Commentary on ‘Predictors of Failure of Closure in Percutaneous EVAR Using the Prostar XL Percutaneous Vascular Surgery Device’

Abstract

Actual outer diameter corresponding to the size given by the manufacturer in mm Size in Fr given by manufacturer 12F 14F 16F 18F 20F 22F In their paper, Rijkee et al. evaluated predictors of failure of closure in percutaneous endovascular aneurysm repair (P-EVAR) using the Prostar XL Percutaneous Vascular Surgery Device (Abbot Vascular, Santa Clara, CA, USA) in a consecutive series of 154 percutaneous accesses performed in 84 patients over a 40 month period. The team was experienced: P-EVAR was performed in 69% of the population treated. The pre-operative status of the common femoral artery (CFA) was properly evaluated on computed tomography (CT) scan, and puncture was systematically performed under per-operative ultrasound guidance to control the site of puncture and to avoid severe calcifications and atheromatous plaques. The authors demonstrated that the use of the Prostar XL device in P-EVAR was safe and feasible, with a success rate of 93.5% in a selected population excluding patients with circumferentially calcified femoral access sites or CFA stenosis. Failure to close access sites was defined as the need for conversion to conventional femoral cutdown to stop bleeding or correct vessel obstruction. In an attempt to predict failures, two potential new factors: (i) a specific calcification and location score system, and (ii) the SA-ratio (the ratio between sheath and CFA diameters) were proposed. This newly introduced calcification quantity and location score system evaluated the degree of arterial wall calcification on CT angiography, which was defined in a percentage of total wall circumference: grade I ( 50%, except circumferentially calcifications). Calcification location was classified as none or posterior, scattered anterior, and fully anterior, but this classification failed to predict failure. This result is probably related to the fact that the authors did the right thing by excluding patients with circumferentially calcified and stenotic CFAs, and puncturing under ultrasound guidance avoiding calcifications and then favoring femoral cut down in non-favorable CFAs. The other indicator was the SA ratio. The SA ratio was demonstrated to be a significant predictor of failure with a