Percutaneous Endovascular Aortic Aneurysm Repair Research Articles

Predicting the learning curve and failures of total percutaneous endovascular aortic aneurysm repair

Percutaneous endovascular aneurysm repair (PEVAR) has been shown to be feasible; however, technical success is variable, reported to be between 46.2% and 100%. The objective of this study was to quantify the learning curve of the PEVAR closure technique and identify predictors of closure failure. We reviewed patient- and procedure-related characteristics in 99 consecutive patients who underwent PEVAR over a 30-month period in a single academic institution. A suture-mediated closure device (Proglide or Prostar XL) was used. Forward stepwise logistic regression was used to investigate associations between the failure of the closure technique and a number of patient and operative characteristics. To ensure objective assessment of the learning curve, a time-dependent covariate measuring time in calendar quarters was introduced in the model. Poisson regression was used to model the trend of observed failure events of the percutaneous technique over time. Overall PEVAR technical success was 82%. Type of closure device (P<.35), patient's body mass index (P<.86), type of anesthesia (P<.95), femoral artery diameter (P<.09), femoral artery calcification (P<.56), and sheath size as measured in Fr (P<.17) did not correlate with closure failure rates. There was a strong trend for a decreasing number of failure events over time (P<.007). The average decrease in the odds of technical failure was 24% per calendar quarter. The predicted probability of closure failure decreased from 45% per patient at the time of the initiation of our PEVAR program to 5% per patient at the end of the 30-month period. There were two postoperative access-related complications that required surgical repair. Need for surgical cutdown in the event of closure failure prolonged the operative time by a mean of 45 minutes (P<.001). No groin infections were seen in the percutaneous group or the failed group. Technical failure can be reduced as the surgeon gains experience with the suture-mediated closure device utilized during PEVAR. Previous experience with the Proglide device does not seem to influence the learning curve.

Commentary on ‘General Anaesthesia is Associated with Adverse Cardiac Outcome after Endovascular Aneurysm Repair’

Much is being discussed regarding surgical/hospital volumerelated outcomes following AAA surgery. The other side of the coin, namely how anaesthesia affects EVAR outcomes (though hinted at in EUROSTAR), seems to be largely ignored. The point is, post-EVAR cardiac complications, albeit low, could be even lower with regional anaesthesia (RA), and that RA for EVAR is not new. Despite undertaking other procedures under RA, there are anaesthetists who will simply put a patient asleep out of sheer convenience/habit, and a matching body of vascular surgeons who do not question that decision. The anecdotal practice of epidural insertion followed by intubation is laughable; the same applies to GA for percutaneous EVAR. Conversions to OR are rare, so a ‘what if’ argument does not apply. Our default approach is RA, namely an epidural (applicable even for procedural extension e.g. IBD deployment), avoiding even transient/unnecessary blood pressure shifts from a spinal, unless RA is clearly contraindicated. This has several advantages, such as patient co-operation with breathing whilst imaging, reducing need for HDU care (patients can have a cup of tea in recovery and go straight to the ward), reduced pulmonary complications (clearly demonstrated in this paper) and early discharge,1 exemplified by our case of a man in his mid-60s, on home oxygenation and under consideration for a heart-lung transplant, who underwent successful EVAR under RA and was discharged in 48 h. GA would not have been an option. There are other non-quantifiable positives from having patients awake and involved with the procedure, which may also be linked to stress response attenuation. The paper by Bakker et al. clearly indicates that even after excluding grey outcomes such as asymptomatic troponin rise (despite increasing recognition of such “chemical MIs”) RA would seem to be another step in further improving EVAR mortality; it also perhaps paves the way for more questions, such as who should be anaesthetising for OR/EVAR? There is a move from the Vascular Anaesthesia Society of Great Britain & Ireland (VASGBI) in this

Ultrasound-guided percutaneous endovascular aneurysm repair success is predicted by access vessel diameter

