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Sarhan DYA, Kölbel T, Grandi A, Nana P, Torrealba JI, Behrendt CA, Panuccio G. The Role of Downsizing of Large-Bore Percutaneous Femoral Access for Pelvic and Lower Limb Perfusion in Transfemoral Branched Endovascular Aortic Repair. J Clin Med 2024; 13:5375. [PMID: 39336864 PMCID: PMC11432116 DOI: 10.3390/jcm13185375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/07/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024] Open
Abstract
Background: Transfemoral access (TFA) is a valuable alternative to upper extremity access (UEA) for branched endovascular aortic repair (bEVAR). However, TFA requires large introducer sheaths, which can reduce blood flow to lower limbs and the pelvis. This study aimed to evaluate the efficacy of sheath downsizing to maintain lower limb perfusion during TFA-bEVAR. Methods: A single-center retrospective review was conducted including patients managed with TFA-performed bEVAR between December 2020 and May 2021. Intra-operative lower limb perfusion was assessed using non-invasive ankle blood pressure measurements and great toe pulse oximetry, with measurements being taken prior to puncture (baseline), one minute after 10F-sheath insertion, three minutes after the main body delivery system insertion, and three minutes after downsizing to a 14F sheath. Outcomes included the incidence of limb perfusion reduction (LPR), defined as a drop in the ankle-brachial index (ABI) < 0.5 or peripheral oxygen saturation (SpO2) < 90%. Results: Out of 47 patients, 24 met the inclusion criteria. LPR occurred in 4.2% of cases after 10F-sheath placement, and 87.5% after main body delivery system placement, and decreased to 12.6% after downsizing to a 14F sheath. No periprocedural major bleeding occurred. Two patients required revision for inadequate hemostasis post-operatively. SCI occurred in 16% of patients, all recovered by discharge. Pre-operative hypogastric artery occlusion was related to persistent LPR after downsizing (100% vs. 16%, p = 0.009). Conclusions: Downsizing the introducer sheath during bEVAR is feasible and safe to restore lower limb and pelvic perfusion. Further research is needed to clarify the access downsizing value during bEVAR.
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Affiliation(s)
- Daour Yousef Al Sarhan
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Alessandro Grandi
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Petroula Nana
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - José I Torrealba
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Christian-Alexander Behrendt
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Centre, Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
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Mirabella D, Bruno S, La Marca MA, Dinoto E, Rodriquenz E, Miccichè A, Pecoraro F. Optimizing Femoral Access in Emergency EVAR with a Decision-Making Algorithm. Life (Basel) 2024; 14:1113. [PMID: 39337897 PMCID: PMC11433623 DOI: 10.3390/life14091113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Revised: 08/19/2024] [Accepted: 09/02/2024] [Indexed: 09/30/2024] Open
Abstract
Endovascular aneurysm repair (EVAR) has become the preferred approach over open repair for abdominal aortic aneurysms (AAAs) due to its minimally invasive nature. The common femoral artery (CFA) is the main access vessel for EVAR, with both surgical exposure and percutaneous access being utilized. However, in emergent cases, percutaneous access can be challenging and may result in complications such as bleeding or dissection thrombosis, leading to the need for surgical conversion. This study aimed to share experiences in implementing a decision-making algorithm to reduce surgical conversions due to percutaneous access failures. A total of 74 aortic patients treated with EVAR in emergency settings were included in this retrospective study. This study focused on various outcomes such as perioperative mortality, morbidity, procedure time, surgical exposure time, and surgical conversion rate. After the implementation of the decision-making algorithm, decreases in surgical conversions and operating time were observed. Percutaneous access was found to be more challenging in cases with specific anatomical characteristics of the CFA, such as severe atherosclerosis or smaller vessel diameter. This study highlighted the importance of carefully assessing patient anatomical features and utilizing a decision-making algorithm to optimize outcomes in EVAR procedures. Further research is needed to continue improving practices for managing aortic aneurysms and reducing complications in femoral artery access approaches.
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Affiliation(s)
- Domenico Mirabella
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (S.B.); (M.A.L.M.); (E.R.); (A.M.); (F.P.)
| | - Salvatore Bruno
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (S.B.); (M.A.L.M.); (E.R.); (A.M.); (F.P.)
| | - Manfredi Agostino La Marca
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (S.B.); (M.A.L.M.); (E.R.); (A.M.); (F.P.)
| | - Ettore Dinoto
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (S.B.); (M.A.L.M.); (E.R.); (A.M.); (F.P.)
| | - Edoardo Rodriquenz
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (S.B.); (M.A.L.M.); (E.R.); (A.M.); (F.P.)
| | - Andrea Miccichè
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (S.B.); (M.A.L.M.); (E.R.); (A.M.); (F.P.)
| | - Felice Pecoraro
- Vascular Surgery Unit, AOUP Policlinico “P. Giaccone”, 90127 Palermo, Italy; (D.M.); (S.B.); (M.A.L.M.); (E.R.); (A.M.); (F.P.)
