Closure of large percutaneous access sites using the Prostar XL Percutaneous Vascular Surgery device

A single institution experience of the Manta closure device in endovascular aortic repair

BACKGROUND

Majority of EVAR procedures are performed with percutaneous arterial access, unless there is severe steno-occlusive disease in the common femoral arteries (CFA). We present our experience of using MANTA closure device with a retrospective evaluation of its safety and efficacy, in the elective setting, and in the emergent setting for ruptured aortic aneurysm.

DESIGN AND METHODS

Between Feb 2021 and May 2023 a total of 75 EVAR procedures were closed with a Manta device. Data was collected prospectively and analysed retrospectively. In 75 patients, 128 CFAs were closed with a Manta closure device including 4 emergent ruptured aneurysms.

RESULTS

67 male and 8 female patients with a median age of 77 years had percutaneous EVAR using Manta as a closure device. 128 CFAs were closed with Manta closure device. 3% (4/128) had deployment failures, with three requiring surgical cut down and closure. In one patient, a second Manta device deployment achieved satisfactory haemostasis. Three deployments were complicated by pseudoaneurysms of the CFA, all requiring no further interventions/treatment. No death related to severe haemorrhage from device failure. The pre- and post-procedure CFA puncture site AP diameter was recorded in a total of 106 cases with appropriate follow-up. 66% of these (70/106) had no reduction in CFA diameter post Manta closure. 34% (36/106) had some reduction of vessel AP size CFA post EVAR. No adverse features or further treatment was required due to reduction of vessel diameter in these cases (ongoing yearly surveillance).

CONCLUSIONS

Manta closure device is safe and easy to deploy with an overall success rate of 97%. There is a short learning curve. Ultrasound assessment and precise puncture at the healthy section of femoral artery are the key to achieve successful haemostasis with Manta closure device. Our findings suggest there is an association of non-clinically significant mild reduction in CFA vessel AP diameter post Manta closure device, which does not require further intervention.

Totally percutaneous endovascular repair for ruptured abdominal aortic aneurysms

Purpose

The PEVAR Trial demonstrated that compared to open femoral exposure, elective percutaneous endovascular AAA repair (ePEVAR) is associated with decreased perioperative morbidity and access site complications. We hypothesized that PEVAR for ruptured AAA (rPEVAR) may also improve perioperative morbidity compared to open femoral exposure (rEVAR). There are currently no reports that evaluate the utility and outcomes of rPEVAR.

Materials and methods

From 2015 to 2021, all patients who underwent an endovascular repair of a ruptured AAA at a single institution were included in the study and grouped into rPEVAR and rEVAR. Demographics, procedural details (successful preclose technique, conversion to femoral cutdown), postoperative variables (blood transfusion, ICU and hospital length of stay) and short-term outcomes (30-day major adverse events (30-day MAE) and 30-day femoral access-site complications (30-day FAAC)) were collected and compared with 50 historical ePEVAR patients from the PEVAR Trial. Statistical significance was determined using χ 2 or Fisher's exact test for categorical variables, and Mann-Whitney U-test for continuous variables.

Results

35 patients were identified (21 rPEVAR; 14 rEVAR), 86% were male with a mean age of 72 ± 9 years. All patients underwent emergent endovascular aortic repair with 100% technical success. Seventeen patients (49%) presented with evidence of hemorrhagic shock and 22 patients (63%) had blood transfusion. 30-day MAE occurred in 12 patients (34%) (7 rPEVAR; 5 rEVAR). There was no difference in demographic, perioperative outcomes and 30-day MAE rate between rPEVAR and rEVAR patients. Compared to ePEVAR patient (from PEVAR trial), rPEVAR patients had higher rate of 30-day MAE (34% vs. 6%; p < 0.006) but no difference in 30-day FAAC (19% vs. 12%; p = 0.54). The success rate of the preclose technique was higher in ePEVAR compared to rPEVAR (96% vs. 76%; p = 0.02), but the rate of conversion to femoral cutdown was similar between the two groups (10% vs. 4%; p = 0.57).