Ultrasound scan-guided access allows for direct visualization of the access artery during percutaneous endovascular aortic aneurysm repair. We hypothesized that the use of ultrasound scan guidance allowed us to safely increase the utilization of percutaneous endovascular aortic aneurysm repair to almost all patients and decrease access complications. A retrospective chart review of all elective endovascular aortic aneurysm repairs, both abdominal and descending thoracic, from 2005 to 2010 was performed. Patients were identified using International Classification of Disease, 9th Revision, Clinical Modification Codes and stratified based on access type: percutaneous vs cut-down. We examined the success rate of percutaneous access and the cause of failure. Sheath size was large (18-24 F) or small (12-16 F). Minimum access vessel diameter was also measured. Outcomes were wound complications (infections or clinically significant hematomas that delayed discharge or required transfusion), operative and incision time, length of stay, and discharge disposition. Predictors of percutaneous failure were identified. One hundred sixty-eight patients (296 arteries) had percutaneous access endovascular aneurysm repair (P-EVAR) whereas 131 patients (226 arteries) had femoral cutdown access EVAR. Ultrasound scan-guided access was introduced in 2007. P-EVAR increased from zero cases in 2005 to 92.3% of all elective cases in 2010. The success rate with percutaneous access was 96%. Failures requiring open surgical repair of the artery included seven for hemorrhage and six for flow-limiting stenosis or occlusion of the femoral artery. P-EVAR had fewer wound complications (0.7% vs 7.4%; P = .001), shorter operative time (153.3 vs 201.5 minutes; P < .001), and larger minimal access vessel diameter (6.7 mm vs 6.1 mm; P < .01). Patients with failed percutaneous access had smaller minimal access vessel diameters when compared to successful P-EVAR (4.9 mm vs 6.8 mm; P < .001). More failures occurred in small sheaths than large ones (7.4% vs 1.9%; P = .02). Access vessel diameter <5 mm is predictive of percutaneous failure (16.7% of vessels <5 mm failed vs 2.4% of vessels ≥ 5 mm failed; P < .001; odds ratio, 7.3; 95% confidence interval, 1.58-33.8; P = .01). Ultrasound scan-guided P-EVAR can be performed in the vast majority of patients with a high success rate, shorter operative times, and fewer wound complications. Access vessel diameters <5 mm are at greater risk for percutaneous failure and should be treated selectively.

Percutaneous endovascular treatment of aortic aneurysms: Clinical evaluation and literature results

In this study we aimed to evaluate the efficiency of percutaneous endovascular aortic aneurysm repair (p-EVAR). Anatomically selected patients treated with a single 10Fr Perclose Prostar XL vascular closure device (VCD) were examined. Primary success rate and common femoral artery (CFA) open conversion (OC) requirement per sheath size used were recorded. A literature review on p-EVAR results was also performed. One-hundred patients were enrolled. Successful p-EVAR was achieved in 183 of the 196 CFA access sites (93.4%), and was specifically 85.9% and 98.3% for sheaths ≥20Fr and ≤18Fr respectively. There were 13 periprocedural complications (bleeding = 10, arterial dissection and thrombosis = 1, pseudoaneurysm = 2) all leading to OC. Use of ≥20Fr sheaths had significantly higher OC rate (P < .05). Reconstruction was achieved with primary repair (N = 11) and patch angioplasty (N = 2). Mean hospital stay was 1.8 days. The literature review (vascular closure of 2921 CFA access sites) revealed an overall technical success rate of 92.3%. Device related- were more common than patient related-OCs (P < .05). p-EVAR procedures are safe and feasible. Sheath size is a significant predictor of OC rate and more OCs might be expected with very large (≥20Fr) sheath sizes.

A Meta-Analysis of Outcome After Percutaneous Endovascular Aortic Aneurysm Repair Using Different Size Sheaths or Endograft Delivery Systems

To determine via a meta-analysis if the success rates for percutaneous EVAR using the "preclose" technique with suture-mediated vascular closure devices (SMCDs) are higher for smaller sheaths [≤ 18-F outer diameter (OD)] than for larger sheaths (≥20-F). All English-language studies on percutaneous EVAR outcomes related to sheath sizes published between 1999 and August 30, 2010, were searched using MEDLINE and SCOPUS. Randomized trials, retrospective or prospective observational studies, and original articles (including a review) were included. The search identified 32 relevant full-text studies; data on percutaneous EVAR outcomes per sheath size category (≤ 18-F and ≥ 20-F OD) were included in the final meta-analysis of data from 17 studies (1 randomized controlled trial and 8 retrospective and 8 prospective cohort observational studies). The final analysis included 1440 patients and 2447 femoral access sites. Primary success was defined as closure of a common femoral artery arteriotomy without the need for any adjunctive surgical or endovascular procedure. Pooled data revealed that success rates were significantly better when percutaneous EVAR was performed with ≤ 18-F sheaths than with ≥ 20-F sheaths (odds ratio 1.78, 95% confidence interval 1.24 to 2.54, p = 0.002). This benefit, although not significant, was more pronounced when multiple rather than single pre-applied SMCDs were deployed (odds ratio 2.16 vs. 1.64, respectively; p = 0.353). When considering primary success, it appears that larger-bore femoral access sheaths (≥ 20-F) introduced for percutaneous EVAR after pre-application of SMCDs are predictors of primary failure and the need for conversion to a femoral cutdown. More advanced large-bore SMCDs are required to further reduce the necessity for conversion. Planned use of multiple SMCDs might be more beneficial when ≤ 18-F sheaths are required.

