Percutaneous Endovascular Aneurysm Repair: Current Status and Future Trends

Percutaneous Closure Device Controlled INCRAFT Stentgraft Implantation Registry (PUCCINI)

BACKGROUND

Percutaneous endovascular repair (PEVAR) of infra-renal abdominal aortic aneurysms (AAA) is increasingly being performed due to the development of low profile endografts and the use of percutaneous closure devices. The feasibility and safety of the use of the INCRAFT AAA Stentgraft System and the ProGlide vascular closure system was assessed.

METHODS

The PUCCINI trial prospectively enrolled patients undergoing elective repair of infrarenal AAA at 3 centres in the Netherlands and 3 centres in Belgium. Patients underwent PEVAR with endograft implantation followed by closure using the ProGlide closure device. Procedural success rates, complications and 30-day follow-up outcomes were collected.

RESULTS

A total of 93 patients, 87% male, were enrolled. The mean aneurysmal diameter was 53.9 ± 10.2 mm. Successful ProGlide placement was achieved in 97.2% in the right and 89.8% in the left groin. Successful closure was achieved in 92.4% of right and 90% of left groins. One patient required surgical access and two surgical closure. Average blood loss was 155.6 ± 175.5ml. Blood transfusion was not required. Average length of hospital stay was 2.1 ± 1.3 days. Post-implantation endoleaks were present in 37 (40.2%) patients (type 1: 12, type 2: 25). At 30-days there was no aneurysmal growth and no deaths. Follow-up imaging showed endoleaks in 39 (41.9%) patients. (type 1:8, type 2:29, type 3:2).

CONCLUSION

The results from the PUCCINI trial demonstrate that the use of a low profile endoprosthesis for treatment of infrarenal AAA with percutaneous closure has a high rate of technical success and low rates of periprocedural complication.

Experience in Treatment of Patients with First Type Secondary Endoleaks

INTRODUCTION: First type secondary endoleaks (EL) require quickest elimination, primarily using the endovascular methods. Despite the existence of a sufficiently large number of methods of their elimination, the results of treatment remain ambiguous. AIM: Analysis of our own experience of elimination of the first type ELs in patients after endoprosthetics of infrarenal abdominal aortic aneurysm. MATERIALS AND METHODS: The study is retrospective with prospective observation. All patients underwent computed tomography (CT) for identification of the type of EL and choosing a method of its elimination. The term first type secondary EL was understood as EL which developed in the long-term period after the primarily negative CT-angiography after endoprosthetic repair of the aorta. RESULTS: ELs of Ia type were diagnosed in 14 cases, in one case EL of Ib type was identified. On average, first type secondary ELs were identified in 34 months after the primary operation for endograft implantation. In 2 of 15 patients, EL were symptomatic. The elimination of the first type EL required an individualized approach in all cases. The main methods of elimination of the first type EL were: elongation using Jotec E-iliac (n = 1); coiling with implantation of Gore cuff and Chimney-stenting of the left renal artery (LRA; n = 2); implantation of Gore cuff (n = 4); reinforcement with Aptus EndoAnchors (n = 2); Cuff Gore implantation and LRA stenting by Chimney-technique (n = 1); implantation of Cuff Jotec and reinforcement with Aptus EndoAnchors (n = 1); aneurysmal sac coiling (n = 2); Gore cuff implantation with fixation with EndoAnchors and LRA stenting using Chimney-technique (n = 1). The technical success of EL elimination was 100% (in all cases, the success was confirmed by intraoperative angiography, as well as by CT angiography or ultrasound duplex scanning with contrast enhancement after surgery), there were no deaths. In the long-term period (from 6 to 60 months), re-interventions were performed in two cases, fatal outcome happened in one case, after a late open conversion for elimination of EL. CONCLUSION: In 13% of cases, first type ELs were symptomatic, and their elimination required individual approach with taking into account anatomical factors and the implanted graft. The medium-term results of the elimination of the first type EL are good, no fatal cases have been reported, and the number of reinterventions has reached 20%, which requires monitoring in the postoperative period.