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90133 Palermo, Italy
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Xu C, Zhang ZX, Gu YM, Yu JF, Fang CW, Xu GX, Jin YQ. Dual Suture Versus Suture and Plug Closure Devices for Large Bore Access Haemostasis During Percutaneous Access Endovascular Aneurysm Repair. Cardiovasc Intervent Radiol 2023; 46:1553-1561. [PMID: 37828234 DOI: 10.1007/s00270-023-03570-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/19/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE This study aimed to compare a dual Proglide strategy versus a combination of one Proglide and dual Exoseal for large-bore access closure during percutaneous access endovascular aneurysm repair (pEVAR). MATERIALS AND METHODS We retrospectively analyzed 97 patients who underwent pEVAR at our center between January 2021 and February 2023. The patients were divided into two groups: dual Proglide (P + P) and one Proglide with dual Exoseal (P + E). The primary outcome measures were technical success and access-related vascular complications. Technical success was defined as achieving complete hemostasis without a bailout strategy. Postprocedural follow-up for access-related vascular complications was evaluated at 30 and 60 days using computed tomography angiography and ultrasonography. Severity was graded according to the Cardiovascular Interventional Radiological Society of Europe (CIRSE) Classification. RESULTS Overall, a dual Proglide strategy was used in 46 patients (47.4%) with 65 groins (46.4%), and a combination of one Proglide and dual Exoseal was used in 51 patients (52.6%) with 75 groins (53.6%). The baseline characteristics were similar between the groups. The total technical success rate was 96.4%, and no significant differences were observed (95.4% vs. 97.3%; p = 0.870). Minor bleeding treatable through compression occurred significantly more often in the P group (CIRSE 1, 10.8% vs. 1.3%, p = 0.042). Hemostasis time, procedural time, length of stay in the hospital, closure device failure, and incidence of unplanned intervention did not differ significantly between the groups. CONCLUSIONS A combined Proglide and Exoseal strategy is safe and effective for large-bore access closure during pEVAR and can be considered an alternative. However, it should be supported by larger prospective studies.
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Affiliation(s)
- Chen Xu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou, 215000, China
| | - Zhi-Xuan Zhang
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou, 215000, China
| | - Yi-Ming Gu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou, 215000, China
| | - Jin-Fan Yu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou, 215000, China
| | - Chang-Wen Fang
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou, 215000, China
| | - Guo-Xiong Xu
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou, 215000, China.
| | - Yi-Qi Jin
- Department of Vascular Surgery and Intervention, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Gusu District, Suzhou, 215000, China
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Hakeem A, Najem M, Khokher Z, Chaudhuri A. A Comparative Analysis of the Early and Late Complication Rates and the Effect of Calcification on the Efficacy of MANTA and ProGlide Vascular Closure Devices. Cureus 2023; 15:e48092. [PMID: 38046720 PMCID: PMC10690066 DOI: 10.7759/cureus.48092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction The Perclose ProGlide and, more recently, MANTA Large-Bore Closure Device are commonly used vascular closure devices (VCDs) for managing large-bore vascular access haemostasis. The extent of calcification in the common femoral artery (CFA) plays a crucial role in choosing between these devices. ProGlide may face challenges with anterior calcification, while MANTA may have issues with posterior calcification. Our study compared their effectiveness, adjunct usage, calcification impact and early/late complications. Methods A retrospective analysis of procedures involving large-bore CFA access from 2017 to 2022 was conducted. Closure was grouped according to VCD as Group A (ProGlide) and Group B (MANTA). Calcification was designated as anterior and posterior and combined on pre-operative computed tomography angiography along 10 mm segments with 0.625 mm slice thickness. The success of haemostasis was graded as Grade 1 (haemostasis without adjuncts), Grade 2 (haemostasis with adjuncts) and Grade 3 (failed haemostasis needing rescue); Grades 1 and 2 were pooled as successful haemostasis. Statistical analysis was undertaken in Minitab 21 for Windows, particularly analysing calcification and its impact on the success of haemostasis. Results We evaluated 370 large-bore CFA accesses, distributed across two groups: Group A(64.9%, n=243) and Group B (35.1%, n=127), for a total of 205 endovascular procedures (93.1% (191) EVAR and 5.3% (11) TEVAR). The mean age was 74.9±8 years, predominantly males (88.2%, n=181). The average body mass index (BMI) was 28±5.8, with 20.9% (43) individuals having diabetes and 18.5% (37) current smokers. The mean sheath size OD was 16±2.5, with 4.5% (11) re-do groins in Group A and 6.2% (8) in Group B. Successful haemostasis was achieved in 91.8% (n=223) in Group A (44.8%, n=109 Grade 2) and 90.5% (n=115) in Group B (21%, n=27 Grade 2). Rescue operations were needed in 8.2% (20) in Group A and 9.1% (12) in Group B. Pseudoaneurysms developed more commonly in Grade 2 haemostasis with 9.9% (11) in Group A and 1.6% (2) in Group B (p=0.3). Anterior calcification was observed in 14.8% (36) in Group A and 18.8% (24) in Group B. In comparison, posterior calcification was present in 62.5% (152) in Group A and 66.9% (85) in Group B. Notably, calcification did not significantly impact haemostasis (p=0.79). Additional VCD deployment was necessary due to device failure in 4.5% (11) cases in Group A and 1.5% (2) cases in Group B. Conclusion The overall success rate was comparable between the two groups. However, Group A required more adjuncts to achieve successful haemostasis. The site of calcification did not impact the efficacy of closure devices. Pseudoaneurysm formation was more frequent when adjuncts were needed.
