Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients

The effect of obesity on the outcome of thoracic endovascular aortic repair: a systematic review and meta-analysis

Background

Obesity is a well-known predictor for poor postoperative outcomes of vascular surgery. However, the association between obesity and outcomes of thoracic endovascular aortic repair (TEVAR) is still unclear. This systematic review and meta-analysis was performed to assess the roles of obesity in the outcomes of TEVAR.

Methods

We systematically searched the Web of Science and PubMed databases to obtain articles regarding obesity and TEVAR that were published before July 2023. The odds ratio (OR) or hazard ratio (HR) was used to assess the effect of obesity on TEVAR outcomes. Body mass index (BMI) was also compared between patients experiencing adverse events after TEVAR and those not experiencing adverse events. The Newcastle-Ottawa Scale was used to evaluate the quality of the enrolled studies.

Results

A total of 7,849 patients from 10 studies were included. All enrolled studies were high-quality. Overall, the risk of overall mortality (OR = 1.49, 95% CI [1.02-2.17], p = 0.04) was increased in obese patients receiving TEVAR. However, the associations between obesity and overall complications (OR = 2.41, 95% CI [0.84-6.93], p = 0.10) and specific complications were all insignificant, including stroke (OR = 1.39, 95% CI [0.56-3.45], p = 0.48), spinal ischemia (OR = 0.97, 95% CI [0.64-1.47], p = 0.89), neurological complications (OR = 0.13, 95% CI [0.01-2.37], p = 0.17), endoleaks (OR = 1.02, 95% CI [0.46-2.29], p = 0.96), wound complications (OR = 0.91, 95% CI [0.28-2.96], p = 0.88), and renal failure (OR = 2.98, 95% CI [0.92-9.69], p = 0.07). In addition, the patients who suffered from postoperative overall complications (p < 0.001) and acute kidney injury (p = 0.006) were found to have a higher BMI. In conclusion, obesity is closely associated with higher risk of mortality after TEVAR. However, TEVAR may still be suitable for obese patients. Physicians should pay more attention to the perioperative management of obese patients.

A single center study of the efficacy and safety of Pro-Glide used for closure in thoracic endovascular aortic repair in patients with previous groin intervention

BACKGROUND

This study aimed to evaluate the efficacy and safety of Pro-Glide, a suture-mediated vascular closure device, regarding technical success and complications in patients who had undergone aortic intervention and had previous groin intervention (PGI).

METHODS

One hundred and thirty-five patients who underwent percutaneous thoracic endovascular aortic repair via the femoral artery and were closed with the Pro-Glide device were analyzed retrospectively. PGI was defined as a history of open surgical access to the femoral artery or wide sheath (>18 F) placement due to endovascular or valvular intervention. The patients were divided into two groups 38 cases with PGI and 97 cases without PGI.

RESULTS

The overall success rate of closure of the femoral artery with Pro-Glide was not statistically significant between the two groups (93.8% vs 92.1%, p = .711). Sheath sizes were compared between the groups and PGI (+) group had significantly higher sheath sizes compared to PGI (-) group (24.3 ± 1.1 F vs 23.8 ± 1.0 F, p = .011). Three patients in the PGI (+) group and six patients in the PGI (-) group experienced technical failure of the percutaneous femoral approach. Femoral complications were seen after the procedures in four patients in the PGI (+) group and four in the PGI (-) group. The PGI (+) group had a higher complication rate when compared to the PGI (-) group; however, this was not statistically significant (p = .181).

CONCLUSION

The present study was conducted on a significantly larger sample compared to previous studies and the findings suggest that the Pro-Glide vascular closure device is a safe option for patients with a history of PGI and may not be considered as a contraindication.

Body Mass Index Impacts Indication But Not Outcomes of Thoracic Endovascular Aortic Repair

BACKGROUND

There are limited studies looking at thoracic endovascular aortic repair (TEVAR) outcomes in obese and overweight patients. Our objective was to determine the rate of complications, reintervention, and short-term mortality in normal weight, overweight, and obese patients undergoing TEVAR.

METHODS

Patients undergoing TEVAR at a large tertiary hospital from October 2007 to January 2020 were analyzed. Patients were stratified into 3 cohorts based on body mass index (BMI): normal (18.5-25 kg/m2), overweight (25-30 kg/m2), and obese (>30 kg/m2). Primary outcomes were 30-day and 1-year survival. Intraoperative, in-hospital, and postdischarge complications were assessed as secondary outcomes using the Clavian-Dindo classification system. In addition, reinterventions associated with the index TEVAR procedure as a secondary outcome.

