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SVS-VESS Scientific Session @ VAM: Session 1b

VESS08 - Outcomes of Upper versus Lower Extremity Access among Patients Treated by Multi-Branched Endovascular Aortic Repair of Complex Aortic Aneurysms in the International Multicenter Aortic Research Group

Wednesday, June 4, 2025
2:28 PM – 2:36 PM CT
Location: Morial CC, Second Floor, Room 228-230

    Submitting & Presenting Author(s)

  • Andrea Vacirca, MD, PhD (he/him/his)

    University Researcher
    Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
    Bologna

    Slides

    • Co-Author(s)

  • BS

    Bruno P. Schmid
  • YH

    Ying Huang

    Assistant Director, Advanced Endovascular Aortic Research Program.
    Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston
    Houston, Texas

  • SH

    Stéphan Haulon

    Professor of Vascular Surgery, Head of Aortic Center
    Hôpital Marie Lannelongue, Paris Saclay University, France

  • Tomasz Jakimowicz, MD, PhD

    Professor
    Medical University of Warsaw
    Warsaw, Mazowieckie, Poland

  • Darren B. Schneider, MD

    Chief of the Division of Vascular Surgery and Endovascular Therapy
    Hospital of the University of Pennsylvania
    Philadelphia, Pennsylvania

  • Adam W. Beck, MD

    Professor of Surgery
    University of Alabama Medical Center
    Birmingham, Alabama

  • Andres Schanzer, MD (he/him/his)

    Professor
    UMass Chan Medical School
    Worcester, Massachusetts

  • Mark A. Farber, MD

    Chief, Division of Vascular Surgery - Professor of Surgery
    University of North Carolina at Chapel Hill
    Chapel Hill, North Carolina

  • Carlos H. Timaran, MD, MS

    Professor of Surgery
    University of Texas Southwestern Medical Center Dallas
    Dallas, Texas

  • TK

    Tilo Kölbel, MD, PhD

    Professor
    German Aortic Center Hamburg
    Hamburg, Germany

  • Enrico Gallitto, MD, PhD

    Associated Professor of Vascular Surgery, University of Bologna, IRCCS Sant'Orsola Bologna, Italy
    University of Bologna
    Bologna, Italy

  • GianLuca Faggioli, MD, PhD

    Full Professor, Vascular Surgery
    University of Bologna
    Bologna, Italy

  • Gustavo S. Oderich, MD

    Vascular Surgeon, Professor of Surgery
    Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston
    Houston, Texas

    • Senior Author(s)

  • MG

    Mauro Gargiulo

    Full Professor, Vascular Surgery
    1-Vascular Surgery, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy. 2-Vascular Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
    Bologna, Italy

Objectives: Recent improvements in steerable sheath technology and smaller profile bridging stent-grafts enabled increased utilization of total trans-femoral approach (TTFA) during fenestrated-branched endovascular aortic repair (FB-EVAR). Although several studies have shown advantages of TTFA including a decreased risk of cerebrovascular events and complications, most are limited by inclusion of patients treated by fenestrated designs and less extensive aneurysms. Aim of this study is to analyze outcomes of upper extremity access (UEA) and TTFA in a large cohort of patients treated by branched endovascular aortic repair (BEVAR) using multi-branched endografts for complex abdominal (CAAAs) and thoracoabdominal aortic aneurysms (TAAAs).

Methods: The clinical data of 6,316 consecutive patients treated by FB-EVAR for CAAAs and TAAAs in 29 international aortic centers between 2006-2024 was retrospectively reviewed. Patients who underwent BEVAR using multi-branched stent-grafts using either TTFA or UEA were analyzed excluding those with mixed fenestrated-branched or fenestrated designs. Endpoints were 30-day/in-hospital mortality, cerebrovascular events, TAAA life-altering events (TALE; mortality, major stroke, permanent spinal cord injury and dialysis), technical success and access-related complications.

Results: There were 1,420 patients (22%) treated by BEVAR using multi-branched stent-grafts (71% males 29% females; mean age 71±9 years-old). Aneurysm extent was TAAA in 1,315 patients (93%) and CAAA in 105 CAAA. Target vessel stenting was performed using UEA in 1,017 patients (72%) and TTFA in 403 (28%). UEA subrgroup had higher prevalence of smoking habit (p=.005), coronary (p=.03) and peripheral artery disease (p <.001) as compared to TTFA, respectively. Overall technical success was 94%, with no differences between UEA and TTFA groups (p=.25). Use of UEA was associated with increased risk of mortality (13% vs 3%, p<.001), cerebrovascular events (4% vs 1%, p=.007), TALE (18% vs 9%, p<.001) and access-related complications (13% vs 7%, p=.004) as compared to TTFA, respectively. On multivariable analysis, UEA was independently associated with increased risk of cerebrovascular events [OR 3.71 (CI 1.31–10.54), p=.01]. Risk of cerebrovascular events (7% vs 3%, p=.01) and TALE (22% vs 17%, p=.03) were significantly higher among patients treated using right as compared to left UEA, respectively.

Conclusions: The use of UEA during BEVAR with multi-branched stent-grafts was associated with a higher risk of cerebrovascular and life-altering events as compared to TTFA, with greater risk observed in patients treated with right- compared to left-sided UEA. However, UEA patients represented a more diseased population, and the higher mortality and TALE risk in this subgroup may be influenced by centers experience and learning curve.