Conclusion

Emergent rPEVAR appears to have similar outcomes when compared to rEVAR. Although patients undergoing rPEVAR have higher 30-day major adverse events rate compared to ePEVAR, the method of percutaneous femoral cannulation does not appear to increase the overall procedural or 30-day femoral artery access-site complications.

A Real World 10-Year Experience With Vascular Closure Devices and Large-Bore Access in Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation

Transcatheter aortic valve replacement (TAVR) has established itself as a safe and efficient treatment option in patients with severe aortic valve stenosis, regardless of the underlying surgical risk. Widespread adoption of transfemoral procedures led to more patients than ever being eligible for TAVR. This increase in procedural volumes has also stimulated the use of vascular closure devices (VCDs) for improved access site management. In a single-center examination, we investigated 871 patients that underwent transfemoral TAVR from 2010 to 2020 and assessed vascular complications according to the Valve Academic Research Consortium (VARC) III recommendations. Patients were grouped by the VCD and both, vascular closure success and need for intervention were analyzed. In case of a vascular complication, the type of intervention was investigated for all VCDs. The Proglide VCD was the most frequently used device (n = 670), followed by the Prostar device (n = 112). Patients were old (median age 83 years) and patients suffered from high comorbidity burden (60% coronary artery disease, 30% type II diabetes, 40% atrial fibrillation). The overall rate of major complications amounted to 4.6%, it was highest in the Prostar group (9.6%) and lowest in the Manta VCD group (1.1% p = 0.019). The most frequent vascular complications were bleeding and hematoma (n = 110, 13%). In case a complication occurred, 72% of patients did not need any further intervention other than manual compression or pressure bandages. The rate of surgical intervention after complication was highest in the Prostar group (n = 15, 29%, p = 0.001). Temporal trends in VCD usage highlight the rapid adoption of the Proglide system after introduction at our institution. In recent years VCD alternatives, utilizing other closure techniques, such as the Manta device emerged and increased vascular access site management options. This 10-year single-center experience demonstrates high success rates for all VCDs. Despite successful closure, a significant number of patients does experience minor vascular complications, in particular bleeding and hematoma. However, most complications do not require surgical or endovascular intervention. Temporal trends display a marked increase in TAVR procedures and highlight the need for more refined vascular access management strategies.

Comparison of Success Rate and Complications of Totally Percutaneous Decannulation in Patients With Veno-Arterial Extracorporeal Membrane Oxygenation and Endovascular Aneurysm Repair

Background: Total percutaneous closure for the site of femoral arterial puncture using Perclose ProGlide (PP) has become prevalent post-percutaneous endovascular aortic repair (EVAR) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

Objective: To evaluate the safety and efficacy of total percutaneous closure of the femoral artery access site post-EVAR compared with VA-ECMO.

Methods: This was a retrospective observational study conducted over 4 years, including 88 patients who underwent EVAR (64 patients) and VA-ECMO (24 patients). Perclose ProGlide devices were used in the femoral artery puncture sites closed percutaneously. In this study, technical success was defined as successful arterial closure of the common femoral artery (CFA) without additional surgical or endovascular procedures to prevent vessel leaking. Access site complications, including overt bleeding requiring transfusion or surgical intervention, minor bleeding, tinea cruris, pseudoaneurysm, and lymphocele, were recorded 24 h and 30 days after arterial closure.

Results: Each group's technical success rates were 95.8% (VA-ECMO) and 92.2% EVAR, respectively. There were no differences in the periprocedural complications of major bleeding, pseudoaneurysm, minor bleeding, acute limb ischemia, and groin infection. Furthermore, we did not observe any complications such as arterial thrombosis, dissection, stenosis, arteriovenous fistula, hematoma, groin infection, or lymphocele at the access site by following-up an ultrasound examination. There was no significant difference in the technical success rate of percutaneous closure by the PP device in the EVAR and VA-ECMO oxygenation groups. Also, no periprocedural or 30-day complications were observed at the access site of the EVAR and VA-ECMO patients.

