Percutaneous Access Downsizing to Achieve Early Limb Reperfusion in Fenestrated/Branched TAAA Repair

Abstract

Introduction - Large-bore introducer sheaths required during complex fenestrated and branched endovascular TAAA repair (F/B-EVAR) can determine non-negligible malperfusion to the pelvis and lower limbs. Early pelvic and limb reperfusion has been linked to improved neurological outcomes secondary to a reduction in spinal cord ischemia during such procedures1. The technique presented hereby allows percutaneous downsizing of the large femoral access required for fenestrated/branched grafts delivery, while maintaining an introducer sheath in place, in order to reduce pelvic and limb ischemia while preserving the femoral access to complete the procedure. Methods - Twenty-one patients were treated between 2015 and 2017 by means of F/B-EVAR and as part of standard procedure received bilateral percutaneous femoral access with two Perclose Proglide vessel closure devices per each side. Once allowed by procedural restraints, the main introducer sheath was removed and replaced by a smaller 10Fr x 11cm sheath, and hemostasis achieved by gently pulling on the Proglide thread. A cohort of 468 patients treated by means of percutaneous TEVAR was analyzed and matched 2:1 to the previous 21 patients according to main introducer sheath size (Fr), common femoral artery diameter (mm) and presence of previous surgical femoral access. The downsizing maneuvers success was evaluated as well as the technical success of percutaneous vessel closure at procedure completion in both the matched and downsizing group. Results - Downsizing technical success was 100% (21/21), with no access requiring premature complete closure or re-introduction of sheaths >10Fr to achieve hemostasis. Technical success at procedure completion was not different: 90% (19/21) in the downsizing group and 93% (39/42) in the matched group. Conclusion - Percutaneous downsizing of a femoral access with partial closure of the Perclose Proglide devices is feasible and safe and does not impair overall technical success of percutaneous vessel closure. Early limb reperfusion during complex aortic procedure can be performed also with percutaneous approach. References1The Impact of Early Pelvic and Lower Limb Reperfusion and Attentive Peri-operative Management on the Incidence of Spinal Cord Ischemia During Thoracoabdominal Aortic Aneurysm Endovascular RepairMaurel, B. et al.European Journal of Vascular and Endovascular Surgery , Volume 49 , Issue 3 , 248 - 254