Editor's Choice - A Randomized Controlled Trial of the Fascia Suture Technique Compared with a Suture-mediated Closure Device for Femoral Arterial Closure after Endovascular Aortic Repair

The Safety and Effectiveness of the Prostar XL Closure Device Compared to Open Groin Cutdown for Endovascular Aneurysm Repair

OBJECTIVE

The aim of this study is to compare the outcomes of percutaneous femoral closure with the Prostar XL for endovascular aneurysm repair (EVAR) to those of open femoral cutdown, and to evaluate factors which may predict the failure of percutaneous closure.

METHODS

Patients undergoing endovascular aneurysm repair for an infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. Patient characteristics, anatomic femoral artery measurements, and postoperative complications were recorded retrospectively. Operator experience was defined with a cut-off point of >30 Prostar XL closures performed. Comparisons were made per access site.

RESULTS

A total of 443 access sites were included, with percutaneous closure used in 257 cases (58.0%) and open cutdown in 186 cases (42.0%). The complication rate was 2.7% for the percutaneous and 4.3% for the open cutdown group (P = .482). No significant differences between groups were found with respect to 30-day mortality, wound infections, thrombosis, seromas, or bleeding complications. Fourteen failures (5.4%) of percutaneous closure occurred. The success rates were similar for experienced and unexperienced operators (94.2% vs 95.5%, P = .768). Renal insufficiency was more common in the failed than in the successful percutaneous closure group (64.3% vs 24.7%, P = .003). Common femoral artery calcification or diameter, BMI, sheath size, or operator experience did not predict failure. No further complications were seen in follow-up CT at 1-3 years postoperatively.

CONCLUSION

The use of the Prostar XL is safe compared to open cutdown. The success rate is 94.6%. Operator experience, sheath size, obesity, or femoral artery diameter or calcification do not appear to predict a failure of percutaneous closure. Complications seem to occur perioperatively, and late complications are rare.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. Therefore, it is critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This Cochrane Review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. However, the technique may be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the previous Cochrane Review published in 2017.

OBJECTIVES

To evaluate the benefits and harms of totally percutaneous access compared to cut-down femoral artery access in people undergoing elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

We used standard, extensive Cochrane search methods The latest search was 8 April 2022.

SELECTION CRITERIA

We included randomised controlled trials in people diagnosed with an AAA comparing totally percutaneous versus surgical cut-down access endovascular repair. We considered all device types. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for ruptured AAAs and those reporting aorto-uni-iliac repairs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. short-term mortality, 2. failure of aneurysm exclusion and 3. wound infection. Secondary outcomes were 4. major complications (30-day or in-hospital); 5. medium- to long-term (6 and 12 months) complications and mortality; 6. bleeding complications and haematoma; and 7. operating time, duration of intensive treatment unit (ITU) stay and hospital stay. We used GRADE to assess the certainty of evidence for the seven most clinically relevant primary and secondary outcomes.

MAIN RESULTS

Three studies with 318 participants met the inclusion criteria, 189 undergoing the percutaneous technique and 129 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report the method of randomisation, allocation concealment or preselected outcomes. The other two larger studies had few sources of bias and good methodology; although one study had a high risk of bias in selective reporting. We observed no clear difference in short-term mortality between groups, with only one death occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.06 to 36.18; 2 studies, 181 participants; low-certainty evidence). One study reported failure of aneurysm exclusion. There was one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 1 study, 151 participants; moderate-certainty evidence). For wound infection, there was no clear difference between groups (RR 0.18, 95% CI 0.01 to 3.59; 3 studies, 318 participants; moderate-certainty evidence). There was no clear difference between percutaneous and cut-down femoral artery access groups in major complications (RR 1.21, 95% CI 0.61 to 2.41; 3 studies, 318 participants; moderate-certainty evidence), bleeding complications (RR 1.02, 95% CI 0.29 to 3.64; 2 studies, 181 participants; moderate-certainty evidence) or haematoma (RR 0.88, 95% CI 0.13 to 6.05; 2 studies, 288 participants). One study reported medium- to long-term complications at six months, with no clear differences between the percutaneous and cut-down femoral artery access groups (RR 0.82, 95% CI 0.25 to 2.65; 1 study, 135 participants; moderate-certainty evidence). We detected differences in operating time, with the percutaneous approach being faster than cut-down femoral artery access (mean difference (MD) -21.13 minutes, 95% CI -41.74 to -0.53 minutes; 3 studies, 318 participants; low-certainty evidence). One study reported the duration of ITU stay and hospital stay, with no clear difference between groups.

AUTHORS' CONCLUSIONS

Skin puncture may make little to no difference to short-term mortality. There is probably little or no difference in failure of aneurysm exclusion (failure to seal the aneurysms), wound infection, major complications within 30 days or while in hospital, medium- to long-term (six months) complications and bleeding complications between the two groups. Compared with exposing the femoral artery, skin puncture may reduce the operating time slightly. We downgraded the certainty of the evidence to moderate and low as a result of imprecision due to the small number of participants, low event rates and wide CIs, and inconsistency due to clinical heterogeneity. As the number of included studies was limited, further research into this technique would be beneficial.

