endovascular approaches are being increasingly utilized to treat a variety of thoracic aortic diseases (TAD), including aneurysms, pseudoaneurysms, dissections, penetrating aortic ulcers, traumatic aortic rupture and coarctation w1x. The procedure is usually done through the femoral arteries w1–3x. Sometimes this access is impossible or not recommended because of the small size of the vessels, obstruction, calcification, dissection or extreme tortuosity. We present a series of five cases and describe the technique in which the axillary artery was used to deliver the endograft for treatment of different TAD.

divided in the direction of its fibers and the insertion of the pectoralis minor was divided. The axillary artery was easily seen superior to the axillary vein and was dissected. A side-biting clamp was applied and an anastomosis was constructed with an 8 mm Dacron tube with a 6-0 prolene suture. The tube was moved to new small stab incision and left long and parallel to the artery (Fig. 1a). A 7-French sheath was attached to the Dacron tube to avoid bleeding and facilitate the manipulation of wires, catheters and the insertion of the device (Fig. 1b). An extra stiff Landerquist 260 cm long guide wire was inserted and the endoprosthesis was introduced without the sheath through the Dacron tube (Fig. 1c). An aortography was done with a pigtail introduced from the same graft, the contralateral arm or from the groin as a diagnostic landmark and before opening the device. Final aortography was performed to check for endoleaks (Fig. 1d). The wires were removed and the Dacron tube was ligated with a large clip 1 cm away from the axillary artery and reinforced with a running suture of 5-0 prolene. There was technical success in all five patients with no hospital mortality or vascular complications.

Negative Results

1. Introduction

Proposal for Bailout Procedure

Keywords: Aortic aneurysm; Endovascular surgery; Axillary artery approach

ESCVS Article

Endovascular procedures are increasing in number for the treatment of thoracic aortic diseases (TAD). Retrograde approach through the femoral artery is the preferred vascular access. Despite the improvements in the devices, femoral artery complications still occurs and some times this access is not possible because of the small size of the vessels, obstruction, calcification, dissection or extreme tortuosity. An axillary approach could be an alternative. We present a series of five patients and describe the technique we used in the axillary artery approach to treat TAD. There were two ascending aortas and three descending aortic aneurysms treated. The left axillary artery was used in three patients and the right in two. There were no local or neurological complications. In this preliminary approach, both axillary arteries were a good alternative access for endovascular graft insertion to treat aortic diseases when femoral access was not possible or was suboptimal. 䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Institutional Report

Received 4 June 2010; received in revised form 12 July 2010; accepted 14 July 2010

Protocol

Eduardo Keller Saadi*, Luiz Henrique Dussin, Leandro Moura, Andre ´ Severo Machado

Work in Progress Report

The axillary artery – a new approach for endovascular treatment of thoracic aortic diseases

New Ideas

Interactive CardioVascular and Thoracic Surgery 11 (2010) 617–619

ARTICLE IN PRESS E.K. Saadi et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 617–619

618 Table 1. Patients’ demographics Patient

Age (years)

Disease

Access problem

Axillary

Prosthesis

1 2

72 83

AA DA

Right Left

TAG 40=100 TAG 37=200

3 4

49 65

PA DA

Right Left

Two AE 32=4.5 TAG 37=150

5

76

DA

Aorto iliac occlusion Small size femoral arteries -7 mm Delivery system too short Small size femoral arteries -6 mm Stenosis and calcification of the femoral arteries

Left

TAG 37=200

AA, ascending aorta aneurysm; TAG, Gore-Tex thoracic aorta self expandable endoprosthesis; DA, descending aorta aneurysm; PA, pseudoaneurysm of ascending aorta; AE, aortic extender cuff for proximal abdominal aorta.

ous or impossible. A conduit anastomosed to the iliac artery is an option w5x. An alternative to groin access is through the axillary artery. The exposure of the axillary artery through a small infraclavicular incision is as familiar to cardiovascular surgeons as the arterial return in cardiopulmonary bypass is in aortic arch surgery w6x. They are often

good-sized vessels and are usually free from atherosclerosis, even in patients with extensive aorto-iliac occlusive disease. Both axillary arteries can be used. The decision as to which side to use is made based on anatomical details and the angle is detected in the preoperative multislice com-

Fig. 1. (a) An 8-mm Dacron tube anastomosed to the right axillary artery and brought through another small stab incision; (b) a long tube with a 7-French sheath inserted and snared allows the introduction of wires, catheters and the device without bleeding; (c) a Gore-Tex (TAG) thoracic stent graft inserted through a rigid guide wire and the Dacron tube; (d) final aortography of two aortic extender cuffs deployed in the ascending aorta through the right axillary artery to treat a pseudoaneurysm.


