Percutaneous endovascular aneurysm repair in morbidly obese patients

Comparison of percutaneous access and open femoral cutdown in elective endovascular aortic repair of abdominal aortic aneurysms

BACKGROUND

The aim of this study was to compare postoperative outcomes of percutaneous access and femoral cutdown methods for elective bifurcated endovascular abdominal aortic aneurysm repair.

METHODS

Between November 2013 and September 2020, a total of 152 patient (135 males, 17 females; mean age: 70.6±6, range, 57 to 87 years) who underwent endovascular repair due to infrarenal abdominal aortic aneurysm were retrospectively analyzed. According to femoral access type, the patients were grouped into two groups as the total percutaneous femoral access and open cutdown femoral access endovascular repair. Intra- and postoperative data were compared, including operative time, amount of contrast media, bleeding requiring transfusion, return to the operating room, access vessel complications, wound complications, and overall length of hospital stay.

RESULTS

Eighty-seven (57.2%) femoral cutdown access repair and 65 (42.8%) percutaneous femoral access repair cases were evaluated in the study. The two groups were comparable in terms of demographic and clinical characteristics (p>0.05), except for chronic obstructive pulmonary disease which was more frequent in the percutaneous access group (p=0.014). After adjustment, age, diabetes mellitus, chronic obstructive pulmonary disease, and obesity were not predictive of percutaneous access failure. Percutaneous femoral access was observed as the only preventing factor for wound infection (odds ratio=0.166, 95% confidence interval: 0.036-0.756; p=0.021).

CONCLUSION

Although femoral access preference does not affect mortality and re-intervention rates, percutaneous endovascular repair reduces operation time, hospital stay, and wound site complications compared to femoral artery exposures.

The long-term implications of access complications during endovascular aneurysm repair

BACKGROUND

Access issues are one of the most common complications of endovascular aneurysm repair (EVAR). However, contemporary rates as well as risk factors for complications and the subsequent impact of access complications on mortality are poorly described.

METHODS

We studied all EVAR for intact abdominal aortic aneurysms without prior aortic surgery in the Vascular Quality Initiative between 2011 and 2018. We studied factors associated with access complications (thrombosis, embolus, wound infection, hematoma, and conversion to cutdown), as well as the interaction with female sex and the impact on survival using multilevel logistic regression and propensity weighting. Multiple imputation was used for missing data.

RESULTS

There were 33,951 EVAR during the study period (91% elective, 9% symptomatic); most cases (70%) involved an attempt at percutaneous access on at least one side, with 30% bilateral cutdowns and 0.1% iliac conduits. There were 1553 patients (4.6%) who experienced at least one access complication. Access complications were almost twice as common in female patients (7.5% vs 3.9%; P < .001). The factors associated with access complications included female sex (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.0-3.6; P < .001), age (OR, 1.05 per 5 years; 95% CI, 1.02-1.1; P < .01), aortouni-iliac device (OR, 1.6; 95% CI, 1.1-2.3; P < .01), smoking (OR, 1.4; 95% CI, 1.1-1.7; P < .01), body mass index of less than 16 (OR, 1.8; 95% CI, 1.3-2.5; P = .001), dual antiplatelet therapy (1.3; 95% CI, 1.02-1.6 P = .03), prior infrainguinal bypass (OR, 1.8; 95% CI, 1.3-2.7; P < .01), and beta blocker use (OR, 1.2; 95% CI, 1.03-1.4; P = .02). Conversion from percutaneous access to open cutdown was associated with higher rates of complications than planned open cutdown (8.6% vs 2.9%; P < .001). In propensity-weighted analysis, percutaneous access was associated with significantly lower odds of access complications in women (OR, 0.6; 95% CI, 0.4-0.96; P = .03). Patients who experienced an access complication had more than four times the odds of perioperative death (OR, 4.2; 95% CI, 2.5-7.1; P < .001), and a 60% higher risk of long-term mortality (hazard ratio, 1.6; 95% CI, 1.2-2.1; P = .001). In addition to death, patients with access site complications had higher rates of other major complications, including reoperation during the index hospitalization (19% vs 1.2%; P < .001), myocardial infarction (3.5% vs 0.7%; P < .001), stroke (0.8% vs 0.2%; P < .001), acute kidney injury (12% vs 3%; P < .001), and reintubation (5.7% vs 0.8%).

