Target Vessel Cannulation with a Transfemoral Retrograde Approach Equals Antegrade Approach from the Upper Extremity in Complex Aortic Treatment with Off the Shelf Inner Branched Endografts in the Italian Branched Registry of E-nside Endograft (INBREED)

Abstract

Objective: The aim of this study was to assess the results of an off the shelf inner branched thoraco-abdominal endograft for treating aortic pathologies, with a specific focus on comparing outcomes between antegrade and retrograde approaches for target vessel (TV) cannulation.

Methods: This was a national, physician initiated, multicentre, observational study. Data from a registry on patients treated with the E-nside endograft were gathered prospectively. Patients were divided into two groups based on the type of endovascular approach for TV cannulation. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Results: From September 2020 to February 2024, 166 procedures were collected, of which 128 (77.1%) used an antegrade upper extremity approach to TV cannulation, while 38 (22.9%) employed a retrograde femoral approach. There were no statistically significant differences in terms of bridging stent choice (balloon expandable only, 69.4% vs. 73.7%; self expandable only, 12.9% vs. 7.9%; mixed configurations, 17.7% vs. 18.4%; p = .68). The mean operation time ± standard deviation was longer for the retrograde approach (282 ± 90 minutes vs. 313 ± 155 minutes; p = .006), but fluoroscopy time, dose area product, and the volume of contrast injected were similar. Six cases of post-operative stroke were reported in the antegrade group (4.7% vs. 0%; p = .17). The 30 day TV related technical success was 94.5% and 94.7%, respectively, for antegrade and retrograde approaches (p = .96). Mean follow up was 14.4 ± 11.3 months (median 12.5 months). Kaplan-Meier estimates (with 95% confidence interval [CI]) at twelve months revealed similar overall survival (87.7%, 95% CI 81 - 95% vs. 91.1%, 95% CI 82 - 100%; log rank = .009, p = .92). Competing risk analysis revealed similar one year estimates of TV instability and TV related re-intervention between groups both in patient centred and TV centred analyses.

Conclusion: A total transfemoral retrograde approach for TV cannulation of inner branches proved to be effective and was not associated with any neurological events.

Keywords: Aortic dissection; Branched endovascular aortic repair; Endoleak; Patency; Target vessel; Thoraco-abdominal aortic aneurysm.