Percutaneous Approach in Endovascular Aortic Procedures Using a Suture-Mediated Closure Device

BACKGROUND

The purpose of this study is to assess the efficacy of a suture-mediated closure device during percutaneous endovascular aortic repair.

METHODS

A single-center, retrospective analysis of patients undergoing endovascular repair for infrarenal, thoracic and thoracoabdominal aortic aneurysms and aortic dissections via percutaneous femoral access between April 2017 and June 2021 was performed. The primary endpoint of the study was the efficacy and technical success of the Perclose ProGlide closure device during percutaneous endovascular procedures. The secondary endpoints were intraoperative and postoperative inguinal and vascular complications during and after device use.

RESULTS

A total of 376 punctures were performed in 263 patients with the deployment of the ProGlide vascular closure system. Twenty-two cases involved percutaneous re-puncture as part of a staged procedure. The primary and secondary technical success rates were 93.1% (350/376) and 94.7% (356/376), respectively. In 20 patients (5.3%), intraoperative femoral exposure due to complications was required. Postoperative complications occurred in 13 cases (3.5%), 2 of which required surgical reintervention. There was no statistical significance between the type of endovascular procedure and primary technical success (p = 0.56). The introduction of larger-diameter sheaths was not associated with increased intraoperative and postoperative complication rates (p = 0.75 and p = 0.78, respectively). Percutaneous re-puncture of the vascular access site did not result in a lower overall technical success rate (20/22, 90.9% primary technical success rate, p = 0.67; 21/22, 95.5% secondary technical success rate, p = 0.86) or an increased number of perioperative complications (1/22, 4.5% intraoperative complications, p = 0.86; 2/22, 9.1% postoperative complications, p = 0.13).

CONCLUSION

The application of the ProGlide closure system is a safe and efficient method to achieve hemostasis during percutaneous endovascular aortic repair. Complex aortic pathologies, which often require a staged approach with re-puncture, can also be successfully treated with this closure system.

Predictors of percutaneous access-related complications in aortic endovascular procedures - 'real-world' insights and a comparison to open access

BACKGROUND

Percutaneous endovascular aneurysm repair (PEVAR) is becoming increasingly popular due to fewer access-related complications, shorter procedural times and length of stay (LOS). Our aim was to explore factors associated with access-related complications and their impact on procedural time and LOS.

METHODS

We retrospectively analysed consecutive aorto-iliac endovascular procedures in a tertiary hub comprising 2 institutions and 18 consultant vascular surgeons and interventional radiologists between 2016 - 2017. Access-related complications were defined as: bleeding requiring cutdown or return to theatre, acute limb ischaemia or common femoral artery (CFA) pseudoaneurysm requiring intervention and wound infection or dehiscence needing hospitalization.

RESULTS

Of 511 patients, 354 (69%) had a percutaneous approach via 589 CFA access sites. In this percutaneous group, access-related complications occurred in 11% of sites (65/589); Their rate varied with procedure type ranging between 3.6% to 17.6%. The most common complication was bleeding due to closure device failure in 8.5% (50/589) of access sites. When uncomplicated, percutaneous interventions were faster compared to open surgical access (p<0.0001). Operation time and median LOS (3 vs. 2 days) were longer for elective standard EVAR patients experiencing access-related complications (p=0.033). In the percutaneous group, multivariate regression analysis demonstrated significant associations between accessrelated complications and eGFR (odds ratio (OR) 0.984 [0.972-0.997], p=0.014), CFA depth (OR 1.026 [1.008-1.045], p=0.005), device used (Prostar vs. Proglide (OR 2.177 [1.236-3.832], p=0.007) and procedural type (complex vs. standard EVAR) (OR 2.017 [1.122-3.627], p=0.019). We developed a risk score which had reasonably good predictive power (C-statistic 0.716 [0.646-0.787],p<0.0001) for avoiding access complications.

CONCLUSIONS

Physiological (low eGFR level), anatomical (increased CFA depth) and technical factors (choice of device and complex procedures) were identified as predictors of access-related complications in this large retrospective series. These are important for safe selection of patients that would benefit from percutaneous access.

A Single Center Study of ProGlide Used for Closure of Large-Bore Puncture Holes After EVAR for AAA

PURPOSE

The objective of this study was to evaluate the primary and assisted secondary percutaneous and non-invasive technical success of the ProGlide device on all-comers in a consecutive case series of percutaneous endovascular aortic aneurysm repair (P-EVAR).

