Femoral artery calcification as a determinant of success for percutaneous access for endovascular abdominal aortic aneurysm repair

Predilation technique with balloon angioplasty to facilitate percutaneous groin access of large size sheath through scar tissue

Purpose

Percutaneous remote access for endovascular aortic repair is an advantageous alternative to open access. Previous surgery in the femoral region and the presence of synthetic vascular grafts in the femoral/iliac arteries represent major limitations to percutaneous remote access. The aim of this study was to evaluate an original technique used for enabling percutaneous remote access for thoracic or abdominal endovascular aortic repair in patients with scar tissue and/or a vascular graft in the groin.

Methods

Twenty-five consecutive patients with a thoracic (11/25; 44%) or an aortic aneurysm (14/25; 66%) and with a synthetic vascular graft in the groin (16/25; 64%) or a redo groin access (9/25; 36%) were managed through the percutaneous remote access. In all patients, a percutaneous transluminal angioplasty balloon was used to predilate the scar tissue and the femoral artery or the synthetic vascular graft after preclosing (ProGlide®; Abbott Vascular, Santa Clara, CA, USA). In 10 patients, requiring a 20 Fr sheath, a 6 mm percutaneous transluminal angioplasty balloon was used; and in the remaining 15, requiring a 24 Fr sheath, an 8 mm percutaneous transluminal angioplasty balloon. Preclosing was exclusively performed using ProGlide®. Mean follow-up was 15 months.

Results

In all cases, stent-graft deployment was successful. There was one surgical conversion (4%; 1/25) due to bleeding from a femoral anastomosis. Two cases required additional percutaneous maneuvers (postclosing with another system in one patient and endoluminal shielding with stent-graft in the other patient). No pseudoaneurysm or access complication occurred during the follow-up.

Conclusions

Percutaneous access in redo groins with scar tissue and/or synthetic vascular graft using ultrasound-guided punction, preclosing with ProGlide® system and predilation with percutaneous transluminal angioplasty balloon to introduce large size sheath as used for endovascular aortic repair showed to be feasible, safe and with few local complications.

The Superficial Femoral Artery: An Alternative Access for Percutaneous Endovascular Aneurysm Repair

BACKGROUND

The aim of this study was to report the results of percutaneous endovascular aortic aneurysm repair (PEVAR) using the superficial femoral artery (SFA) for large bore vessel access.

METHODS

We reviewed all PEVAR procedures at our institution over an 18-month period, identifying all patients who underwent PEVAR with the use of one or both SFAs for endograft delivery with dual ProGlide large bore access closure. Indications for use of the SFA instead of the common femoral artery (CFA) included morbid obesity, CFA vessel wall disease, and scarring from previous CFA surgery.

RESULTS

In total, 158 percutaneous access closures were performed in 79 patients. Ten patients had one or both SFAs used. We accessed a total of 13 SFAs: 6 for the endograft main body (size range 18- to 20-French) and 7 for the limb (14- to 16-French). The freedom from open conversion was 84.6%. In comparison, of 145 CFA accesses (in 76 patients) there were 9 conversions (93.7% success). Of the 13 SFAs accessed, there were no major access site complications (pseudoaneurysm, access site bleed, limb ischemia, or need to return to the operating room). All SFAs accessed remained patent at the latest follow-up (range 1-13 months, median 8 months).

CONCLUSIONS

Our preliminary case series suggests that, in the absence of a healthy or percutaneously accessible CFA, a healthy SFA may be considered for PEVAR access. While likely carrying a higher risk of open conversion, this technique, when combined with intraoperative duplex ultrasound (both before and after the procedure) and with meticulous ultrasound-guided vascular access, appears safe for up to 20-French device diameters.

Hybrid Treatment of an Abdominal Aortic Aneurysm with Severe Calcification of the Neck and Aortic Bifurcation

BACKGROUND

Severe calcification of the aorta or iliac vessels remains a major concern when planning open or endovascular treatment of an abdominal aortic aneurysm (AAA). Therefore, we present a unique case of an AAA with concomitant severe calcification of the entire infrarenal aortoiliac region and discuss on proper management.

