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Evaluation of Safety of Overhead Upper Extremity Positioning During Fenestrated–Branched Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Abstract

Purpose

Peripheral nerve and brachial plexus injury can occur from compression or stretching during positioning for operative procedures. The aim of this study was to evaluate the safety of overhead upper extremity positioning to optimize imaging during fenestrated–branched endovascular aortic repair (FB-EVAR) of pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs).

Methods

Forty-four consecutive patients enrolled in a prospective non-randomized study underwent FB-EVAR with overhead upper extremity positioning. Patients underwent intra-operative neuromonitoring of upper and lower extremities and neurological examination prior to discharge and at 2 months following the procedure. End points were peripheral or brachial plexus nerve injury, quality of lateral projection and cone beam computed tomography (CBCT) and major adverse event (MAEs).

Results

There were 28 (64%) male patients with mean age of 74 ± 8 years treated for 10 PRAs (23%) and 34 (78%) TAAAs. Mean body mass index was 29 ± 7 kg/m2, with 17 obese patients (39%). Open surgical upper extremity access was used in 19 patients (43%). Three patients (16%) had access-related complications, all focal brachial artery dissections treated by patch angioplasty. Two patients (5%) developed upper extremity changes in neuromonitoring, which immediately resolved with repositioning of the upper extremity. Technical success was 95%. Lateral projection and rotational CBCT were feasible in all patients with satisfactory imaging quality for catheterization and stenting of the celiac axis and superior mesenteric artery. There was one mortality (2%) at 30 days, and six patients (14%) had MAEs. There were no upper extremity neurological injuries.

Conclusion

Overhead upper extremity position allows optimal imaging on lateral projections and rotational CBCT during FB-EVAR. There were no upper extremity neurological injuries in this study.

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Funding

This study was not supported by any funding.

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Correspondence to Gustavo S. Oderich.

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Conflict of interest

Gustavo Oderich MD has received consulting fees and grants from Cook Medical, W. L. Gore, and GE Healthcare (all paid to Mayo Clinic with no personal income). Other co-authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This is a retrospective review of a prospective maintained database of patients treated by FB-EVAR conducted under the US Food and Drug Administration (FDA) PS-IDE G130030 and G130266 and registered under ClinicalTrial.gov NCT01937949 and NCT02089607. The study was approved by the Institutional Review Board at University of Texas Health Science Center at Houston and Mayo Clinic Rochester.

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Informed consent was obtained from all individual participants included in the study.

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Marcondes, G.B., Tenorio, E.R., Baumgardt, G. et al. Evaluation of Safety of Overhead Upper Extremity Positioning During Fenestrated–Branched Endovascular Repair of Thoracoabdominal Aortic Aneurysms. Cardiovasc Intervent Radiol 44, 1895–1902 (2021). https://doi.org/10.1007/s00270-021-02992-1

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Keywords

  • Fenestrated–branched endovascular aortic repair
  • Pararenal aortic aneurysm
  • Thoracoabdominal aortic aneurysm
  • Upper extremity position
  • Overhead position