METHOD

A single-center consecutive case series where 434 elective and acute P-EVAR procedures were registered prospectively between May 2011 and July 2017. The mean age was 74.5 years ± SD 11.4 years. 82.3% of the patients were male. All patients were pre-planned from CT angiography. Percutaneous access punctures, performed in local anesthesia in the common femoral artery, with a final introducer size between 12-22 Fr OD were included and stratified in 2 groups, 12-16 Fr and 17-22 Fr.

RESULTS

By screening 868 access groins 22 groins were excluded. Of the remaining 846 groins, intended to be treated with ProGlide, 9 groins were excluded peri-procedurally and treated with the Fascia Suture Technique or surgical cutdown. The remaining 837 groins had access closure with ProGlide, with a mean value of 2.15 devices per groin with a slight significant difference between the 2 stratification groups. Primary ProGlide technical success was achieved in 68.1% of the groins. Secondary percutaneous or non-invasive technical success was achieved in 96.9%. Here there was no statistically significant difference between the 2 stratification groups. Thirty-one (3.7%) groin complications were registered during 30-day follow-up and 17 required additional treatment. Total mortality was 2.8%. None of these deaths were related to the access site.

CONCLUSION

ProGlide by itself has a significant failure rate in the closure of large-bore access holes on an unselected cohort of patients eligible for P-EVAR. However, together with adjunct percutaneous or non-invasive methods a success rate of 97% can be achieved. The access complication rate was lower than 4% at 30-day follow-up.

Pivotal Clinical Study to Evaluate the Safety and Effectiveness of the MANTA Vascular Closure Device During Percutaneous EVAR and TEVAR Procedures

Purpose: To evaluate the safety and effectiveness of the MANTA percutaneous vascular closure device in patients undergoing percutaneous endovascular aneurysm repair (PEVAR) or thoracic endovascular aortic repair (TEVAR). Materials and Methods: The SAFE MANTA Study ( ClinicalTrials.gov identifier NCT02908880) was a prospective, single-arm, multicenter trial in patients undergoing endovascular interventions using large-bore sheaths (transcatheter aortic valve replacement, PEVAR, or TEVAR) at 20 sites in North America. Patient selection intended to test the MANTA device in populations without morbid obesity, severe calcification, or a severely scarred femoral access area. Of the 263 patients enrolled in the primary analysis cohort, 53 (20.2%) patients (mean age 74.9±8.9 years; 41 men) underwent PEVAR (n=51) or TEVAR (n=2) procedures and form the cohort for this subgroup analysis. Per protocol a single MANTA device was deployed in all PEVAR/TEVAR cases. Results: The mean time to hemostasis in the PEVAR/TEVAR cohort was 35±91 seconds, with a median time of 19 seconds vs 24 seconds in the overall SAFE MANTA population. The MANTA device met the definition for technical success in 52 (98%) of 53 PEVAR/TEVAR cases compared with 97.7% in the overall SAFE MANTA population. One (1.9%) major complication (access-site stenosis) occurred in this subgroup compared to 14 (5.3%) events in the SAFE population. In the PEVAR/TEVAR group, 1 pseudoaneurysm was noted prior to discharge, another at 30-day follow-up, and one at 60 days. One (1.9%) of the 3 minor pseudoaneurysms was treated with ultrasound-guided compression and the other 2 required no treatment. Conclusion: The MANTA device demonstrated a short time to hemostasis and low complication rates compared with published literature results of other percutaneous closure devices. Time to hemostasis and complication rates were comparable between the PEVAR/TEVAR patients and the full SAFE MANTA study cohort. The MANTA device provides reliable closure with a single percutaneous device for PEVAR/TEVAR procedures.

Ultrasound-guided fascia closure as bailout technique for large-bore percutaneous femoral access failure: Report of two cases

Percutaneous endovascular abdominal aortic aneurysm repair is nowadays considered a safe and effective procedure and has gained widespread globally acceptance. However, intraoperative persistent bleeding due to percutaneous access closure device failure can occur. Open conversion is first-line treatment to manage this complication. The fascia suture technique was introduced as an alternative to access closure device or as a solution to manage unsatisfactory hemostasis during percutaneous endovascular abdominal aortic aneurysm repair. In this article, we report a new simple minimally invasive ultrasound-guided fascia suture technique as a bailout method to manage persistent bleeding after percutaneous endovascular abdominal aortic aneurysm repair avoiding open conversion. This technique was successfully used in two cases at our center with satisfactory hemostasis and no further complications. Ultrasound-guided fascia suture technique can be proposed as a minimally invasive bailout technique for access closure device failure.

Superficial femoral artery access for endovascular aortic repair

OBJECTIVE

The majority of endovascular aneurysm repair procedures are performed through the common femoral artery (CFA). Arterial access is gained by surgical cutdown or percutaneous approach. The surgical approach has a relatively high local complication rate. We describe superficial femoral artery (SFA) access as an alternative to CFA exposure to minimize wound complications and to facilitate swift recovery.