RESULTS

Among 204 patients fitting the study criteria, we identified 65 with normal BMI, 78 overweight, and 61 obese patients. Obese patients were younger than the overweight and normal BMI patients (mean age 62.2 vs. 66.7 vs. 70.7, respectively, P = 0.003). In terms of TEVAR indication, the obese cohort had the highest percentage of patients with type B aortic dissection (36.4%), while the normal BMI cohort had the higher proportion of patients undergoing TEVAR for isolated thoracic aortic aneurysm (63.9%). Intraoperative complications did not significantly differ between cohorts. Postoperatively, in-hospital complications, postdischarge complications and 30-day return to the operative room did not differ significantly between study cohorts. Odds of reintervention did not differ significantly between cohorts, both on univariate and multivariate analysis. Log-rank test of Kaplan Meier analysis revealed no difference in reintervention-free survival (P = 0.22). Thirty-day mortality and 1-year overall survival were similar across cohorts. Both univariate and multivariate logarithmic regression revealed no difference in likelihood of 30-day mortality between the obese and normal cohort.

CONCLUSIONS

There were no measurable differences in complications, reinterventions, or mortality, suggesting that vascular surgeons can perform TEVAR across a spectrum of BMI without compromising outcomes.

The Implications of Surgeon Case Volume and Hospital Volume on Outcomes of Aortobifemoral Bypasses in Obese Patients

BACKGROUND

Aortobifemoral (ABF) bypass is the gold standard for treating symptomatic aortoiliac occlusive disease. In the era of heightened interest in the length of stay (LOS) for surgical patients, this study aims to investigate the association of obesity with postoperative outcomes at the patient, hospital, and at surgeon levels.

METHODS

This study utilized the Society of Vascular Surgery (SVS) Vascular Quality Initiative (VQI) suprainguinal bypass database from 2003-2021. The selected study cohort was divided into obese patients (BMI ≥30) (Group I) and non-obese patients (BMI <30) (Group II). Primary outcomes of the study included mortality, operative time, and postoperative LOS. Univariate and multivariate logistic regression analyses were performed to study the outcomes of ABF bypass in Group I. Operative time, and postoperative LOS were transformed into binary values by median split for regression analysis. A p-value of ≤ 0.05 was deemed statistically significant in all the analyses of this study.

RESULTS

The study cohort consisted of 5,392 patients. In this population, 1,093 were obese (Group I), and 4,299 were non-obese (Group II). Group I was found to have more females with higher rates of comorbid conditions, including hypertension, diabetes mellitus, and congestive heart failure. Patients in Group I had increased odds of prolonged operative time (≥ 250 mins) and an increased LOS (≥6 days). Patients in this Group also had a higher chance of intraoperative blood loss, prolonged intubation, and required vasopressors postoperatively. There was also an increased odds of postoperative decline in renal function in the obese population. Patients with prior history of CAD, hypertension, diabetes mellitus, and urgent or emergent procedures were found to be risk factors for LOS>6 days in obese patients. An increase in the surgeons' case volume was associated with lesser odds of operative time ≥ 250 mins; however, no significant impact was found on postoperative LOS. Hospitals where ≥ 25% ABF bypasses were performed on obese patients were also more likely to have LOS <6 days after ABF operations, compared to hospitals where <25% of ABF bypasses were performed on obese patients. Patients undergoing ABF for CLTI or acute limb ischemia had longer LOS and increased operative time.

CONCLUSION

ABF bypass in obese patients is associated with prolonged operative times and longer LOS than in non-obese patients. Obese patients operated by surgeons with more cases of ABF bypasses have shorter operative times. An increasing hospital's obese patient proportion was related to decreased LOS. These findings support the known volume-outcome relationship that with a higher surgeon case volume and increased proportion of obese patients in a hospital, there is an improvement in outcomes of obese patients undergoing ABF bypass.

Control of Femoral Cannulation with a ProGlide Pre-Closure Device during Cardiac Surgery: Is It Reliable?

Background

The use of ProGlide as a percutaneous vascular closure device in cardiac surgery remains inconclusive. This study investigated the clinical outcomes of using Pro- Glide in the percutaneous cannulation of femoral vessels in adult cardiac surgery.