Suture-mediated closure devices for percutaneous endovascular abdominal aneurysm repair

Purpose

Endovascular procedures such as endovascular aneurysm repair or transcatheter aortic valve implantation have become very common because of reduced patient traumatisation and the ability to use shorter or local anaesthesia. In these procedures large-bore sheath devices are used. Access with percutaneous closure is an alternative method to surgical cutdown in groins. The aim of the study was to assess the correlation between sheath size and unsuccessful haemostasis. In addition, the effectiveness of haemostasis after a percutaneous procedure and the number and type of complications were evaluated.

Material and methods

There were 202 patients included in the study. Patients with abdominal aortic aneurysm were qualified to percutaneous aortic stentgraft implantation with Perclose Proglide preclosure technique.

Results

There were 384 access sites performed with 12F to 22F sheaths during aortic stentgraft implantation with Perclose Proglide (Abbott Vascular, Santa Clara, CA, USA) preclosure technique. High effectiveness of haemostasis (98%), low percentage of short- and mid-term complications (2.6%), and infinitesimal number of surgical conversions (n = 5) were stated in the study. There was no correlation between diameter of used introducer sheath and lack of haemostasis observed (Fisher-Freeman-Halton test; p = 0.122). No relationship between diameter of introducer sheath and number of closure devices was observed (c² = 2.436; df = 5; p = 0.786).

Conclusions

Large-bore device percutaneous procedures with closure devices are effective and safe. High effectiveness of haemostasis (98%) was observed in the study group, with a low percentage of complications (2.6%). There was no correlation between size of the vascular access and the lack of haemostasis found in the study.

[Endoleaks in endovacular treatment of infrareneral abdominal aortic aneurysm (part I)]

We analyzed the PubMed, Scopus databases and the eLIBRARY electronic library regarding appropriate literature data. In the first part, modern classifications of endoleaks type 1 and 2 after stenting of infrarenal aortic aneurysm are considered. We described causes, risk factors and effectiveness of various treatment options.

Is percutaneous access superior to cutdown access for endovascular abdominal aortic aneurysm repair? A meta-analysis

OBJECTIVE

The objective is to investigate whether percutaneous access (pEVAR) is superior to cutdown access (cEVAR) in terms of safety and efficacy during endovascular repair of abdominal aortic aneurysms (AAAs).

METHODS

We searched PubMed, Embase, and Cochrane Library from January 1999 to December 2020 for studies reporting on the comparison between percutaneous and cutdown techniques for endovascular repair of AAAs. Outcomes evaluated were technical success rates, access site-related complications and operative time, and hospital stay.

RESULTS

Four randomized controlled trials and nine observational studies with a total of 1683 patients comprising 2715 groin accesses were eligible for the meta-analysis. pEVAR was associated with a lower risk of overall complications (odds ratio (OR) = 0.63; p = .005) and seroma/lymphorrhea (OR, 0.18; p = .0001) and shortened operation time (MD = -39.04; p = .002) and the length of hospital stay (MD = -0.75; p < .00001) compared with cEVAR. The technical success rate for pEVAR was 95.1% (694/729), with an overall OR of 0.27 (95% CI 0.14-0.55, p = .0003) comparing pEVAR with cEVAR. Furthermore, pEVAR did not increase the risk of site infection, femoral artery thrombosis, postoperative hematoma, nerve injury, dissection, and bleeding.

CONCLUSION

Percutaneous endovascular aneurysm repair is a safe and effective method for the treatment of AAA. It reduces the risk of overall complications and shortens the operation time and hospital stay. The technical success rate of pEVAR is lower than that of cEVAR, which may be linked to the selection of patients, operator experience, and the use of ultrasound. Large definitive trials are required to draw robust conclusions.