METHODS

A single-center, retrospective study of patients undergoing endovascular aneurysm repair between 2014 and 2016 was performed; 195 patients undergoing 215 procedures were included, 114 with CFA cutdown, 87 with SFA cutdown, and 14 with combined SFA and CFA procedures. Epidemiologic parameters, risk factors, procedural details, operative and postoperative complications, and time to discharge were assessed. Independent samples two-sided t-test and χ² test were used to compare the SFA and CFA. A P value < .05 was considered statistically significant. A multivariate adjusted model confirmed the results. The proximal SFA is assessed by computed tomography angiography for patency and suitability. The minimal SFA diameter of 6 mm was determined for considering SFA access. Through a longitudinal incision at the upper thigh, the SFA is exposed and catheterized. Devices are inserted sheathless and replaced by small-diameter sheaths (14F-16F). Patients undergo peripheral vascular examination before and after the procedure.

RESULTS

Age, sex, and risk factor distribution were similar in both groups. Aneurysm size and device diameters were also similar. There were 12.1% of cases that were not suitable for the SFA approach. Access-related bleeding (0.7% SFA, 7% CFA; P = .004), ischemia (0.7% SFA, 7.6% CFA; P = .002), and venous injury (0% SFA, 1.3% CFA; P = .102) were minimized with SFA exposure. This led to almost 50% decrease in patients requiring additional arterial reconstruction during the procedure (6.5% SFA, 12.8% CFA; P = .059). SFA cutdown was also associated with lower wound complication rate (infection, seroma, and hematoma; 13.2% SFA, 34.9% CFA; P = .000). Neuropathy (mostly sensory) was higher with SFA exposure (13.8% SFA, 5.2% CFA; P = .008). The patients' recovery was faster in the SFA group, resulting in 14.3% reduction of hospital stay after the procedure (P = .005). Secondary access-related procedures were also lower in the SFA group (2.2% SFA, 8.7% CFA; P = .045).

CONCLUSIONS

The SFA approach is easier to perform and has a lower complication rate compared with the CFA approach. During the procedure, there is no dissection or damage to arterial branches, especially to the deep femoral artery. The SFA approach has a low complication rate and can be an alternative to percutaneous access when it is unsuitable.

Effectiveness of fascial closure technique following percutaneous endovascular aneurysm repair

INTRODUCTION

Percutaneous access and closure is commonly performed for patients undergoing endovascular aneurysm repair (EVAR). It has proven to be a safe and successful method of closure associated with fewer complications when compared with the traditional open technique. Fascial closure is an alternative technique that can be used for closure reducing the risks associated with the open technique. The aim of this study was to assess the safety and durability of fascial closure for failed percutaneous closure device following EVAR.

MATERIALS AND METHODS

Over a 12-month period, 49 patients who had undergone EVAR were identified via our EVAR register. Retrospective analysis of the clinical records was undertaken. We identified all the patients who had fascial closure of the groins following a failed percutaneous closure device. Patients had a computed tomography angiogram one month postoperatively, with duplex imaging and clinic follow-up three months later.

RESULTS

Fascial closure was performed in 14 groins. It failed in three groins and these patients had traditional open repair. Fascial closure was successful in 11 groins (7 patients). Of these seven patients, one was female (6%). The mean age was 80 years (range 68-92 years). Two patients died and one was lost to follow-up. One pseudoaneurysms were seen on computed tomography angiogram, which was managed conservatively and had resolved on follow-up imaging.

CONCLUSIONS

Fascial closure is a very good alternative to open repair after failure of the closure device.

Fascial suture technique versus open femoral access for thoracic endovascular aortic repair

BACKGROUND

Fascial suture technique (FST) has proved to be a safe and effective access closure technique after endovascular repair of the abdominal aorta. FST has not yet been investigated for closure of large-bore access after thoracic endovascular aortic repair (TEVAR). The aim of this study was to compare FST with open femoral access in terms of access safety, hemostasis efficacy, and reintervention rate after TEVAR.

METHODS

A retrospective study including consecutive patients undergoing TEVAR with either FST or open femoral access between January 2010 and April 2016 was undertaken. Exclusion criteria included the use of closure devices. The composite primary end point was defined as any access-related complication (bleeding, femoral artery stenosis or occlusion, pseudoaneurysm, and wound infection) during 30 postoperative days. Preoperative and procedural variables were examined in a multiple logistic regression model as potential associated factors with access morbidity. All access vessels were postoperatively examined by clinical examination and computed tomography angiography before discharge as well as during the follow-up period. In case of suspected pseudoaneurysm, additional duplex ultrasound and computed tomography angiography confirmed the diagnosis.