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Affiliation(s)
- Abdul Hakeem
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedfordshire Hospitals NHS Foundation Trust, Bedford, GBR
| | - Mojahid Najem
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedfordshire Hospitals NHS Foundation Trust, Bedford, GBR
| | - Zakir Khokher
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedfordshire Hospitals NHS Foundation Trust, Bedford, GBR
| | - Arindam Chaudhuri
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedfordshire Hospitals NHS Foundation Trust, Bedford, GBR
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Meertens MM, Tenorio ER, Lemmens CC, Marcondes GB, Lima GBB, Schurink GWH, Mendes BC, Oderich GS, Mees BME. Safety of Percutaneous Femoral Access for Endovascular Aortic Aneurysm Repair Through Previously Surgically Exposed or Repaired Femoral Arteries. J Endovasc Ther 2023; 30:730-738. [PMID: 35514295 PMCID: PMC10503241 DOI: 10.1177/15266028221092980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Percutaneous femoral artery access is being increasingly used in endovascular aortic repair (EVAR). The technique can be challenging in patients with previously surgically exposed or repaired femoral arteries because of excessive scar tissue. However, a successful percutaneous approach may cause less morbidity than a "re-do" open femoral approach. The aim of this study was to assess the impact of prior open surgical femoral exposure on technical success and clinical outcomes of percutaneous approach. METHODS This study retrospectively reviewed the clinical data of patients who underwent percutaneous EVAR between 2010 and 2020 at 2 major aortic centers. Patients were divided into 2 groups (with or without prior open surgical femoral access) for analysis of clinical outcomes. Only punctures with sheaths ≥12Fr were included for analysis. The access and (pre)closure techniques were similar in both institutions. Primary end points were intraoperative technical success, access-related revision, and access complications. A multivariate analysis was performed to identify determinants of conversion to open approach and femoral access complications in intact and re-do groins. RESULTS A total of 632 patients underwent percutaneous (complex) EVAR: 98 had prior open surgical femoral access and 534 patients underwent de novo femoral percutaneous access. A total of 1099 femoral artery punctures were performed: 149 in re-do and 950 in intact groins. The extent of endovascular repair included 159 infrarenal, 82 thoracic, 368 fenestrated/branched, and 23 iliac branch devices. No significant differences were seen in technical success (re-do 93.3% vs intact 95.3%, p=0.311), access-related surgical revision (0.7% vs 0.6%, p=0.950), and access complications (2.7% vs 4.0%, p=0.443). For the whole group, significant predictors for access complications in multivariate analyses were main access site (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.07%-5.35%; p=0.033) and increase of the procedure time per hour (OR 1.65; 95% CI 1.34%-2.04%; p<0.001), while increase in sheath-vessel ratio had a protective effect (OR 0.33; 95% CI 0.127%-0.85%; p=0.021). Surgical conversion was predicted by main access site (OR 2.32; 95% CI 1.28%-4.19%; p=0.007) and calcification of 50% to 75% of the circumference of the access vessel (OR 3.29; 95% CI 1.38%-7.86%; p=0.005). CONCLUSION Within our population prior open surgical femoral artery exposure or repair had no negative impact on the technical success and clinical outcomes of percutaneous (complex) endovascular aortic aneurysm repair.
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Affiliation(s)
- Max M. Meertens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Emanuel R. Tenorio
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Charlotte C. Lemmens
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Giulianna B. Marcondes
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Guilherme B. B. Lima
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Geert Willem H. Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
| | - Bernardo C. Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S. Oderich
- Division of Vascular and Endovascular Surgery, University of Texas Health Science, Houston, TX, USA
| | - Barend M. E. Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- European Vascular Center Aachen-Maastricht, Aachen, Germany
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Grandi A, Gronert C, Panuccio G, Rohlffs F, Yousef Al Sarhan D, Kölbel T. Transvenous Access for Emergent Thoracic and Thoracoabdominal Aortic Aneurysm Repair in Patients Without Femoral Access. J Endovasc Ther 2023:15266028231197972. [PMID: 37688485 DOI: 10.1177/15266028231197972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2023]
Abstract
PURPOSE To describe the technique of transvenous access for emergent endovascular repair of thoracic and thoracoabdominal aneurysms exemplified with 2 cases. TECHNIQUE Transvenous access to the aorta is described as an alternative access method to deliver aortic endografts in emergency situations. A 68-year-old female patient with severely compromised iliac and subclavian artery access was treated for a ruptured extent V thoraco-abdominal aortic aneurysm with a t-Branch (Cook Medical, Bjaeverskov, Denmark) delivered through a transcaval access. To avoid severe aortocaval shunting a balloon-expandable covered stent was deployed through a carotid access due to severe bilateral subclavian ostial stenosis. A 71-year-old man with an acute type B aortic dissection and bilateral narrow long-segment stenting of the iliac arteries was treated with a physician-modified thoracic endovascular aortic repair using an arteriovenous fenestration created at the level of the common iliac artery. We describe the access creation by fenestration using a transseptal needle. CONCLUSION Transvenous access for thoracic and thoraco-abdominal aortic aneurysm repair is safe and feasible in selected emergent cases. CLINICAL IMPACT A transvenous approach may be helpful in selected patients when an endovascular repair needs to be performed but no arterial femoral access is available. This approach proved to be feasible even with large-bore introducer sheaths, taking its place in the armamentarium of the vascular surgeon for emergent complex endovascular aortic repairs.
