Upper extremity (UE) access is associated with an increased risk of perioperative strokes and transient ischemic attacks (TIAs) after F-BEVAR. Left-sided UE access avoids crossing the arch and the origin of the supra-aortic vessels, which could reduce cerebral embolization and the risk of perioperative cerebrovascular events. Although right UE access is convenient, ergonomic and may reduce operator radiation exposure, whether it results in increased risk of perioperative cerebrovascular events has not been established. The purpose of this study was to assess the perioperative cerebrovascular events after F-BEVAR using right vs. left-side upper extremity access.

Between 2005 and 2020, 1681 patients underwent endovascular repair for complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA) using manufactured fenestrated and branched stent-grafts at nine centers. Data was prospectively collected using a standardized database with external auditing. Outcomes were compared between patients undergoing right vs. left UE access. The primary composite outcome was perioperative strokes and transient ischemia attacks (TIAs). Secondary outcomes included technical success, local access related complications, and perioperative mortality.

UE access was used in 1100 patients (70% men, mean age 73.25±8.1 years) undergoing F-BEVAR for 234 (21%) CAAAs, 391 (38%) extent IV TAAAs and 475 (43%) extent I-III TAAAs. The right-side was used in 395 (36%) and the left-side in 705 (64%) patients. Right UE access was primarily used for extent I-III TAAAs (49.1% vs. 39.9%, P=.003), whereas left UE access was used more frequently for extent IV TAAAs (40.3% vs. 27%; P<.001). Technical success was achieved in 1062 patients (96.56%). In-patient or 30-day mortality was 2.9%. There were 31 (2.8%) perioperative cerebrovascular events, 25 (2.3%) strokes and six (0.6%) TIAs. Perioperative cerebrovascular events occurred with similar frequency after F-BEVAR with right vs. left UE access (2.5% vs. 2.9%; P=.67). Technical success was significantly reduced after F-BEVAR with right UE access (94.4% vs. 97.7% among those with left UE access; P=.004) and repairs for extent I-III TAAAs (94.5% vs. 98% among those with CCCAs and type IV TAAAs; P=.001). Right UE access (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.2-4.5; P=.002) and extent I-III TAAAs (OR, 2.75; 95% CI, 1.4-5.5; P=.004) were identified as independent predictors of technical failure by multivariable analysis. No significant differences were observed between right and left UE access in perioperative mortality (2.8% vs. 3.0% P=.85) and local access related complications (6.5% vs. 6.3%; P=.43).

The use of right UE access for F-BEVAR is not associated with an increased risk of perioperative cerebrovascular events with respect to left UE access. Although the reduced technical success after F-BEVAR with right UE may in part be related to the extent of the aneurysms treated, further evaluation is needed to elucidate the mechanisms of failure.