RESULTS

From a total of 206 patients undergoing TEVAR, 109 (53%) had FST, whereas 93 (45%) had an open femoral access. Four patients were excluded: closure device was used in one; one had primary conversion after percutaneous puncture without FST; and in two, no data were available about the femoral access. The access complication rate was higher in FST (FST, 14 [13%]; open access, 3 [3%]; P = .01). Five (4.6%) patients needed early reintervention, two for bleeding and three for vessel occlusion. Seven (6.4%) pseudoaneurysms were detected during the 30-day period in the FST group; three had successful exclusion with thrombin injection, one was treated with manual compression, one was treated with open repair, and two were managed conservatively. Four (3.6%) patients in the FST group and three (3%) patients in the open access group had wound complications. After multiple logistic regression, FST was the only independent factor for any access complication (odds ratio, 5.176; 95% confidence interval, 1.402-19.114; P = .014). During follow-up, neither new pseudoaneurysm nor stenosis or occlusion was detected.

CONCLUSIONS

FST for large-hole closure had higher risk for any access complication compared with open access in TEVAR during the 30-day postoperative period. No other complications during 12 months of follow-up were observed in FST patients.

Fascia Suture Technique and Suture-mediated Closure Devices: Systematic Review

Background  The aim of the present study is to review the available data on suture-mediated closure devices (SMCDs) and fascia suture technique (FST), which are alternatives for minimizing the invasiveness of percutaneous endovascular aortic aneurysm repair (p-EVAR) and reduce the complications related to groin dissections. Methods  The Medline, ClinicalTrials.gov, and Cochrane library - Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for publications regarding SMCD and FST between January 1999 and December 2016. Results  We review 37 original articles, 30 referring to SMCDs (Prostar XL and Proglide), which included 3,992 patients, and 6 articles referring to FST, which include 426 patients. The two techniques are compared only in one article (100 patients). The two types of SMCDs were Prostar and Proglide. In most studies on SMCDs, the reported technical success rates were between 89 and 100%, but the complication rates varied greatly between 0 and 25%. Concerning FST, the technical success rates were also high, ranging between 87 and 99%. However, intraoperative complication rates ranged between 1.2 and 13%, whereas postoperative complication rates varied from 0.9 to 6.2% for the short-term and from 1.9 to 13.6% for the long-term. Conclusions  SMCDs and FST seem to be effective and simple methods for closing common femoral artery (CFA) punctures after p-EVAR. FST can reduce the access closure time and the procedural costs with a quite short learning curve, whereas it can work as a bailout procedure for failed SMCDs suture. The few failures of the SMCDs and FST that may occur due to bleeding or occlusion can easily be managed.

A Retrospective Analysis of Surgical Femoral Artery Closure Techniques: Conventional versus Purse Suture Technique

BACKGROUND

Different techniques have been reported for the exploration and repair of femoral artery (FA) in patients who undergo minimally invasive cardiac surgery (MICS) and endovascular aortic surgery. We used a modified approach alternative to the conventional technique (group CT) since May 2013, which specifies a shorter groin incision and diamond-shaped hemostatic purse sutures for arteriotomy closure without the requirement of cross-clamping (group PT [purse suture technique]) and evaluated early outcomes and the complication profiles of the 2 techniques for femoral access.

METHODS

In our clinic, between May 2011 and December 2015, 503 FA cannulations were performed on 345 patients who underwent MICS (n = 109, mean age 64.1 ± 17.6 years, female/male ratio 71/38), endovascular abdominal aneurysm repair (n = 158, mean age 71.3 ± 10.2 years, female/male ratio 63/95), thoracal endovascular aneurysm repair (n = 50, mean age 65.0 ± 15.3 years, female/male ratio 15/35), and transaortic valve implantation (n = 28, mean age 80.8 ± 5.9 years, female/male ratio 13/15). A total of 295 FAs were exposed via mini incision and were repaired with the PT. We compared the duration of femoral closure (FC), wound infection, and vascular complications including bleeding hematoma, thromboembolic and ischemic events, pseudoaneurysm, seroma, surgical reintervention rates, delayed hospital stay for groin complications, and existence of postoperative local luminal narrowing (LLN) at the intervention site over 25% for both groups.

RESULTS

FC time (CT 14.9 ± 3.16 min, PT 6.5 ± 1.12 min, P < 0.0001), bleeding hematoma frequency (CT 6.2%, PT 1.7%, P = 0.01), and prolonged hospital stay for groin complications (CT 14.9%, PT 3.4%, P < 0.0001) were significantly lower in the PT group. Rate of technical success (CT 80.3%, PT 87.4%, P = 0.03) and event-free patient (CT 66.1%, PT 77.5%, P = 0.03) were significantly better in the PT group. There were no differences between groups in terms of ischemic events, wound infection rates, development of pseudoaneurysm and seroma, surgical reintervention rates, and LLN of FA over 25% at 6-month duplex evaluation.

CONCLUSIONS

The comparison of the 2 approaches revealed the advantages of the PT in terms of bleeding hematoma and shortening in FC time and the length of hospital stay. We suggest performing a smaller skin incision for FA access and utilizing purse sutures, which allows completing the procedure without cross-clamping, thus providing a favorable approach and excellent comfort for the surgeon.