CASE REPORT

A 70-year-old patient with a symptomatic AAA was scheduled for repair. The diagnostic investigation revealed a 70-mm-diameter AAA with severe calcification of the neck and the iliac and femoral arteries, raising major concerns regarding the proper repair strategy. Under careful consideration of all the risks and parameters, the patient underwent a hybrid treatment with endovascular balloon occlusion of the aortic neck and careful clamping just proximal to the bifurcation. Minimal mobilization of the aorta, careful transecting and drilling of the aortic wall, and careful suturing of a straight graft were part of the whole strategy. One-year follow-up of the patient is unremarkable.

CONCLUSIONS

In cases of AAA with significantly calcified aorta and aortic bifurcation, careful preoperative planning is imperative, taking into consideration the individualized characteristics of each patient. Hybrid techniques including proximal endovascular occlusion, careful mobilizations, aortic wall drilling, and tight suturing of the graft could be a reasonable strategy for such patients. However, larger case series is needed to prove the efficacy of this method.

Single-Center Experience Following the Introduction of a Percutaneous Endovascular Aneurysm Repair First Approach

We evaluated our experience following the introduction of a percutaneous endovascular aneurysm repair (pEVAR) first approach using Perclose Proglide assessing efficacy, complications, and identification of factors that could predict failure. A retrospective cohort study on patients over a 2-year period following the introduction of a pEVAR first approach was performed. The primary end point was defined as successful deployment and access site hemostasis. Percutaneous EVAR was technically successful in 41 (77.4%) of 53 patients and 83 (86.5%) of 96 access sites. Factors associated with failure were smaller common femoral artery (CFA) diameter ( P = .045) and CFA circumferential calcification of greater than 50% ( P = .0001). The incidence of access site infection was significantly higher in the failure group ( P = .008) as was procedure duration ( P = .026). Percutaneous EVAR first approach must be introduced with caution. Percutaneous EVAR failure occurs more often in patients with unfavorable access site anatomy. Success rate can be improved with careful patient selection.

24h and 30 day outcome of Perclose Proglide suture mediated vascular closure device: An Indian experience

Introduction

Advantages of vascular closure device over manual compression include patient comfort, early mobilisation and discharge, avoidance of interruption of anticoagulation, avoidance of local compression and its sequelae and less time constraint on staff. No published Indian data exist regarding Perclose Proglide suture mediated vascular closure device (SMC).

Aim

To study the 24 h and 30 day outcome of Perclose Proglide SMC retrospectively.

Study design

Retrospective observational study conducted in the Department of Cardiology, Government Medical College, Calicut, Kerala from June 2013 to June 2015.

Methodology

All consecutive patients with Perclose Proglide SMC deployment done by a single operator for achieving access site haemostasis where 24 h and 30 day post-procedure data were available were included. Major and minor complications, procedure success, device failure were predefined.

Results

323 patients were analysed. Procedure success rate was 99.7% (322/323). Transient oozing occurred in 44 patients (13.6%), minor and major complications occurred in 2% and 1.5% of patients respectively. Major complication included one case of retroperitoneal bleed, one access site infection, one pseudo aneurysm formation and two access site arterial stenosis. There was no death or complication requiring limb amputation. “Preclose” technique was used successfully in six patients. Primary device failure occurred in 12 cases which were tackled successfully with second Proglide in all except one.

Conclusion

Perclose Proglide SMC is a safe and effective method to achieve haemostasis up to 22F with less complication rate.

Local Anesthesia for Percutaneous Thoracic Endovascular Aortic Repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) requires large-bore vascular access due to the considerable diameters of the endoprosthesis and delivery device. The preclose technique preceding endograft delivery has opened the door for an evolved access strategy. In addition, treatment under local anesthesia offers the advantage of optimal neuromonitoring. The goal of this study was to analyze the efficacy and safety of percutaneous TEVAR under local anesthesia.

METHODS

All patients undergoing TEVAR in an elective setting at the Antwerp University Hospital between June 2012 and June 2015 were prospectively entered into an endovascular database. This database was queried for demographics, procedural details, and access-related complications. All patients underwent a percutaneous approach with the Perclose Proglide under local anesthesia.

RESULTS

This review identified 34 patients in whom 37 percutaneous TEVAR procedures were completed under local anesthesia. All patients experienced adequate analgesia, and no conversions to general anesthesia were implemented. The mean size of the arteriotomy was 23.8 ± 1.3 French (F). The number of Proglide deployments was 80, with an 8% rate of failure on deployment. There were no conversions to surgical cutdown, and adequate hemostasis was obtained in all procedures. The incidence of postprocedural access-related complications was 3%.