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Affiliation(s)
- Alessandro Grandi
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharina Gronert
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daour Yousef Al Sarhan
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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7
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Mario D, Alessandro G, Giovanni P, Gianbattista P, Rocco G, Mauro G, Nicola M, Roberto C, Sandro L, Luca B. Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2): Short-term and 1-Year Outcomes From a National Multicenter Registry. J Endovasc Ther 2023:15266028231179864. [PMID: 37326371 DOI: 10.1177/15266028231179864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The use of steerable sheaths to allow total transfemoral access (TFA) of branched endovascular repair (BEVAR) of thoracoabdominal aortic aneurysms has been proposed as an alternative to upper extremity access (UEA); however, multicenter results from high-volume aortic centers are lacking. MATERIALS AND METHODS The Total Transfemoral Branched Endovascular Thoracoabdominal Aortic Repair (TORCH2) study is a physician-initiated, national, multicenter, retrospective, observational registry (Clinicaltrials.gov identifier: NCT04930172) of patients undergoing BEVAR with a TFA for the cannulation of reno-visceral target vessels (TV). The study endpoints, classified according to Society for Vascular Surgery reporting standards, were (1) technical success; (2) 30-day peri-operative major adverse events; (3) 30-day and midterm clinical success; (4) 30-day and midterm branch instability and TV-related adverse events (reinterventions, type I/III endoleaks). RESULTS Sixty-eight patients (42 males; median age: 72 years) were treated through a TFA. All the centers included their entire experience with TFA: 18 (26%) used a homemade steerable sheath, and in 28 cases (41%), a stabilizing guidewire was employed. Steerable technical success was achieved in 66 patients (97%) with an overall in-hospital mortality of 6 patients (9%, 3 elective cases [3/58, 5%] and 3 urgent/emergent cases [3/12, 25%]) and major adverse event rate of 18% (12 patients). Overall, 257 bridging stents were implanted; of these, 225 (88%) were balloon-expandable and 32 (12%) were self-expanding. No strokes were observed among the patient completing the procedure from a TFA. One patient (2%) who failed to be treated completely from a TFA and needed a bailout UEA suffered an ischemic stroke on postoperative day 2. There were 10 (15%) major access-site complications. At 1-year follow-up, overall survival was 80%, and the rate of branch instability was 6%. CONCLUSIONS A TFA for TV cannulation is a safe and feasible option with high technical success preventing the stroke risk of UEA. Primary patency at midterm seems comparable to historical controls, and future larger studies will be needed to assess potential differences with alternative options. CLINICAL IMPACT Using a transfemoral approach for retrograde cannulation of reno-visceral branches is feasiable, safe and effective, thereby representing a reliable alternative for BEVAR interventions.
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Affiliation(s)
- D'Oria Mario
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Grandi Alessandro
- Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pratesi Giovanni
- Vascular and Endovascular Surgery Unit, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Parlani Gianbattista
- Vascular and Endovascular Surgery Unit, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Giudice Rocco
- UOC di Chirurgia Vascolare, Dipartimento Cardiovascolare, Azienda Ospedaliera San Giovanni-Addolorata, Rome, Italy
| | - Gargiulo Mauro
- Unit of Vascular Surgery, Department of Experimental Diagnostic and Specialty Medicine (DIMES), S. Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy
| | - Mangialardi Nicola
- Department of Vascular Surgery, Ospedale San Camillo-Forlanini, Rome, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
| | - Lepidi Sandro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" San Raffaele University, Milan, Italy
- Division of Vascular Surgery, Department of Surgical and Clinical Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
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8
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Rohlffs F, Grandi A, Panuccio G, Detter C, von Kodolitsch Y, Kölbel T. Endovascular Options for the Ascending Aorta and Aortic Arch - A Scoping Review. Ann Vasc Surg 2023:S0890-5096(23)00316-3. [PMID: 37328096 DOI: 10.1016/j.avsg.2023.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
The gold standard for aneurysmal repair of the ascending aorta and the aortic arch has been open surgery with an established track record of good results in suitable patients. In recent years, with innovations in the endovascular field alternative endovascular solutions for pathologies of the aortic arch and ascending aorta became available. At first reserved only for highly selected patients unfit for open surgery, endovascular aortic arch repair is now being offered to patients with suitable anatomy in high volume referral centers after discussion in an interdisciplinary team. The present scoping review aims at providing an overview on indications, available devices, technical aspects and feasibility studies of endovascular arch repair both in elective and emergent situations, including also experiences and considerations from our center.
