PS168. Novel Aorto-Ilio-Femoral Assessment (AIFA) for the Evaluation of Access Vessels Based on Unenhanced Computer Tomography (CT)

Abstract

Patients undergoing endovascular procedures, such as aortic valve implantations and aortic endografts, often have renal insufficiency. Pre-operative evaluation with contrast-enhanced studies remain a standard practice. We evaluated the efficacy of unenhanced CT with a new classification to prospectively study the candidates' access vessels for transfemoral deployment of endovascular large device (ELD) implants. 117 patients (2009-11) were studied by unenhanced CT for transfemoral ELD(22-28 Fr.) implants and assigned an IFAC type (Table). 60 were selected for ultrasound-guided percutaneous delivery using ProGlide pre-closure. Implantation success and access complications were tracked to gauge pre-procedure assessment reliability.TableIliac-Femoral-Aortic Classification (IFAC)IFAC TypeUnenhanced CT findingsClinical correlationAnticipated complexity of the transfemoral accessType IMeets minimal diameter criteria at all levels with only mild or moderate calcification and/or tortuosityNo secondary procedures likely.Minimally complexType IIMostly meets minimal diameter criteria but there is one area with plaque and moderate calcification and/or tortuosityMay require angioplasty and/or stent. This single area of concern has to be safely amenable to angioplasty/stent.Moderately complexType IIIMostly meets minimal diameter criteria but there are two areas of plaque with severe and/or concentric calcificationWill likely need adjuvant endovascular procedures. May potentially be associated with increased access complications, increased procedure length, and significantly increased total IV dye.Severely complexType IVDiffusely small and/or severely calcified at more than two areas (or) clearly not meeting minimal diameter criteria at multiple areas (or) concern that stenosis areas carry high rupture/bleeding risk if dilated (or) prior surgical history contraindicating transfemoral accessNot amenable to the transfemoral approach unless surgical conduit or direct cutdown to iliacs and/or aorta is performed as intended initial plan.Percutaneous Transfemoral approach NOT recommended Open table in a new tab Primary success for device delivery was 98.3%, with uncomplicated percutaneous deployment in 93.3%. 6 patients developed early access complications requiring intervention. None developed late access complications. IFAC I and II cases were uncomplicated. IFAC III and IV strongly correlated with access-related secondary procedures. 2 IFAC 4 cases required surgical reconstruction. We report a new classification using unenhanced CT that is accurate and reliable for assessment of access vessels for percutaneous ELD deployment. The classification is defined relative to the delivery sheath, applicable to any ELD implant and can facilitate inter-center and inter-device studies related to transfemoral endovascular access.