CONCLUSION

Local anesthesia for percutaneous TEVAR can be performed safely and effectively. The percutaneous approach facilitates local anesthesia, which provides the added benefit of early recognition of neurologic complications while maintaining a low risk of access-related complications despite the need for large-bore vascular access.

Vascular Complications Associated with Transfemoral Aortic Valve Replacement

Background Transfemoral aortic valve replacement (TAVR) is a novel technique for treating aortic stenosis, yet vascular complications are yet to be delineated. Objectives This study aims to study the vascular complications of TAVR with Edwards Sapien valves (Edwards Lifesciences Corp., Irvine, CA). Methods We performed a retrospective evaluation of TAVR patients. Standard demographics, femoral vessel and sheath size, access type (femoral cut-down [FC], percutaneous access [PFA], and iliac conduit [IC]), and treatment method were recorded. Complications were defined by the Valve Academic Research Consortium Criteria. Logistic regression was used for statistical analysis. Results A total of 99 patients underwent TAVR between February 15, 2012 and July 17, 2013 with an Edwards Sapien valve. Out of which, 48 were males with a mean age of 83 ± 7 years. Overall, 33 had FC, 58 had PFA, and 6 had an IC. A total of 17 major (2 aortic and 15 iliac) and 38 minor complications (36 access and 2 emboli) occurred. Aortic complications were managed by open repair (OR, 1) or percutaneous repair (PR, 1). Overall, 12 iliac injuries were managed by PR and 3 by OR. Out of the 33 groin complications in FC patients 8 (24%) were treated by OR, whereas 30 (52%) of the 58 groin complications in PTA patients were treated by PR. There were no differences in transfusion requirements or length of stay. Conclusion Vascular complications of TAVR are common with most being minor, related to access site and causing no immediate sequelae. Iliac injury can be managed by PR or OR. Aortic injury is associated with significant mortality. These findings increase vascular surgeons' awareness of these complications and how to manage them.

Predictors and treatments of Proglide-related complications in percutaneous endovascular aortic repair

Purpose

To investigate the predictors and treatment of the 6-Fr Perclose Proglide-related complications (PRC) in percutaneous endovascular aortic repair (pEVAR).

Methods

We retrospectively analyzed the PRC after pEVAR for the treatment of aortic aneurysm or dissection in our center from December 2012 to November 2013. Procedure success was defined as effective functioning of the two devices and local hemostasis. Access-related adverse events included vascular complications and device failures. Operative data and angiographic and computed tomography images were collected to assess the complications and treatment strategy.

Results

A total of 198 patients with 275 puncture sites underwent pEVAR with the 6-Fr Perclose Proglide. The procedure was successful in 178 patients (89.9%), whereas PRC occurred in 20 cases (10.1%), including 10 device failures and 10 vascular complications. An extra manual ancillary compression was conducted in 7 patients, one more device was used in 8 patients, and surgical repair of the femoral artery was performed in 5 patients. PRC had a tendency to occur in patients with body mass index (BMI)>30 kg/m² (p = 0.021), thoracic stent grafts (p = 0.038), common femoral artery (CFA) calcification (p = 0.001), CFA depth>4 cm (p = 0.001), and sheath size>20Fr (p = 0.005). Device failure-related mortality was zero. None of the access sites had complications during the midterm follow-up.

Conclusions

The pre-close technique with 6-Fr Perclose Proglide devices for pEVAR appears to be safe and effective with low technical failure and complication rates. Careful patient selection and proficiency in device manipulation might reduce the device related complications.

Essentials of endovascular abdominal aortic aneurysm repair imaging: postprocedure surveillance and complications

OBJECTIVE

Lifelong postprocedural imaging surveillance is necessary after endovascular abdominal aortic aneurysm repair (EVAR) to assess for complications of endograft placement, as well as device failure and continued aneurysm growth. Refinement of the surveillance CT technique and development of ultrasound and MRI protocols are important to limit radiation exposure.

CONCLUSION

A comprehensive understanding of EVAR surveillance is necessary to identify life-threatening complications and to aid in secondary treatment planning.