Percutaneous Endovascular Aortic Repair of Complex Aneurysms Using Large-Diameter Sheaths for Thoracic, Fenestrated, and Branched Endografts

Abstract

This study reviewed the outcomes of percutaneous endovascular aortic repair (PEVAR) of complex aortic aneurysms using large-diameter sheaths for thoracic, fenestrated, and branched stent grafts. We reviewed the outcomes of all consecutive patients who underwent PEVAR of descending thoracic (DTA), thoracoabdominal (TAAA), pararenal (PRA) or aortoiliac aneurysms (AIAs) using large-diameter sheaths for placement of thoracic, fenestrated, or branched stent grafts. Patients treated by fenestrated and branched stent grafts were enrolled in prospective physician-sponsored investigational device exemption protocols. A percutaneous approach was selected in patients with <50% posterior, minimal anterior, or no calcification in the common femoral artery using standardized preclosure technique with two Perclose devices (Abbott Vascular Inc., Redwood City, Calif) in each femoral puncture site. End points were technical success, conversion to open femoral artery repair, 30-day mortality and major adverse events, and freedom from femoral access-site complications. There were 102 patients treated for 48 PRAs, 27 TAAAs, 19 DTAs, and 8 AIAs. A total of 171 femoral arteries were closed using preclosure technique. Transfemoral sheath size was 18F in four vessels (3%), 20F in 120 (70%), and ≥22F in 47 (27%). Eighty-three patients (81%) had visceral branch incorporation, which required brachial artery access using small incision in 48. Technical success for percutaneous transfemoral closure was 95% (162 of 171). Nine intraoperative failures were managed by open femoral conversion using primary repair in six, interposition graft in two, and patch angioplasty in one. Mean estimated blood loss was 444 ± 569 mL. There were no patients with uncontrolled puncture-related hemorrhage, retroperitoneal hematoma, or intra-operative hypotension. The 30-day mortality was 0.9% (one of 101) and 30-day rate of major adverse events was 15% (16 of 102). Spinal cord injury occurred in one patient (0.9%). Five (3%) access-related complications occurred, including femoral artery occlusion in three and hematoma or pseudoaneurysm in one each. Wound-related complications occurred in one patient (0.5%) who required open femoral artery conversion for exposure and repair. After a mean follow up of 1-year, freedom from femoral access-site complication was 97% ± 2%. PEVAR using the preclosure technique is safe and effective in select patients with complex aortic aneurysms who have minimal or no femoral calcifications and require large-diameter sheaths for thoracic, fenestrated, and branched stent grafts. Rate of puncture (3%) and wound-related complications (0.5%) is low, and no uncontrolled puncture-related hemorrhage, retroperitoneal hematoma, or systemic hypotension occurred in this series.