ARTICLE IN PRESS E.K. Saadi et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 617–619

4. Conclusion

Protocol Institutional Report ESCVS Article Proposal for Bailout Procedure Negative Results Follow-up Paper State-of-the-art

w1x Melissano G, Bertoglio L, Civilini E, Marone EM, Calori G, Setacci F, Chiesa R. Results of thoracic endovascular grafting in different aortic segments. J Endovasc Ther 2007;14:150–157. w2x Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology FoundationyAmerican Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266–e369. w3x Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders TC, Kundt G, Scheinert D, Czerny M, Kleinfeldt T, Zipfel B, Labrousse L, Ince HS, for the INSTEAD Trial. Randomized comparison of strategies for type B aortic dissection. Circulation 2009;120:2519–2528. w4x Alric P, Canaud L, Branchereau P, Marty-Ane ´ C, Berthet JP. Preoperative assessment of anatomical suitability for thoracic endovascular aortic repair. Acta Chir Belg 2009;109:458–464. w5x Criado FJ. Iliac arterial conduits for endovascular access: technical considerations. J Endovasc Ther 2007;14:347–351. w6x Sabik JF, Nemeh H, Lytle BW, Blackstone EH, Gillinov M, Rajeswaran J, Cosgrove DM. Cannulation of the axillary artery with a side graft reduces morbidity. Ann Thorac Surg 2004;77:1315–1320. w7x Probst C, Esmailzadeh B, Schiller W, Wilhelm K. Emergent antegrade endovascular stent placement in a patient with perforated Stanford B dissection via right axillary artery. Eur J Cardiothorac Surg 2008; 33:1148–1149. w8x Moore KL, Agur AMR. Essential clinical anatomy, 3rd ed. Philadelphia: Lippincott Williams and Wilkins; 2007. p. 428. w9x Almeida RM, Leal JC, Saadi EK, Braile DM, Rocha AST, Volpiani J, Centola C, Zago A. Thoracic endovascular aortic repair – a Brazilian experience in 255 patients over a period of 112 months. Interact CardioVasc Thorac Surg 2009;8:524–528.

Work in Progress Report

References

New Ideas

In this initial small series, we were able to implant stent grafts in all five patients with TAD without complications. Endovascular aortic procedures through the axillary artery is an attractive alternative in patients where a transfemoral approach is contraindicated. Further studies with more patients and longer follow-up periods are needed to validate this method.

Editorial

puted tomography scan with 3D reconstruction. If both arteries are of good size and the angle in relation to the aortic arch is favorable we prefer to use the left artery. We believe there is less chance of debris embolization to the carotid artery if we avoid the brachiocephalic trunk. If the left subclavian artery has been involved in the dissection or aneurysm we use the right artery. In four cases, we used a Gore-Tex (TAG) thoracic endoprosthesis. In these patients, we introduced the graft without a sheath through the Dacron tube and delivered it in an antegrade approach. The advantage of this graft for antegrade insertion is that it is designed exactly with the same configuration and the same radial force in both extremities. This does not occur with other commercially available stent grafts. In one case of pseudoaneurysm of the ascending aorta we used two extension cuffs (aortic extender) through the right axillary artery. The length of the delivery system, designed for the abdominal aorta, is not long enough to reach the ascending aorta through the groin. The infraclavicular incision to expose the axillary artery is very well tolerated with minimal pain or discomfort. The use of a side graft has been shown to reduce morbidity associated with axillary cannulation w6x. The direct cannulation can cause damage to the artery that can be difficult to repair. The stab incision provides a smooth angle of entry that facilitates the introduction of large devices w5x. There are only a few case reports in the literature where the axillary artery has been used to deploy endografts in the aorta w7x. If there is no other alternative the artery can be ligated without major consequences to the arm perfusion w8x. In this small series, we did not have any complications related to access vessels or neurological problems. Major vascular injury remains a frequent complication of endovascular procedures in the aorta. We recently published a series on 255 patients who underwent endovascular treatment of TAD through the femoral artery with 3.1% of major vascular access complications w9x.

619

Best Evidence Topic Nomenclature Historical Pages Brief Case Report Communication


The axillary artery a new approach for endovascular treatment of thoracic aortic diseases Eduardo Keller Saadi, Luiz Henrique Dussin, Leandro Moura and AndréSevero Machado Interact CardioVasc Thorac Surg 2010;11:617-619; originally published online Aug 5, 2010; DOI: 10.1510/icvts.2010.245274 This information is current as of October 21, 2010 Updated Information & Services

including high-resolution figures, can be found at: http://icvts.ctsnetjournals.org/cgi/content/full/11/5/617

References

This article cites 8 articles, 5 of which you can access for free at: http://icvts.ctsnetjournals.org/cgi/content/full/11/5/617#BIBL

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