Comments regarding ‘Fascial Closure Following Percutaneous Endovascular Aneurysm Repair’

During the last decade, endovascular abdominal aortic repair (EVAR) has emerged as the preferred treatment in a selected group of patients with suitable aortic anatomy for endografting. In order to both minimise its invasiveness and reduce complications related to groin dissections, Harrison and coworkers studied a fascial closure technique of the puncture site without the need to touch the femoral artery itself. In 1997, Diethrich was the first to describe closure of the cribriform fascia where it covers the common femoral artery access. Larzon and colleagues published the largest series so far and analysed 131 sutured fascial cases during EVAR. In their hands, complication rate was 13.7% (89% <24 h postEVAR) with the majority due to haemorrhage, thrombosis or dissection. Late complications were only noticed in two patients (neuralgia and pseudo-aneurysm, respectively). In this series of Harrison and colleagues, the only modification of the technique has been the use of ultrasound guidance to puncture the common femoral artery at the optimal spot, which is above the femoral bifurcation and below the inguinal ligament. Similar to Larzon, success rate is high (87%) and mid-term complications are low. Leaving the guidewire in place during suturing appears to be a safe trick and is highly recommended. Therefore, the safety and feasibility of this technique seem to be proven and the authors can be appreciated for that. On the other hand, why do we need a technique which still requires wound dissection in the era of sole percutaneous EVAR (P-EVAR) procedures? In a recent systemic

Percutaneous Endovascular Aortic Aneurysm Repair: A Prospective Evaluation of Safety, Efficiency, and Risk Factors

To evaluate the efficiency of totally percutaneous endovascular aortic aneurysm repair in a large cohort of patients and to define risk factors for failure with a 10-F vascular closure system. A prospective study examined the feasibility and safety of percutaneous femoral artery closure with a single Prostar XL 10-F vascular closure device applied in conjunction with the preclose technique. Between January 2004 and December 2005, 535 consecutive patients were treated for aortic aneurysmal disease. Thirty-five patients were excluded, leaving 500 patients (417 men; mean age 72+/-6.6 years) treated for aortic aneurysms using the Talent or Zenith stent-graft delivered through sheaths measuring 14-F (191, 21.2%), 16-F (33, 3.7%), 18-F (179, 19.8%), 20-F (2, 0.2%), 22-F (228, 25.2%), and 24-F (271, 29.9%). Primary clinical success was defined as the freedom from additional early or late procedures to treat any complication at the access site. Data were analyzed to reveal any correlation of access site complications or early/late repairs to operator experience or risk factors (obesity, extensive femoral artery calcification, and previous interventions/scars in the groin). Primary success was achieved in 96.1% of all percutaneous approaches. Twenty-three patients developed early (n = 16) or late (n = 7) complications at the access vessel; in 12 cases, hemostasis was achieved using pledgets with the Prostar sutures. No wound complications were recorded. The need for early conversion to an open access correlated with CFA calcification (OR 74.5, 95% CI 17.8 to 310.7; p<0.001) and operator experience (OR 43.2, 95% CI 9.8 to 189.0; p<0.001). The risk of late access site repairs was significantly higher in the presence of a groin scar (OR 48.8, 95% CI 9.2 to 259.0; p<0.001). Correlation of sheath size with early conversion to open access was weaker compared to all the other factors (OR 1.2, CI 95% 1.0 to 1.4; p<0.05). Obesity was not a risk factor for any complication. Percutaneous EVAR using the Prostar XL is safe, with minimal early and late complications. Operator experience is one of the most significant predictors of success. Anterior wall calcification and severe fibrosis of the access vessel are also predictors of primary failure, whereas obesity and sheath size are not.

Percutaneous endovascular abdominal aortic aneurysm repair leads to a reduction in wound complications

While endovascular aortic aneurysm repair (EVAR) has significantly reduced the morbidity associated with open surgery, efforts continue to minimise the surgical insult to the patient. We report our experience of percutaneous EVAR. Since June 2005, 17/20 EVARs (85%) have been attempted percutaneously by deployment of two Perclose) devices into each femoral artery prior to passage of the device sheath. The sutures are left untied until the sheath is removed at the end of the procedure, when haemostasis is obtained. Patients were entered onto a prospectively maintained database and followed up at regular intervals in a dedicated EVAR clinic. Access and subsequent graft deployment was successful in all the 17 cases. The range of defects closed ranged from 12-24 Fr. Five patients (29%) required open groin exploration at the end of the procedure to achieve haemostasis. There was a significantly lower incidence of wound complications in the percutaneous EVAR group (6 vs. 10% open cutdown cases, P < 0.05, Mann-Whitney U test). Percutaneous EVAR is both a feasible and safe method of performing endovascular abdominal aortic aneurysm repair, which is associated with a reduction in wound complication rates.