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Vascular Access for Thoracic Stent Grafting: Approaches & Complications

Benjamin M. Jackson, Ronald M. Fairman, Grace Wang, Joseph E. Bavaria, Alberto Pochettino, Wilson Y. Szeto, Edward Y. Woo, Jagajan Karmacharya, Jeffrey P. Carpenter.
Hospital of the University of Pennsylvania, Philadelphia, Pa.

OBJECTIVES: A continued drawback to thoracic aortic stent grafting is the large French sizes of the required delivery systems and sheaths. We reviewed a large single-institution experience with thoracic stent grafting to determine the frequency of and risk factors for access vessel injury, and to determine the clinical consequence of access-related complications.

METHODS: All thoracic stent grafting procedures performed at a single university hospital between January 2001 and September 2007 (81 months) were retrospectively examined. In this time period, 285 patients underwent 297 procedures.

RESULTS: Vascular access for thoracic stent grafting was accomplished most often via the femoral arteries (74% of cases), direct iliac artery puncture (21%), or conduit to the iliac artery (2%). The overall incidence of access-related complications in our cohort was 17% (50/297). There were 55 discrete injuries in those 50 procedures. The most common injuries were common femoral disruption (n=15, requiring endarterectomy, patch angioplasty, or interposition graft), external iliac rupture or avulsion (n=13, requiring ilio-femoral or femoral-femoral bypass), and external iliac dissection or leak (n=8, requiring covered or bare-metal stenting). Selected and potential risk factors for vascular access complications are summarized in the table. Age did not confer increased risk of vascular complications. The minimum diameter of the larger external iliac in those patients suffering access-related complications was 6.2±1.5 mm; it was 7.4±1.8 mm in others (p=.007). Those suffering access-related injuries had a perioperative mortality of 10%, while other patients had a perioperative mortality of 7% (p=.39).

CONCLUSIONS: Women and those with small external iliacs are at increased risk of vascular injury during thoracic stent grafting. Judicious selection of the most appropriate access vessel, and liberal utilization of adjunctive procedures such as stenting and stent grafting in the case of iliac artery injury, are essential. Improvements in thoracic stent graft sheaths and delivery systems, including especially the reduction in the size thereof, are imperative.

AUTHOR DISCLOSURES: B.M. Jackson, None; R.M. Fairman, None; G. Wang, None; J.E. Bavaria, None; A. Pochettino, None; W.Y. Szeto, None; E.Y. Woo, None; J. Karmacharya, None; J.P. Carpenter, None.