Elsevier

Annals of Vascular Surgery

Volume 23, Issue 5, September–October 2009, Pages 621-626
Annals of Vascular Surgery

Clinical Research
Percutaneous Access for Endovascular Abdominal Aortic Aneurysm Repair: Can Selection Criteria Be Expanded?

https://doi.org/10.1016/j.avsg.2008.09.002Get rights and content

Previous reports suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (P-EVAR) is as safe as open access (O-EVAR) in patients with favorable femoral anatomy. Severe femoral artery calcification and obesity have been considered relative contraindications to P-EVAR, but these criteria have not been evaluated. The purpose of this study was to assess the postoperative anatomic changes associated with P-EVAR versus O-EVAR using three-dimensional (3-D) computed tomographic (CT) reconstruction and to evaluate the overall results of the two procedures in a group of patients with suboptimal femoral anatomy. During a recent 26-month period, 173 patients underwent EVAR at our institutions, including 35 P-EVARs. Of these, 22 (63%) had complete pre- and postoperative CT imaging of the femoral arteries. These subjects were compared to 22 matched controls who underwent O-EVAR during the same period. Automated 3-D reconstructions were used to measure the following anatomic femoral artery parameters before and after EVAR: arterial depth, calcification score, minimum diameter and area, and maximum diameter and area. Of the 88 study arteries, 50 underwent open access and 38 percutaneous access (Proglide, n = 11; Prostar XL, n = 27). Both groups were similar regarding sheath size, number of components, operative time, blood loss, and length of stay. Significantly more O-EVAR subjects suffered groin complications (p = 0.02), including five hematomas, two wound infections, two femoral thromboses, and one vessel which required patch repair. In the P-EVAR group there was only one hematoma, which was managed conservatively. There was no difference between the P-EVAR and O-EVAR groups with respect to femoral artery calcification (Agatston scores 667 ± 719 vs. 945 ± 1,248, p = 0.37). Obesity (body mass index >30) was documented in six (27%) of both the P-EVAR and O-EVAR groups (p = nonsignificant). Pre- and postoperative CT-derived anatomic data showed a significant decrease in the minimal vessel area with O-EVAR compared to P-EVAR (p = 0.02). This study demonstrates that patients with obesity or severely calcified femoral arteries can be successfully treated percutaneously with fewer minor groin complications.

Introduction

Endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) has been accepted worldwide for patients with suitable aneurysm morphology. Due to the need for introduction of large sheaths, open common femoral artery (CFA) exposure has become the gold standard for EVAR access. However, improvements in arteriotomy closure devices have made percutaneous access possible, with secure closure even after the use of large sheaths. The first report of percutaneous EVAR with the “preclose” technique appeared in 1999.1 Although subsequent limited experience has been favorable, percutaneous EVAR has not been considered universally applicable. Due to potential problems with secure arteriotomy closure, the anatomic considerations of femoral artery calcification and morbid obesity have generally been considered relative contraindications to percutaneous EVAR.2, 3 However, these criteria have not been systematically evaluated. As we have gained experience with percutaneous EVAR (P-EVAR) in selected patients, we hypothesized that the technique could be applied to most patients regardless of femoral artery calcification or body mass index (BMI). The purpose of this study was to evaluate whether P-EVAR can be safely performed in patients with suboptimal femoral anatomy, with particular emphasis on anatomic changes in the CFAs using automated three-dimensional (3-D) reconstruction measurements.

Section snippets

Methods

We reviewed our experience with 173 consecutive patients who underwent EVAR at our institution from March 2005 to April 2007. During this period, 35 patients (20%) underwent P-EVAR. Twenty-two of these (63%) had complete pre- and postoperative computed tomographic (CT) imaging for analysis of the femoral arteries, and these subjects served as the focus of our study. Patients with inadequate imaging of the femoral arteries were excluded. Excluded studies mainly included poorly contrasted scans,

Results

P-EVAR and O-EVAR patients had similar demographics and comorbidities, as seen in Table I. Obesity (BMI >30 kg/m2) was relatively common in this study, occurring in six (27%) of the percutaneous and six (27%) of the open access patients (p = 0.78). There was no difference in the type of EVAR device (p = 0.19) (Table I), and the median sheath size was 18F in CFAs accessed in both groups (p = 0.98). The mean number of components placed through each CFA was 1.6 ± 0.7 in the percutaneous group and 1.4 ± 0.5

Discussion

A completely percutaneous approach for EVAR is appealing. It is consistent with the minimally invasive nature of EVAR, patients like it, and it has the benefit of fewer local wound complications. The devices are used off-label for P-EVAR, and there are no large, randomized studies comparing it to O-EVAR. However, there have been increasing reports of successful use of the preclose technique.5, 6, 7, 8 There is a learning curve as with any other technique, and patient selection may play an

Conclusion

This study demonstrates that patients with obesity or severely calcified femoral arteries can be successfully treated percutaneously with fewer minor groin complications. Anatomic analysis demonstrated no deformation of the CFAs after P-EVAR.

References (10)

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