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Affiliation(s)
- Fiona Rohlffs
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - Alessandro Grandi
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Giuseppe Panuccio
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Christian Detter
- Cardiothoracic Surgery, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Yskert von Kodolitsch
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center Hamburg, Dept. of Vascular Medicine, University Heart Center, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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9
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Bertoglio L, Melloni A, Bugna C, Grignani C, Bucci D, Foglia E, Chiesa R, Odone A. In-hospital cost-effectiveness analysis of open versus staged fenestrated/branched endovascular elective repair of thoracoabdominal aneurysms. J Vasc Surg 2023:S0741-5214(23)01034-0. [PMID: 37076108 DOI: 10.1016/j.jvs.2023.03.503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 04/21/2023]
Abstract
OBJECTIVE To compare costs and effectiveness of elective open (OR) versus fenestrated/branched endovascular (ER) repair of thoracoabdominal aneurysms (TAAA) in a high-volume center. METHODS This single-center retrospective observational study (PRO-ENDO TAAA Study, NCT05266781) was designed as part of a larger Health Technology Assessment analysis. All electively treated TAAAs between 2013 and 2021 were analyzed and propensity-matched. Endpoints were clinical success, major adverse events (MAE), hospital direct costs, and freedom from all causes and aneurysm-related mortality and reinterventions. Risk factors and outcomes were homogeneously classified according to the Society of Vascular Surgery reporting standards. Cost-effectiveness value (CEV) and Incremental Cost-Effectiveness Ratio (ICER) were calculated, considering the absence of MAEs as a measure of effectiveness. RESULTS Propensity matching identified 102 pairs of patients out of 789 TAAAs. Mortality, MAE, permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for OR (13% vs 5%, p=.048; 60% vs 17%, p<.001; 10% vs 3%, p=.045; 91% vs 18%, p<.001; 16% vs 6%, p=.024; 27% vs 6%, p<.001; respectively). Access complication rate (6% vs 27%; p<.001) was higher in the ER group. Intensive Care Unit stay was longer (p<.001) for OR and ER patients were discharged home more frequently (3% vs 94%; p<.001). No differences in mid-term endpoints were observed at 2 years. Despite ER reducing all the hospital cost items (-42% to -88%, p<.001), the higher expenses (p<.001) of the endovascular devices increased the overall cost of ER by 80%. CEV for ER was favorable to OR (56 365 vs 64 903 €/patient) with an ICER of 48 409 € per MAE saved. CONCLUSIONS ER of TAAA reduces perioperative mortality and morbidity compared to OR, with no differences in reinterventions and survival rates at midterm follow-up. Despite the expenses for endovascular grafts, ER resulted more cost-effective in preventing MAEs.
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Affiliation(s)
- Luca Bertoglio
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Andrea Melloni
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Bugna
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Camilla Grignani
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Daria Bucci
- School of Public Health, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuela Foglia
- School of Industrial Engineering, Carlo Cattaneo - LIUC University and LIUC Business School, Castellanza, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Anna Odone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
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10
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Rylski B, Berkarda Z, Beyersdorf F, Kondov S, Czerny M, Majcherek J, Protasiewicz M, Milnerowicz A. Efficacy and Safety of Percutaneous Access Via Large-Bore Sheaths (22-26F Diameter) in Endovascular Therapy. J Endovasc Ther 2023:15266028231161490. [PMID: 36942671 DOI: 10.1177/15266028231161490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE To evaluate the closure success rate's outcomes with suture-mediated vascular closure device Perclose ProGlide in patients undergoing aortic or iliac artery endovascular repair using large delivery systems (>21F). MATERIALS AND METHODS We screened all the patient records in aortic databases at 2 centers who had undergone vascular interventions via ProGlide for percutaneous femoral access >21F between 2016 and 2020. Patients were divided into 2 groups according to the delivery system size: large (L) (22F-23F) and extra-large (XL) (24F-26F). Demographics, anatomical details, and outcome of percutaneous access were evaluated. RESULTS Included were 239 patients: 121 in the L group and 118 the XL group. Intraprocedural conversion to open surgery because of bleeding was necessary in 2% L and 6% XL patients (p=0.253). Severe femoral artery calcification was the sole risk factor for converting to open surgery (odds ratio=23.44, 95% confidence interval=1.49-368.17, p=0.025). In all, 2% of L and 3% of XL (p=0.631) did require late percutaneous intervention due to stenosis (all treated with balloon angioplasty). Overall, 3% developed pseudoaneurysm treated conservatively in all except one patient requiring surgical repair. Hematoma and groin infection were observed in 9% and 1%, respectively; none required surgical therapy. CONCLUSION A femoral arterial defect after accessing the artery via a large bore sheath (22F-26F) can be closed successfully with ProGlide in more than 90% of patients. Severe femoral artery calcification is a risk factor for conversion to open surgery caused by bleeding. CLINICAL IMPACT This study adds evidence on efficacy of accessing the artery via a large bore sheath (22-26F) secured by ProGlide. In more than 200 patients conversion to open surgery was necessary in only 4%. Severe femoral artery calcification was the sole risk factor for converting to open surgery. Our findings encourage physicians to choose the percutaneous access even in patients requiring the use of large bore sheath.
