Percutaneous Access for Endovascular Aortic Aneurysm Repair. Potential Predictors of Success must be Reappraised

Abstract

Thank you for the excellent systematic review on percutaneous access for endovascular aneurysm repair (pe-EVAR).1Malkawi A.H. Hinchliffe R.J. Holt P.J. Loftus I.M. Thompson M.M. Percutaneous access for endovascular aneurysm repair: a systematic review.Eur J Vasc Endovasc Surg. 2010; 39: 676-682Google Scholar Data abstraction reveals that, relevant studies published online several months before Malkawi et al. submission, were ommitted.1Malkawi A.H. Hinchliffe R.J. Holt P.J. Loftus I.M. Thompson M.M. Percutaneous access for endovascular aneurysm repair: a systematic review.Eur J Vasc Endovasc Surg. 2010; 39: 676-682Google Scholar Evidence of significantly lower primary success rates with increasing sheath size was mentioned.1Malkawi A.H. Hinchliffe R.J. Holt P.J. Loftus I.M. Thompson M.M. Percutaneous access for endovascular aneurysm repair: a systematic review.Eur J Vasc Endovasc Surg. 2010; 39: 676-682Google Scholar This fact remains a logical scenario but conflicting results appeared after the largest available study by Eisenack et al. (adding another 500 patients or 904 femoral groins) with negligible effect of sheath size on success rate.2Eisenack M. Umscheid T. Tessarek J. Torsello G.F. Torsello G.B. Percutaneous endovascular aortic aneurysm repair: a prospective evaluation of safety, efficiency, and risk factors.J Endovasc Ther. 2009; 16: 708-713Google Scholar Instead, the significant issue of operator experience, had the pivotal role in predicting pe-EVAR outcomes.2Eisenack M. Umscheid T. Tessarek J. Torsello G.F. Torsello G.B. Percutaneous endovascular aortic aneurysm repair: a prospective evaluation of safety, efficiency, and risk factors.J Endovasc Ther. 2009; 16: 708-713Google Scholar Considering all 4 missing studies, and a recent study by Krajcer et al.,3Krajcer Z. Gregoric I. Totally percutaneous aortic aneurysm repair: methods and outcomes using the fully integrated IntuiTrak endovascular system.J Cardiovasc Surg (Torino). 2010; 51: 493-501Google Scholar adding totally 714 more patients (1219 femoral groins), thus ∼40% expansion of the previous review population, and when splitting all pe-EVAR literature in two equal quantitative periods, (1st: 1999–2008 and 2nd: 2008–2010, initial 1450 and latest 1509 femoral access sites respectively) we found that (Table 1) the earlier period had worse primary success rate (88.7% vs 95.4%) and increased combined device-related and patient-related open conversion rates (8.6% vs 3.4%).Table 1Early and late pe-EVAR results.PatientsFemoral access sitesMean sheath size used (Fr)Overall pe-EVAR success rateaReported on pre-close technique femoral access entry site basis.DR-/PR-OC’saReported on pre-close technique femoral access entry site basis.(%)P value1st period (1999–2008)917145017.788.7104 (7.1)/22 (1.5)2nd period (2008–2010)884150918.895.450 (3.3)/2 (0.13)Total1801295992.4 (weighted mean)154 (5.2%)/24 (0.8%)<0.001/<0.001DR-OC: device-related open conversions, PR-OC: patient-related open conversions.a Reported on pre-close technique femoral access entry site basis. Open table in a new tab DR-OC: device-related open conversions, PR-OC: patient-related open conversions. Considering that mean sheath size is almost the same, and assuming that learning curves are rather similar among institutions, this discrepancy might be explained by operator expertise. Interestingly, increasing experience eliminates other potential predictors of pe-EVAR success rates like sheath size or anatomically related factors, like obesity.2Eisenack M. Umscheid T. Tessarek J. Torsello G.F. Torsello G.B. Percutaneous endovascular aortic aneurysm repair: a prospective evaluation of safety, efficiency, and risk factors.J Endovasc Ther. 2009; 16: 708-713Google Scholar A meta-analysis is warranted to further clarify the contribution of all possible predictor of success in pe-EVAR era. Percutaneous Access for Endovascular Aneurysm Repair: A Systematic ReviewEuropean Journal of Vascular and Endovascular SurgeryVol. 39Issue 6PreviewRecent developments in aortic stent-graft technology have led to an increase in the use of wholly percutaneous endovascular aneurysm repair (P-EVAR). The literature was systematically reviewed to analyse the results of P-EVAR. Full-Text PDF Open Archive