CONCLUSIONS

Although access complications are infrequent in the current era, they are associated with both perioperative and long-term morbidity and mortality. Female patients in particular are at high risk of access complications, but may benefit from percutaneous access.

Effect of obesity on radiation exposure, quality of life scores, and outcomes of fenestrated-branched endovascular aortic repair of pararenal and thoracoabdominal aortic aneurysms

BACKGROUND

The aim of the present study was to assess the effect of obesity on procedural metrics, radiation exposure, quality of life (QOL), and clinical outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms.

METHODS

We reviewed the clinical data from 334 patients (236 men; mean age, 75 ± 8 years) enrolled in a prospective nonrandomized study to evaluate FB-EVAR from 2013 to 2019. The patients were classified using the body mass index (BMI) as obese (BMI ≥30 kg/m²) or nonobese (BMI <30 kg/m²). QOL questionnaires (short-form 36-item questionnaire) and imaging studies were obtained preoperatively and at 2 months and 6 months postoperatively, and annually thereafter. The procedures were performed using two different fixed imaging systems. The end points included procedural metrics (ie, total operative time, fluoroscopic time, contrast volume), radiation exposure, technical success, 30-day mortality, and major adverse events, QOL changes, freedom from target vessel instability, freedom from reintervention, and patient survival.

RESULTS

The aneurysm extent was a pararenal aortic aneurysm in 117 patients (35%) and a thoracoabdominal aortic aneurysm in 217 patients (65%). Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for a greater incidence of hyperlipidemia and diabetes among the obese patients (P < .05). No significant differences were found in the procedural metrics or intraprocedural complications between the groups, except that the obese patients had greater radiation exposure than the nonobese patients (mean, 2.5 vs 1.6 Gy; P < .001), with the highest radiation exposure in those obese patients who had undergone the procedure using system 1 (fusion alone) instead of system 2 (fusion and digital zoom; mean, 4.1 vs 1.5 Gy; P < .001). Three patients had died within 30 days (0.8%), with no difference in mortality or major adverse events between the groups. The mental QOL scores had improved in the obese group at 2 and 12 months compared with the nonobese patients, with persistently higher scores up to 3 years. At 3 years, the obese and nonobese patients had a similar incidence of freedom from target vessel instability (74% ± 6% vs 80% ± 3%; P = .99, log-rank test), freedom from reintervention (66% ± 6% vs 73% ± 4%; P = .77, log-rank test), and patient survival (83% ± 5% vs 75% ± 4%; P = .16, log-rank test).

CONCLUSIONS

FB-EVAR was performed with high technical success and low mortality and morbidity, with no significant differences between the obese and nonobese patients. The procedural metrics and outcomes were similar, with the exception of greater radiation exposure among obese patients, especially for the procedures performed using system 1 with fusion alone compared with system 2 (fusion and digital zoom). Obese patients had higher QOL mental scores at 2 and 12 months, with a similar reintervention rate, target vessel outcomes, and survival compared with nonobese patients.

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.

The Obesity-associated Risk in Open and Endovascular Repair of Abdominal Aortic Aneurysm

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The rising pandemic of obesity in modern society should direct attention to a more comprehensive approach to abdominal aortic aneurysm (AAA) treatment in the affected population. Although overweight patients are considered prone to increased surgical risk, studies on the subject did not confirm or specify the risks well enough.

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Associated comorbidities inevitably lead to a selection bias leaning towards endovascular abdominal aortic repair (EVAR), as a less invasive treatment option, which makes it hard to single out obesity as an independent risk factor. The increased technical difficulty often results in prolonged procedure times and increased blood loss. Several smaller studies and two analyses of national registries, including 7935 patients, highlighted the advantages of EVAR over open repair (OR) of abdominal aortic aneurysm, especially in morbidly obese population (relative risk reduction up to 47%). On the other hand, two other studies with 1374 patients combined, concluded that EVAR might not have an advantage over OR in obese patients (P = 0.52). Obesity is an established risk factor for wound infection after both EVAR and OR, which is associated with longer length of stay, subsequent major operations, and a higher rate of graft failure. Percutaneous EVAR technique could present a promising solution to reducing this complication.

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EVAR seems like a more feasible treatment option than OR for obese patients with AAA, due to lower overall morbidity and mortality rates, as well as reduced wound-related complication rates. However, there is a clear lack of high-quality evidence on the subject, thus future prospective trials are needed to confirm this advantage.