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Affiliation(s)
- Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Zeynep Berkarda
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stoyan Kondov
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | | | - Artur Milnerowicz
- Department of Vascular Surgery, 4th Military Hospital, Wroclaw, Poland
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11
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Rinaldi E, Melloni A, Gallitto E, Fargion A, Isernia G, Kahlberg A, Bertoglio L, Faggioli G, Lenti M, Pratesi C, Gargiulo M, Melissano G, Chiesa R, Luigi B, Luca B, Roberto C, Gianluca F, Aaron F, Cecilia F, Enrico G, Mauro G, Giacomo I, Massimo L, Antonino L, Andrea K, Chiara M, Germano M, Andrea M, Rodolfo P, Carlo P, Enrico R, Gioele S, Sara S. Spinal Cord Ischemia After Thoracoabdominal Aortic Aneurysms Endovascular Repair: From the Italian Multicenter Fenestrated/Branched Endovascular Aneurysm Repair Registry. J Endovasc Ther 2022; 30:281-288. [PMID: 35236159 DOI: 10.1177/15266028221081074] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study is to report an Italian multicenter experience analyzing the incidence and the risk factors associated with spinal cord ischemia (SCI) in a large cohort of thoracoabdominal aortic aneurysms (TAAAs) treated by fenestrated-branched endovascular aneurysm repair (F-/B-EVAR). MATERIALS AND METHODS All consecutive patients undergoing F-/B-EVAR in 4 Italian university centers between 2008 and 2019 were prospectively recorded and retrospectively analyzed. Spinal cord ischemia, 30 day/in-hospital adverse events, and mortality were assessed as early outcomes. Risk factors for SCI were determined by multivariable analysis. RESULTS A total of 351 patients received F-/B-EVAR for a TAAA. Twenty-eight (8.0%) patients died within 30 postoperative days or during the hospitalization. Regarding SCI, 47 patients (13.4%) developed neurological symptoms related to spinal cord impaired perfusion. Among them, 17 (4.8%) had a major permanent impairment. The multivariable analysis identified that SCI was associated with Crawford extent I to III (odds ratio [OR]: 20.90, p=0.004, 95% confidence interval [CI]=2.69-162.57), and with endovascular procedures performed for ruptured TAAA (OR: 5.74, p=0.010, 95% CI=1.53-21.57). Spinal cord ischemia was also significantly associated with a grade 3 bleeding during the visceral stage (OR: 4.34, p=0.005, 95% CI=1.55-12.16) and a grade 2 renal insufficiency at 30 days (OR: 7.45, p=0.002, 95% CI=2.12-26.18). CONCLUSION The present study indicates that SCI is still an open issue after extent I to III TAAA endovascular repair, while its incidence in extent IV TAAA and pararenal/juxtarenal aneurysms is rare. Thoracoabdominal aortic aneurysms extension, urgent TAAA repair for rupture, severe bleeding, and 30 day renal insufficiency have been identified as significant risk factors for SCI. In the presence of such factors, adjunctive strategies may be considered to reduce SCI rates, while in low-risk patients invasive or potentially-risky maneuvers might not be justified.
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Affiliation(s)
- Enrico Rinaldi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Andrea Kahlberg
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Massimo Lenti
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Baccani Luigi
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Bertoglio Luca
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiesa Roberto
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Faggioli Gianluca
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Fargion Aaron
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Fenelli Cecilia
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gallitto Enrico
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gargiulo Mauro
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Isernia Giacomo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Lenti Massimo
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Logiacco Antonino
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Kahlberg Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Mascoli Chiara
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Melissano Germano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Melloni Andrea
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pini Rodolfo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, IRCCS Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Pratesi Carlo
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Rinaldi Enrico
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Simonte Gioele
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Speziali Sara
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
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12
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Gradinariu G, Lyons O, Musajee M, Yap T, Johnson O, Bujoreanu I, Shalhoub J, Wilkins J, Gkoutzios P, Tyrrell M, Abisi S, Modarai B, Sandford B. Predictors of percutaneous access-related complications in aortic endovascular procedures - 'real-world' insights and a comparison to open access. INT ANGIOL 2022; 41:118-127. [PMID: 35112825 DOI: 10.23736/s0392-9590.22.04799-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- George Gradinariu
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK -
| | - Oliver Lyons
- Vascular Endovascular and, Transplant Surgery, Christchurch Public Hospital, Canterbury, New Zealand.,University of Otago, Canterbury, New Zealand
| | - Mustafa Musajee
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Trixie Yap
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Oscar Johnson
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Iulia Bujoreanu
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Joseph Shalhoub
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jason Wilkins
- Department of Vascular Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Panos Gkoutzios
- Department of Interventional Radiology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Mark Tyrrell
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Said Abisi
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bijan Modarai
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Becky Sandford
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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13
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Qiao Y, Mao L, Wang Y, Luan J, Chen Y, Zhu T, Luo K, Fan J. Hemodynamic effects of stent-graft introducer sheath during thoracic endovascular aortic repair. Biomech Model Mechanobiol 2022; 21:419-431. [PMID: 34994871 DOI: 10.1007/s10237-021-01542-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/26/2021] [Indexed: 12/19/2022]
Abstract
Thoracic endovascular aortic repair (TEVAR) has become the standard treatment of a variety of aortic pathologies. The objective of this study is to evaluate the hemodynamic effects of stent-graft introducer sheath during TEVAR. Three idealized representative diseased aortas were designed: aortic aneurysm, coarctation of the aorta, and aortic dissection. Computational fluid dynamics studies were performed in the above idealized aortic geometries. An introducer sheath routinely used in the clinic was virtually placed into diseased aortas. Comparative analysis was carried out to evaluate the hemodynamic effects of the introducer sheath. Results show that the blood flow to the supra-aortic branches would increase above 9% due to the obstruction of the introducer sheath. The region exposed to high endothelial cell activation potential (ECAP) expands in the scenarios of coarctation of the aorta and aortic dissection, which indicates that the probability of thrombus formation may increase during TEVAR. The pressure magnitude in peak systole shows an obvious rise, and a similar phenomenon is not observed in early diastole. The blood viscosity in the aortic arch and descending aorta is remarkably altered by the introducer sheath. The uneven viscosity distribution confirms the necessity of using non-Newtonian models, and high-viscosity region with high ECAP further promotes thrombosis. Our results highlight the hemodynamic effects of stent-graft introducer sheath during TEVAR, which may associate with perioperative complications.