Methods

From September 2017 to July 2018, 131 consecutive patients underwent femoral vessel cannulation during cardiac surgery. The ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA) with percutaneous cannulation was used in 118 patients (mean age, 55.7±15.5 years). The accessibility of femoral cannulation was evaluated through preoperative computed tomography. For cannulation, sonography was routinely used. The postoperative ankle-brachial index (ABI) was used to evaluate femoral artery stenosis.

Results

Of the 118 patients, 112 (94.9%) and 6 (5.1%) underwent minimally invasive cardiac surgery and median sternotomy, respectively. Most femoral cannulations were performed on the right side (98.3%) using 15F to 19F arterial cannulas. The technical success rate of cannulation with ProGlide was 99.2%, with no delayed bleeding or cannulation site-related complications during hospitalization. During follow-up, only 1 patient showed femoral artery stenosis with claudication and was treated with interventional balloon angioplasty. The postoperative ABI revealed no significant difference in functional stenosis between the cannulation and non-cannulation sides (n=86; cannulation vs. non-cannulation, 1.2±0.1 vs. 1.1±0).

Conclusion

Percutaneous femoral cannulation with ProGlide was safe and feasible in adult cardiac surgery. This technique may be a good alternative option in patients requiring femoral vessel cannulation for cardiac surgery.

Comparison between PeRcutanEous and surgical femoral aCcess for endovascuLar aOrtic repair in patientS with typE III aortic Dissection (PRECLOSE Trial)

OBJECTIVES

Aortic dissections are cardiovascular events with high mortality and morbidity rates. Management might be either with medical or interventional approach. Recently, thoracic endovascular intervention (TEVAR) becomes the first treatment of choice because of its better results and lower rates of complications in patients with type III aortic dissections. The intervention might be performed via femoral artery either with percutaneous or with surgical approach. Because of large sheath insertion to femoral artery, Pre-close technique is described in literature. The aim of this study was to investigate and compare the outcomes and safety of 'Pre-close technique' to surgical approach in patients with type III aortic dissections who underwent TEVAR with femoral access ≥22 F.

METHODS

A total of 96 patients whom had type III aortic dissection and was performed TEVAR were retrospectively included in the study. Fifty-six patients had TEVAR with percutaneous approach and these patients are named as P-TEVAR group, and 40 patients had TEVAR with surgical approach and these patients are named as S-TEVAR group. Pre- and post-procedural data with complications and procedural data during TEVAR were evaluated for both groups and compared in between.

RESULTS

The main finding was that there was no significant difference between S-TEVAR and P-TEVAR groups in terms of complications and technical success. Operating room time was significantly decreased in P-TEVAR group (P < 0.001). Overall success rate for femoral approach in patients with Pre-close technique was 94.6% and was 100% for surgical approach. P-TEVAR group had post-operative complications in three patients and S-TEVAR group had in four patients.

CONCLUSIONS

Total percutaneous approach with Pre-close technique using Pro-Glide device is a safe and feasible method of femoral access in patients with type III aortic dissections.

Perclose Proglide™ for vascular closure

In the past 20 years, numerous percutaneous vascular closure devices have been tested and compared with manual compression and to surgical cut-down. The suture-mediated closure device Perclose ProGlide™ system (Abbott Vascular, CA, USA) emerged as a safe and effective alternative for many procedures requiring either small or large bore vascular accesses. In this review, we will discuss the characteristics of this vascular closure device and the main studies that proved its potential to reduce vascular complications, time to deambulation, time to discharge and patient discomfort.

Clinical efficacy and safety of the PRO-glide device as a sUture-mediated ClosurE in Thoracic EndoVascular Aortic Repair in patients with previous groin intervention (from the PRODUCE-TEVAR Trial)

BACKGROUND

While the percutaneous approach is increasingly preferred, suture-mediated closure devices have been put into clinical practice to close the femoral artery during procedures requiring a large-sized introducer. However, scar in the groin is considered a contraindication or an exclusion criterion for percutaneous procedures. The aim of our study was to investigate the outcomes and safety of Pro-Glide device as suture-mediated closure device in patients who underwent thoracic endovascular aortic repair with percutaneous femoral access ≥22 F who had previous groin intervention.

METHODS

A total of 73 patients who underwent endovascular repair with percutaneous femoral access were retrospectively included in the study. Previous groin intervention was defined as history of open surgical access or large sheath insertion (>18 F) to femoral artery because of endovascular or valvular intervention. Patients were divided into two groups as who had previous groin intervention PGI (+) and had not PGI (-).