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.

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

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

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

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

Minimally Invasive Endovascular Repair of Ascending Thoracic Aortic Aneurysm with Use of Local Anesthesia and Conscious Sedation

Ascending thoracic aortic aneurysm (ATAA) is typically treated surgically. No commercially available device has been specifically designed for endovascular ATAA repair, and currently, multiple anatomic and technical challenges affect its feasibility. Previously, such repairs have been performed with the patients under general anesthesia. We describe a novel, minimally invasive approach to endovascular repair of ATAA, involving local anesthesia, conscious sedation, and 24-hour hospitalization. Two consecutive male patients (ages, 79 and 54 yr) who had comorbidities underwent percutaneous transfemoral endovascular ATAA repair with use of commercially available endografts. Patient 1 had a saccular aneurysm, and Patient 2 had a pseudoaneurysm consequent to recent surgical ATAA repair. The patients were discharged from the hospital 24 hours after technically successful, uncomplicated procedures. At 2 months, computed tomograms showed no endoleak or stent-graft migration. Our experience shows that minimally invasive endovascular ATAA repair is feasible for selected high-risk patients. We describe the procedure, access and closure devices, and challenges associated with this approach.

Factors Associated with Wound Complications after Open Femoral Artery Exposure for Elective Endovascular Abdominal Aortic Aneurysm Repair

We identified factors that would lead to wound complications after open femoral exposure for endovascular abdominal aortic aneurysm repair (oEVAR). Using the National Surgical Quality Improvement Program dataset (2005-2014), we examined the patients who underwent oEVAR. Patients were stratified on whether they developed postoperative wound complications. Comparisons were made between group with wound complications and those without and adjusted analyses performed to identify variables that independently increased the risk of wound complications. There were 14,868 patients in the study cohort and 2.6% (384 patients) developed wound complications after EVAR. Among those with wound complications, 94% (360 patients) of patients had superficial and deep surgical site infection. Patients who had wound complication were likely to be younger (72.6 vs. 73.7 years old ( p  = 0.02), functionally dependent (5.4 vs. 2.5%) ( p  < 0.05), smoker (3 vs. 2.4%, p =0.03), female (4 vs. 2.2%), with significantly higher body mass index (31 vs. 28), and more commonly had diabetes (4 vs. 2.4%, p  < 0.001) or renal failure (12 vs. 3%, p  < 0.001). Although perioperative survival was similar, patients who had wound complications had significantly longer hospital length of stay (LOS) (7.3 ± 12 vs. 3.4 ± 5 days, p  < 0.001). Up to 3% patients developed wound complications after open femoral exposure during EVAR with significantly higher LOS and therefore cost utilization.

Long-Term Evaluation of Percutaneous Groin Access for EVAR

BACKGROUND

Percutaneous endovascular aneurysm repair (PEVAR) has been shown to have high success rates, shorter operating times and length of stay compared to open access. However, there exists a lack of long-term follow-up data on these patients, and questions remain regarding longer-term outcomes. This study aims to assess the long-term complications and evolution of accessed vessels post-PEVAR.

METHODS

Sixty-one cases of bilateral PEVAR (122 groins) with > 36 months follow-up were analysed. Vessel diameter, calcification, dissection, lymphocele, pseudoaneurysm and thrombus formation were reviewed at 30th day and at the most recent follow-up CT. Notes were reviewed for groin infections, haematomas and nerve injury. Complications were considered 'major' if they required intervention or treatment.

RESULTS

Mean follow-up time from procedure to most recent scan was 49.9 months. There were no major short- or long-term complications. The early complication rate was 9.8%, with six pseudoaneurysms, four dissections, one thrombus, one nerve injury and no lymphoceles, haematomas or groin infections. The long-term complication rate was 0.8%, with only one pseudoaneurysm. The remainder of early complications resolved naturally without intervention. Accessed vessel showed significantly (P ≤ 0.05) increased diameter and calcification between 30th day and last follow-up scan.