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Affiliation(s)
- Yonghui Qiao
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China
| | - Le Mao
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Wang
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China
| | - Jingyang Luan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yanlu Chen
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China
| | - Ting Zhu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kun Luo
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China. .,Shanghai Institute for Advanced Study of Zhejiang University, Shanghai, China.
| | - Jianren Fan
- State Key Laboratory of Clean Energy Utilization, Zhejiang University, Hangzhou, China. .,Shanghai Institute for Advanced Study of Zhejiang University, Shanghai, China.
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14
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Role of historical and procedural staging during elective fenestrated and branched endovascular treatment of extensive thoracoabdominal aortic aneurysms. J Vasc Surg 2021; 75:1501-1511. [PMID: 34861361 DOI: 10.1016/j.jvs.2021.11.056] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/08/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Procedural staging is often performed to reduce the incidence of spinal cord ischemia (SCI) during endovascular treatment of extensive thoracoabdominal aortic aneurysms (TAAAs). However, its role in the case of previous thoracic or infrarenal aortic repair (historical staging) has been controversial. In the present study, we evaluated the SCI rates when procedural staging was routinely used and studied its potential benefits when previous aortic repairs had already been performed. METHODS The data from patients treated electively with fenestrated/branched endovascular aortic repair for extent I, II, III, and V TAAAs were retrieved from a multicenter registry (four high-volume national teaching hospitals) and analyzed. The primary endpoint was the rate of SCI and its association with preoperative and postoperative variables, including historical staging, procedural staging, and an impaired collateral network (subclavian or hypogastric stenosis >75% per occlusion). Variables were defined in accordance with the Society for Vascular Surgery reporting standards. A logistic regression model with stepwise selection was used to identify the predictors of SCI. RESULTS A total of 240 patients (76% male; median age, 73 years) were analyzed. Of the 240 patients, 43 (18%) had presented with an impaired collateral network, 136 (57%) had had historical staging, and 157 (65%) had received procedural staging. Preoperative spinal fluid cerebrospinal drainage was performed in 130 patients (54%). Permanent grade 3 SCI was observed in 13 patients (5%) and was negatively affected by both an impaired collateral network (odds ratio [OR], 17.3; 95% confidence interval [CI], 1.7-176; P = .016) and the presence of bilateral iliac occlusive disease (OR, 10.1; 95% CI, 1.1-98.3; P = .046). Both historical (OR, 0.02; 95% CI, 0.001-0.46; P = .014) and procedural (OR, 0.01; 95% CI, 0.02-0.7; P = .019) staging mitigated the permanent SCI rates. The need for postoperative transfusions (OR, 1.4; 95% CI, 1.1-1.8; P = .014) and the occurrence of postoperative renal complications (OR, 6.5; 95% CI, 1.2-35.0; P < .001) were associated with the development of SCI. Among the patients with historical staging, no further benefit from procedural staging was observed (SCI with procedural staging, 1%; vs no staging, 2%; P = NS). CONCLUSIONS For patients with extensive TAAAs treated with fenestrated/branched endovascular aortic repair, both historical and planned procedural staging were associated with reduced permanent SCI rates. However, no additional benefit was observed when procedural staging was performed in patients with historical staging and an intact collateral network. The protective role of preoperative cerebrospinal fluid drainage placement requires further investigation.