RESULTS

A total of 73 patients [60 male (82.2%)] were included in the study. Seventeen patients had PGI, and 56 did not. When groups were compared in terms of sheath sizes, a significantly higher sheath sizes were used in PGI (+) patients (24.5 ± 1.1 F vs. 23.8 ± 0.9 F, p = 0.005). The overall success rate in the femoral approach with pre-close technique was statistically insignificant between two groups (94.1% vs. 96.4%, p = 0.55). One patient in PGI (+) group and two patients in PGI (-) had technical failure for percutaneous femoral approach. One patient (5.9%) in PGI (+) group and one patient (1.8%) in PGI (-) group had femoral complications after the procedures; however, there was no significant difference between the groups in terms of complications (5.9% vs. 1.8%, p = 0.13).

CONCLUSION

Pro-Glide device may be a safe and less invasive method for femoral access in patients with PGI and might not be considered as a contraindication for patients with history of PGI.

Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair

OBJECTIVE

The objective of this study was to evaluate the performance of percutaneous femoral access with large-bore sheaths (>21F outer diameter) mainly employed for thoracic and thoracoabdominal aortic endovascular treatment and to stratify the outcomes on the basis of the introducer size.

METHODS

Between December 2015 and December 2018, all consecutive patients who received endovascular repair through a percutaneous approach with a suture-mediated vascular closure device (VCD) and the preclose technique were included in a retrospective single-center study called Totally Percutaneous Approach to Endovascular Treatment of Aortic Aneurysms (PEVAR-PRO). The morphologic characteristics of the access vessels and patients' demographics were recorded, and 30-day closure success was defined as the primary end point. Analysis of the closure success comparing large-bore sheaths vs small-bore sheaths (≤21F outer diameter) was performed after 1:1 propensity score matching of preoperative confounding variables.

RESULTS

The closure success rate of the entire study cohort was 94% (622 femoral accesses in 360 patients; median age, 74 years; 84% male). Univariate analysis identified eight different factors associated with failure, but only two remained significant on multivariate analysis: diabetes (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .011) and common femoral artery stenosis >50% (OR, 4.5; 95% CI, 1.3-13.7; P = .019). After propensity score matching (1:1, 172 femoral accesses per group), closure success rate was not significantly different between large-bore and small-bore sheaths (90.7% vs 93.0%; P = .43). Multivariate analysis of the large-sheath group identified two factors associated with failure: small (<9 mm) femoral arteries (OR, 6.9; 95% CI, 1.5-31.6; P = .13) and access vessel calcifications involving more than one-third of the circumference (OR, 7.9; 95% CI, 2.1-29.4; P = .002). Neither previous femoral cutdown (44 accesses [23%]) nor percutaneous closure with VCDs (38 accesses [20%]) affected the closure success rate in the large-sheath group. Closure failure did not significantly increase the need for postoperative blood transfusions or hospital length of stay.

CONCLUSIONS

Off-label use of VCDs and the preclose technique for percutaneous approach with large-bore sheaths needed for complex aortic endovascular procedures is safe and feasible. Closure success rate is not significantly different from that obtained with on-label application of VCDs with smaller sheaths.

Successful percutaneous access for endovascular aneurysm repair is significantly cheaper than femoral cutdown in a prospective randomized trial

OBJECTIVE

Because of its minimally invasive nature, percutaneous femoral access for endovascular aneurysm repair (pEVAR) is currently undergoing rapid popularization. Compared with surgical cutdown for femoral access (cEVAR), it offers the advantage of faster recovery after surgery as well as a reduction in wound complications. Despite proposed advantages, the method is largely considered uneconomical because of its reliance on costly closure devices.

METHODS

There were 50 patients undergoing EVAR who were enrolled in this randomized prospective single-center trial. Each patient randomly received percutaneous access in one groin and surgical access in the other. The primary end points were access duration and cost. Secondary end points were wound complications and the postoperative pain levels.