Editor's Choice - Arteriotomy Closure Devices in EVAR, TEVAR, and TAVR: A Systematic Review and Meta-analysis of Randomised Clinical Trials and Cohort Studies

OBJECTIVES

Cardiac and vascular surgery benefit from percutaneous interventions. Arteriotomy closure devices (ACDs) enable minimally invasive access to the common femoral artery (CFA). The objective of this review was to assess the differences between ACDs and surgical cut down (SCD) of the CFA regarding the number of complications, duration of surgery (DOS), and hospital length of stay (HLOS).

DESIGN

A systematic literature search with predefined search terms was performed using MEDLINE, Embase, and the Cochrane Library (2000-2016). All studies reporting on ACD and SCD for a puncture of the CFA of at least 12 French (Fr.) were assessed for eligibility.

METHODS

Included were randomised controlled trials and cohort studies comparing both techniques. Patient characteristics, exclusion criteria, and conversion rates were evaluated. Complications, DOS, and HLOS were compared.

MATERIALS

A total of 17 studies were included for meta-analysis, describing 7889 vascular access sites; four studies were randomised trials, two studies reported from a prospective database, and 11 studies reported retrospective cohorts.

RESULTS

ACD was associated with fewer post-operative seromas (odds ratio [OR] 0.15, 95% confidence interval [CI] 0.06-0.35), less wound dehiscence (OR 0.14, 95% CI 0.03-0.78), and fewer surgical site infections (OR 0.38, 95% CI 0.23-0.63). Post-operative pseudoaneurysms were significantly more common in the ACD group (OR 3.83, 95% CI 1.55-9.44). In five of 17 studies, DOS and HLOS were not reduced in the ACD group. When all studies reporting a mean DOS and/or HLOS were compared in a non-parametric analysis, neither was significantly different.

CONCLUSION

This meta-analysis favours ACD regarding the number of wound complications compared with SCD in endovascular aneurysm repair, thoracic endovascular aneurysm repair, and transcatheter aortic valve repair. Treatment duration (DOS and HLOS) was not reduced in ACD. The differences are of limited clinical significance and with this equivocal quality of evidence, the ACD may be considered safe for CFA access in suitable patients.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the review first published in 2014.

OBJECTIVES

This review aims to compare the clinical outcomes of percutaneous access with surgical cut-down femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

For this update the Cochrane Vascular Information Specialist (CIS) searched their Specialised Register (last searched October 2016) and CENTRAL (2016, Issue 9). We also searched clinical trials registries and checked the reference lists of relevant retrieved articles.

SELECTION CRITERIA

We considered only randomised controlled trials. The primary intervention was a totally percutaneous endovascular repair. We considered all device types. We compared this against surgical cut-down femoral artery access endovascular repair. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for a ruptured abdominal aortic aneurysm and those reporting aorto-uni-iliac repairs.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected all data. Owing to the small number of trials identified we did not conduct any formal sensitivity analysis. Heterogeneity was not significant for any outcome.

MAIN RESULTS

Two studies with a total of 181 participants met the inclusion criteria, 116 undergoing the percutaneous technique and 65 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report method of randomisation, allocation concealment or pre-selected outcomes. The second study was a larger study with few sources of bias and good methodology.We observed no significant difference in mortality between groups, with only one mortality occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50; 95% confidence interval (CI) 0.06 to 36.18; 181 participants; moderate-quality evidence). Only one study reported aneurysm exclusion. In this study we observed only one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 151 participants; moderate-quality evidence). No wound infections occurred in the cut-down femoral artery access group or the percutaneous group across either study (moderate-quality evidence).There was no difference in major complication rate between cut-down femoral artery access and percutaneous groups (RR 0.91, 95% CI 0.20 to 1.68; 181 participants; moderate-quality evidence); or in bleeding complications and haematoma (RR 0.94, 95% CI 0.31 to 2.82; 181 participants; high-quality evidence).Only one study reported long-term complication rates at six months, with no differences between the percutaneous and cut-down femoral artery access group (RR 1.03, 95% CI 0.34 to 3.15; 134 participants; moderate-quality evidence).We detected differences in surgery time, with percutaneous approach being significantly faster than cut-down femoral artery access (mean difference (MD) -31.46 minutes; 95% CI -47.51 minutes to -15.42 minutes; 181 participants; moderate-quality evidence). Only one study reported duration of ITU (intensive treatment unit) and hospital stay, with no difference found between groups.

AUTHORS' CONCLUSIONS

This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion, major complications, wound infection and long-term (six month) complications, and high-quality evidence for no difference in bleeding complications and haematoma. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate as a result of the limited number of studies, low event numbers and imprecision. As the number of included studies were limited, further research into this technique would be beneficial. The search identified one ongoing study, which may provide an improved evidence base in the future.