CONCLUSION

This study provides the largest clinical cohort and the longest mean follow-up time reported in the literature and demonstrates the long-term safety of PEVAR. PEVAR has a very low long-term complication rate, without any major complications in our cohort. The accessed common femoral arteries do not show stenosis or thrombosis. Minor short-term complications appear to gradually resolve without intervention. Larger multi-centre studies are recommended.

A new option using adjunctive microsheath angiography to increase the safety during percutaneous endovascular aortic aneurysm repair

BACKGROUND

Percutaneous endovascular aortic repair (PEVAR) is widespread for the treatment of abdominal aortic aneurysm (AAA). The purpose of this study was to present outcomes of PEVAR using simultaneous angiography via microsheath.

METHODS

There were 100 punctures in 50 patients undergoing PEVAR for AAA. All cases used the ProGlide closure device (Abbot Vascular, Santa Clara, CA, USA) for PEVAR, and another puncture with microsheath placed on the common femoral artery for a second insertion point of the ProGlide. Basically, a single ProGlide was used for each puncture in the PEVAR. Hemostasis, stenosis, dissection, and distal embolization were confirmed in angiography via the adjunctive microsheath after removal of the delivery system. Since the PEVAR for AAA requires at least two punctures, this procedure was applied to both sites. Primary outcome was technical success and occurrence rates of access-related complications in PEVAR. Technical success was defined as complete hemostasis without surgical intervention and the need for conversion to general anesthesia.

RESULTS

Technical success was achieved in 98% (98/100) of the cases. Access-related complications on perioperative periods were identified in two cases. One case involved a tip of the microsheath being transected by the ProGlide that led to a distal embolization, which is why a cut down was required to retrieve the tip of the sheath. Another case required a cut down due to persistent hemorrhage from the puncture site of the microsheath. Although persistent hemorrhage was identified in five punctures (5.0%) via the adjunctive microsheath angiography, additional manual compression or ProGlide achieved complete hemostasis. Both stenosis and dissection following PEVAR were not identified in any case.

CONCLUSIONS

A supporting angiography via microsheath in confirming the absence of hemorrhage, stenosis, dissection, and distal embolization may be worthwhile to selectively use for cases of PEVAR.

Endovascular Treatment of Symptomatic Thoracic Aneurysm Due to Periaortic Lymphoma

An aggressive periaortic lymphoma could very rarely invade the aortic wall. We present a unique case of a patient with symptomatic thoracic aneurysm and imminent rupture due to the periaortic lymphoma, in which endovascular treatment using stent graft was applied. After stabilization of the aorta and histological confirmation of aggressive B-cell lymphoma by computed tomography-guided biopsy, the antilymphoma therapy was initiated. Despite the full treatment, the patient died 12 months later.

Financial Impact of PEVAR Compared With Standard Endovascular Repair in Canadian Hospitals

OBJECTIVES

The percutaneous endovascular abdominal aortic repair (PEVAR) approach is a minimally invasive technique that has demonstrated clinical benefit over traditional surgical cut down associated with standard endovascular abdominal aortic aneurysm (AAA) repair (EVAR). The objective of our study was to evaluate the budget impact to a Canadian hospital of changing the technique for AAA repair from the EVAR approach to the PEVAR approach.

METHODS

We examined the budget impact of replacing the EVAR approach with the PEVAR approach in a Canadian hospital that performs 100 endovascular AAA repairs annually. The model incorporates the costs associated with surgery, length of stay, and postoperative complications occurring within 30 days.

RESULTS

The use of PEVAR in AAA repair is associated with increased access device costs when compared with the EVAR approach (CAD$1000 vs CAD$400). However, AAA repair completed with the PEVAR approach demonstrates reduced operating time (101 minutes vs 133 minutes), length of stay (2.2 days vs 3.5 days), time in the recovery room (174 minutes vs 193 minutes), and postoperative complications (6% vs 30%), which offset the increased device costs. The model establishes that switching to the PEVAR approach in a Canadian hospital performing 100 AAA repairs annually would result in a potential cost avoidance of CAD$245,120.