RESULTS

Surgery was performed per protocol in 44 patients. Mean access times for pEVAR and cEVAR were 11.5 ± 3.4 minutes and 24.8 ± 12.1 minutes (P < .001), respectively. Total access costs were €559.65 ± €112.69 for pEVAR and €674.85 ± €289.55 for cEVAR (P = .016). Eight complications in six patients were attributed to cutdown, none to pEVAR (P = .02). The percutaneously accessed groin was significantly less painful at day 1 and day 5 after surgery (P < .001). An intention-to-treat analysis (N = 50 patients) included six cases of pEVAR conversion due to technical failure in three patients (6%) and change of the operative strategy in another three patients (eg, aortouni-iliac stent graft followed by crossover bypass). The intention-to-treat analysis showed shorter mean overall access time for pEVAR (pEVAR, 14.65 ± 10.20 minutes; cEVAR, 25.12 ± 11.77 minutes; P < .001) and no cost difference between the two methods (pEVAR, €651.29 ± €313.49; cEVAR, €625.53 ± €238.29; P = .65).

CONCLUSIONS

Our data confirm proposed potential benefits attributable to the minimally invasive nature of pEVAR while demonstrating cost-effectiveness despite the additional cost of closure devices. Taking into account pEVAR failures still does not increase pEVAR costs over cEVAR. Further considering reduced postoperative pain and wound complications, the technique deserves consideration in suitable patients.

Totally Percutaneous Access Using Perclose Proglide for Endovascular Treatment of Aortic Diseases

Objective

To evaluate our experience following the introduction of a percutaneous program for endovascular treatment of aortic diseases using Perclose Proglide® assessing efficacy, complications and identification of potential risk factors that could predict failure or major access site complications.

Methods

A retrospective cohort study during a two-year period was performed. All the patients submitted to totally percutaneous endovascular repair (PEVAR) of aortic diseases and transcatheter aortic valve implantation since we started the total percutaneous approach with the preclosure technique from November 2013 to December 2015 were included in the study. The primary endpoint was major ipsilateral access complication, defined according to PEVAR trial.

Results

In a cohort of 123 patients, immediate technical success was obtained in 121 (98.37%) patients, with only two (0.82%) cases in 242 vascular access sites that required intervention immediately after the procedure. Pairwise comparisons revealed increased major access complication among patients with >50% common femoral artery (CFA) calcification vs. none (P=0.004) and > 50% CFA calcification vs. < 50% CFA calcification (P=0.002). Small artery diameter (<6.5 mm) also increased major access complication compared to bigger diameters (> 6.5 mm) (P=0.027).

Conclusion

The preclosure technique with two Perclose Proglide® for PEVAR is safe and effective. Complications occur more often in patients with unfavorable access site anatomy and the success rate can be improved with proper patient selection.

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.

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.

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.

Kidney Transplantation Significantly Improves Patient and Graft Survival Irrespective of BMI: A Cohort Study

Obesity and end-stage renal disease (ESRD) are on the increase worldwide. Kidney transplantation is the treatment of choice for ESRD. However, obesity is considered a contraindication for transplantation. We investigated the effect of BMI on mortality in transplanted and patients remaining on the waiting list in the United Kingdom. We analyzed the UK Renal Registry (RR) and the National Health Service Blood and Transplant (NHSBT) Organ Donation and Transplantation data for patients listed from January 1, 2004 to December 31, 2010, with follow-up until December 31, 2011. Seventeen thousand six hundred eighty-one patients were listed during the study period, with BMI recorded for 13 526 (77%). One- and five-year patient survival was significantly better in all BMI bands (<18.5, 18.5-<25, 25-<30, 30-<35, 35-<40, and 40+kg/m(2) ) in the transplant group when compared to those who remained on the waiting list (p < 0.0001). The analyses were repeated excluding live donor transplants and the results were essentially the same. On analyses of patient survival with BMI as a continuous variable or using 5 kg weight bands, there was no cut-off observed in the higher BMI patients where there would be no benefit to transplantation. For transplanted patients (N = 8088), there was no difference in patient or graft survival between the defined BMI bands. Thus, irrespective of BMI, patient survival is improved if transplanted.

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.

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.

Transcatheter Aortic Valve Replacement

The role of transcatheter aortic valve replacement (TAVR) continues to evolve and expand at a rapid pace. The advanced age and frailty of many TAVR candidates often presents complex vascular access challenges when contemplating the exact route of valve delivery. As the indications and approved routes of delivery have evolved, so have the direct open vascular and percutaneous techniques paramount to success. We review the spectrum of access options that may be available for consideration during TAVR procedures and highlight the “pearls and pitfalls” of each technique. We additionally highlight reasons a technique may be preferred for a specific patient subset, as well as the concerns addressed by the anesthesiologist in approaching TAVR.