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15
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Percutaneous transAXillary access for endovascular aortic procedures in the multicenter international PAXA registry. J Vasc Surg 2021; 75:868-876.e3. [PMID: 34600031 DOI: 10.1016/j.jvs.2021.08.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of the study was to demonstrate the safety and effectiveness of a suture-mediated vascular closure device to perform hemostasis after an axillary artery access during endovascular procedures on the aortic valve, the aorta and its side branches. METHODS A physician-initiated, international, multicenter, retrospective registry was designed to evaluate the success rate (VARC-2 reporting standards) of percutaneous transaxillary access closure with a suture-mediated closure device. Secondary end points were minor access vascular complications, transient peripheral nerve injury, stroke, and influence on periprocedural outcomes of puncture technique. RESULTS Three hundred thirty-one patients (median age, 76 years; 69.2% males) in 11 centers received a percutaneous transaxillary access during endovascular cardiac (n = 166) or vascular (n = 165) procedures. The closure success rate was 84.6%, with 5 open conversions (1.5%), 45 adjunctive endovascular procedures (13.6%), and 1 nerve injury (0.3%). Secondary closure success was obtained in 325 patients (98%) after 7 bare stenting, 37 covered stenting, and 1 thrombin injection. Introducer sheaths 16F or larger (odds ratio, 3.70; 95% confidence interval, 1.22-11.42) and balloon-assisted hemostasis (odds ratio, 4.45; 95% confidence interval, 1.27-15.68) were associated with closure failure. A threshold of five percutaneous axillary accesses was associated with decreased rates of open conversion, but not with increased primary closure success. Primary closure success was 90.3% in the 175 patients with sheaths smaller than 16F, performed after the first 5 procedures in each center. Temporary nerve injury and stroke were observed in 2% and 4% of patients, respectively. CONCLUSIONS Percutaneous transaxillary aortic procedures, in selected patients, can be performed with low rates of open conversion. The need for additional endovascular bailout procedures is not negligible when introducers sheaths 16F or larger are required.
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16
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Loschi D, Melloni A, Grandi A, Baccellieri D, Monaco F, Melissano G, Chiesa R, Bertoglio L. Open or endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology after frozen elephant trunk: perioperative and mid-term outcomes. Eur J Cardiothorac Surg 2021; 61:120-129. [PMID: 34355733 DOI: 10.1093/ejcts/ezab335] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/26/2021] [Accepted: 06/11/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the outcomes of open and endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology in patients who underwent previous frozen elephant trunk (FET). METHODS Data were retrieved to evaluate mortality, cardiac, pulmonary, cerebrovascular, renal and spinal cord major adverse events, early- and mid-term reintervention and survival rates. The Society for Vascular Surgery endovascular reporting standards were used. RESULTS From 2011 to 2020, 48 patients (36 males, median age 60 years) underwent downstream aortic repair at a median of 18 months (interquartile range: 6-57) after the initial FET. Twenty-eight patients (58.3%) received open and 20 (41.7%) endovascular repair. The overall 30-day mortality was 6.3% and the initial clinical success was 88%, with no inter-group differences (P = 0.22 and 0.66 respectively). Six spinal cord deficits were recorded (13%): 3 (6.3%) were permanent. The major adverse events incidence was lower in the endovascular cohort [4 (20%) vs 14 (50%); P = 0.047], mainly due to a lower rate of grade ≥2 respiratory complications (5% vs 42.9%; P = 0.004). Assisted primary clinical success at 5 years was higher in the endovascular group (95% vs 68%, P = 0.022); freedom from reintervention at competing risk analysis (P = 0.3) and overall survival at Kaplan-Meier curves (log-rank P = 0.29) were similar. CONCLUSIONS Downstream aortic repair after FET is feasible with both open and endovascular repair with acceptable mortality and permanent paraplegia rates. The endovascular approach has potential perioperative and mid-term advantages, but long-term durability has to be further investigated in larger cohorts.
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Affiliation(s)
- Diletta Loschi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Melloni
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Grandi
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Domenico Baccellieri
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Monaco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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17
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Grant JK, Maniam A, Celli D, Orozco-Sevilla V, Braghiroli J. Large-bore arterial access in the era of structural cardiovascular disease. J Card Surg 2020; 35:3088-3098. [PMID: 32741006 DOI: 10.1111/jocs.14909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/18/2022]
Abstract
Over the last two decades, the medical community witnessed an outstanding and accelerated development on minimally invasive therapies. The definition of what constitutes large bore access is subject to discussion, however within the field it is generally accepted to reflect a catheter diameter exceeding 8-French. We sought in this review to explore the evolution, characteristics and vascular compatibility of the current commercially available devices, analyze the devices along with access site-specific complications rates and finally review the present methods for percutaneous vascular closure.
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Affiliation(s)
- Jelani K Grant
- Department of Medicine, Jackson Memorial Hospital, University of Miami, Coral Gables, Florida
| | - Akash Maniam
- Department of Medicine and Oncology, Sangre Grande County Hospital, Sangre Grande, Trinidad and Tobago
| | - Diego Celli
- Department of Medicine, Jackson Memorial Hospital, University of Miami, Coral Gables, Florida
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joao Braghiroli
- Cardiovascular Division, Department of Medicine, Jackson Memorial Hospital, University of Miami, Coral Gables, Florida
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18
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Melloni A, Grandi A, Melissano G, Chiesa R, Bertoglio L. Safety and Feasibility of Percutaneous Purse-String-Like Downsizing for Femoral Access During Complex Endovascular Aortic Repair. Cardiovasc Intervent Radiol 2020; 43:1084-1090. [DOI: 10.1007/s00270-020-02508-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/25/2020] [Indexed: 12/17/2022]
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