The advancement of endovascular therapy has led to minimally invasive solutions to increasingly complex aortic pathology, including thoracoabdominal aneurysms and those involving the visceral segment. Upper extremity access is beneficial in a variety of these complex interventions, and may be absolutely required for certain procedures such as placement of parallel chimney grafts. Traditionally, the brachial artery has been the primary access site on the arm, using either a percutaneous or open approach. Brachial access is safe and effective, and remains suitable for the majority of clinical situations. More recently though, descriptions of axillary and radial access have emerged and may provide a useful alternative in specific cases. These options should be viewed as complementary rather than competitive, and facility with all three techniques is desirable. Here, we describe in detail the various options for upper extremity access during complex aortic aneurysm repair and their relative advantages.