Percutaneous access for endovascular aortic aneurysm repair: A systematic review and meta-analysis

Purpose

Our objective was to undertake a comprehensive review of the literature and conduct an analysis of the outcomes of percutaneous endovascular aneurysm repair.

Methods

MEDLINE; EMBASE; CINAHL; CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; and ISRCTN Register, and bibliographic reference lists were searched to identify all studies providing comparative outcomes of the percutaneous technique for endovascular aneurysm repair. Success rate and access-related complications were defined as the primary outcome parameters. Combined overall effect sizes were calculated using fixed effect or random effects models. We conducted a network meta-analysis of different techniques for femoral access applying multivariate meta-analysis assuming consistency.

Findings

Three randomised controlled trials and 18 observational studies were identified. Percutaneous access was associated with a lower frequency of groin infection ( p < 0.0001) and lymphocele ( p = 0.007), and a shorter procedure time ( p < 0.0001) and hospital length of stay ( p = 0.03) compared with open surgical access. Moreover, percutaneous endovascular aneurysm repair did not increase the risk of haematoma, pseudoaneurysm, and arterial thrombosis or dissection.

Conclusion

Percutaneous access demonstrates advantages over conventional surgical exposure for endovascular aneurysm repair, as indicated by access-related complications and hospital length of stay. Further research is required to define its impact on resource utilization, cost-effectiveness and quality of life.

Comparison of a collagen plug arterial closure device with manual compression after endovascular interventions for peripheral artery disease

OBJECTIVE

Arterial closure devices (ACDs) seem to be safe and effective to obtain hemostasis for cardiac interventions and diagnostic vascular procedures. However, only limited evidence is presented on therapeutic interventions in patients with peripheral atherosclerotic disease. We compared ischemic and hemorrhagic complications of an ACD vs manual compression (MC) after puncture of the femoral artery for endovascular lower extremity procedures.

METHODS

The records of all subsequent endovascular interventions for peripheral artery disease performed in a large teaching hospital, from January 2012 to April 2014, were retrospectively reviewed. The primary outcome was an ischemic complication requiring reintervention. Secondary outcomes were hematoma (needing conservative or invasive intervention) and infection (needing intervention or antibiotics). Multivariate analysis was performed to identify predictors for any complication.

RESULTS

The Angio-Seal (St. Jude Medical, Minnetonka, Minn) closure device was used in 244 of 463 endovascular interventions (54%). Five patients (2%) who received an ACD needed emergency surgery for ischemic complications vs none in the MC group (P = .06). Hematomas occurred in 22 patients (9%) after ACD vs in six (3%) after MC (adjusted odds ratio [OR], 3.4; 95% confidence interval [CI], 1.4-8.9; P = .015). There were no infections in either group. ACD (OR, 3.8; 95% CI, 1.5-9.7) and current smoking (OR, 2.6; 95% CI, 1.01-6.7) were independent predictors for any complication.

CONCLUSIONS

This study demonstrates that ACD use in patients with peripheral artery disease can lead to serious adverse events resulting in increased morbidity. Therefore, the potential benefits of an ACD over MC should be carefully weighed.

Vascular closure devices for femoral arterial puncture site haemostasis

BACKGROUND

Vascular closure devices (VCDs) are widely used to achieve haemostasis after procedures requiring percutaneous common femoral artery (CFA) puncture. There is no consensus regarding the benefits of VCDs, including potential reduction in procedure time, length of hospital stay or time to patient ambulation. No robust evidence exists that VCDs reduce the incidence of puncture site complications compared with haemostasis achieved through extrinsic (manual or mechanical) compression.

OBJECTIVES

To determine the efficacy and safety of VCDs versus traditional methods of extrinsic compression in achieving haemostasis after retrograde and antegrade percutaneous arterial puncture of the CFA.

SEARCH METHODS

The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (April 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 3). Clinical trials databases were searched for details of ongoing or unpublished studies. References of articles retrieved by electronic searches were searched for additional citations.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials in which people undergoing a diagnostic or interventional procedure via percutaneous CFA puncture were randomised to one type of VCD versus extrinsic compression or another type of VCD.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the methodological quality of trials. We resolved disagreements by discussion with the third author. We performed meta-analyses when heterogeneity (I(2)) was < 90%. The primary efficacy outcomes were time to haemostasis and time to mobilisation (mean difference (MD) and 95% confidence interval (CI)). The primary safety outcome was a major adverse event (mortality and vascular injury requiring repair) (odds ratio (OR) and 95% CI). Secondary outcomes included adverse events.

MAIN RESULTS

We included 52 studies (19,192 participants) in the review. We found studies comparing VCDs with extrinsic compression (sheath size ≤ 9 Fr), different VCDs with each other after endovascular (EVAR) and percutaneous EVAR procedures and VCDs with surgical closure after open exposure of the artery (sheath size ≥ 10 Fr). For primary outcomes, we assigned the quality of evidence according to GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria as low because of serious imprecision and for secondary outcomes as moderate for precision, consistency and directness.For time to haemostasis, studies comparing collagen-based VCDs and extrinsic compression were too heterogenous to be combined. However, both metal clip-based (MD -14.81 minutes, 95% CI -16.98 to -12.63 minutes; five studies; 1665 participants) and suture-based VCDs (MD -14.58 minutes, 95% CI -16.85 to -12.32 minutes; seven studies; 1664 participants) were associated with reduced time to haemostasis when compared with extrinsic compression.For time to mobilisation, studies comparing collagen-, metal clip- and suture-based devices with extrinsic compression were too heterogeneous to be combined. No deaths were reported in the studies comparing collagen-based, metal clip-based or suture-based VCDs with extrinsic compression. For vascular injury requiring repair, meta-analyses demonstrated that neither collagen (OR 2.81, 95% CI 0.47 to 16.79; six studies; 5731 participants) nor metal clip-based VCDs (OR 0.49, 95% CI 0.03 to 7.95; three studies; 783 participants) were more effective than extrinsic compression. No cases of vascular injury required repair in the study testing suture-based VCD with extrinsic compression.Investigators reported no differences in the incidence of infection between collagen-based (OR 2.14, 95% CI 0.88 to 5.22; nine studies; 7616 participants) or suture-based VCDs (OR 1.66, 95% CI 0.22 to 12.71; three studies; 750 participants) and extrinsic compression. No cases of infection were observed in studies testing suture-based VCD versus extrinsic compression. The incidence of groin haematoma was lower with collagen-based VCDs than with extrinsic compression (OR 0.46, 95% CI 0.40 to 0.54; 25 studies; 10,247 participants), but no difference was evident when metal clip-based (OR 0.79, 95% CI 0.46 to 1.34; four studies; 1523 participants) or suture-based VCDs (OR 0.65, 95% CI 0.41 to 1.02; six studies; 1350 participants) were compared with extrinsic compression. The incidence of pseudoaneurysm was lower with collagen-based devices than with extrinsic compression (OR 0.74, 95% CI 0.55 to 0.99; 21 studies; 9342 participants), but no difference was noted when metal clip-based (OR 0.76, 95% CI 0.20 to 2.89; six studies; 1966 participants) or suture-based VCDs (OR 0.79, 95% CI 0.25 to 2.53; six studies; 1527 participants) were compared with extrinsic compression. For other adverse events, researchers reported no differences between collagen-based, clip-based or suture-based VCDs and extrinsic compression.Limited data were obtained when VCDs were compared with each other. Results of one study showed that metal clip-based VCDs were associated with shorter time to haemostasis (MD -2.24 minutes, 95% CI -2.54 to -1.94 minutes; 469 participants) and shorter time to mobilisation (MD -0.30 hours, 95% CI -0.59 to -0.01 hours; 469 participants) than suture-based devices. Few studies measured (major) adverse events, and those that did found no cases or no differences between VCDs.Percutaneous EVAR procedures revealed no differences in time to haemostasis (MD -3.20 minutes, 95% CI -10.23 to 3.83 minutes; one study; 101 participants), time to mobilisation (MD 1.00 hours, 95% CI -2.20 to 4.20 hours; one study; 101 participants) or major adverse events between PerClose and ProGlide. When compared with sutures after open exposure, VCD was associated with shorter time to haemostasis (MD -11.58 minutes, 95% CI -18.85 to -4.31 minutes; one study; 151 participants) but no difference in time to mobilisation (MD -2.50 hours, 95% CI -7.21 to 2.21 hours; one study; 151 participants) or incidence of major adverse events.

AUTHORS' CONCLUSIONS

For time to haemostasis, studies comparing collagen-based VCDs and extrinsic compression were too heterogeneous to be combined. However, both metal clip-based and suture-based VCDs were associated with reduced time to haemostasis when compared with extrinsic compression. For time to mobilisation, studies comparing VCDs with extrinsic compression were too heterogeneous to be combined. No difference was demonstrated in the incidence of vascular injury or mortality when VCDs were compared with extrinsic compression. No difference was demonstrated in the efficacy or safety of VCDs with different mechanisms of action. Further work is necessary to evaluate the efficacy of devices currently in use and to compare these with one other and extrinsic compression with respect to clearly defined outcome measures.

Percutaneous Large Arterial Access Closure Techniques

Endovascular repair has replaced open surgical repair as the standard of care for treatment of abdominal and thoracic aortic aneurysms in appropriately selected patients owing to its decreased morbidity and length of stay and excellent clinical outcomes. Similarly, there is a progressive trend toward total percutaneous repair of the femoral artery using percutaneous suture-mediated closure devices over open surgical repair due to decreased complications and procedure time. This article describes the techniques of closure for large-bore vascular access most commonly used in endovascular treatment of abdominal and thoracic aortic aneurysms, but could similarly be applied to any procedure requiring large-bore arterial access, such as transcatheter aortic valve replacement.