CONCLUSIONS

A change in AAA repair technique from EVAR to PEVAR can be a cost-effective solution for Canadian hospitals.

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

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

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.

Current Status of Percutaneous Endografting

Totally percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) using suture-mediated closure devices (SMCDs) has several well-established advantages over standard open femoral exposure as a direct consequence of being less invasive and having shorter times to hemostasis and procedure completion. The first multicenter randomized controlled trial designed to assess the safety and efficacy of PEVAR and to compare percutaneous access with standard open femoral exposure was recently published (the PEVAR trial). The PEVAR trial demonstrated that percutaneous endografting is safe, effective, and noninferior to standard open femoral exposure among trained operators. The study reaffirmed the results of several recent single center and nonrandomized studies, demonstrating that percutaneous access facilitated shorter procedures, shorter times to secure hemostasis, and improved quality of life for patients. As PEVAR has gained popularity among patients and physicians, refinements to the technique and patient selection process have been made. There has been growing interest in treating patients with anatomical characteristics previously thought to be unsuitable for PEVAR, such as common femoral artery (CFA) calcifications, scarred groins, small CFA diameter, and high patient body mass index (BMI). However, observance of strict procedural technique and consideration for patient selection criteria remain paramount in achieving acceptable technical success rates with PEVAR.

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.

Integration of endovascular therapy of ruptured abdominal and iliac aneurysms in the treatment algorithm: a single-center experience in a medium-volume vascular center

PURPOSE

To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality.

MATERIALS AND METHODS

We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients.

RESULTS

During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively.

CONCLUSION

Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%.

Safety and Efficacy of the Prostar XL Vascular Closing Device for Percutaneous Closure of Large Arterial Access Sites

Purpose. The purpose of this study is to retrospectively evaluate the efficacy and safety of the Prostar XL device for percutaneous large access site closure in an unselected patient and operator collective. Materials and Methods. All patients (n = 50) who had received percutaneous vascular closing with the Prostar XL device in our institution with follow-up data of at least 6 months were retrospectively included. Primary (freedom from surgical conversion) and continued (freedom from groin surgery in further course) technical success and major (deviations from expected outcome requiring surgery) and minor (other deviations from expected outcome) complications were assessed. Success and complications rates were correlated with delivery system size (Mann-Whitney Rank Sum Tests) and operator experience (paired samples t-test). Results. Rates of primary and continued technical success as well as major and minor complications were 93.6%, 89.7%, 10.3%, and 10.3% (groin based) and 90.0%, 84.0%, 16.0%, and 16.0% (patient based), respectively. No correlation of success and complications rate was found with delivery system sizes and operator experience. Conclusions. Application of the Prostar XL device for percutaneous closure of large arterial access sites is safe with a relatively high rate of technical success and low rate of major complications. Sizes of the delivery systems and the experience of the operator did not influence the results.

Ultrasound-guided percutaneous endovascular aneurysm repair success is predicted by access vessel diameter

OBJECTIVE

Ultrasound scan-guided access allows for direct visualization of the access artery during percutaneous endovascular aortic aneurysm repair. We hypothesized that the use of ultrasound scan guidance allowed us to safely increase the utilization of percutaneous endovascular aortic aneurysm repair to almost all patients and decrease access complications.

METHODS

A retrospective chart review of all elective endovascular aortic aneurysm repairs, both abdominal and descending thoracic, from 2005 to 2010 was performed. Patients were identified using International Classification of Disease, 9th Revision, Clinical Modification Codes and stratified based on access type: percutaneous vs cut-down. We examined the success rate of percutaneous access and the cause of failure. Sheath size was large (18-24 F) or small (12-16 F). Minimum access vessel diameter was also measured. Outcomes were wound complications (infections or clinically significant hematomas that delayed discharge or required transfusion), operative and incision time, length of stay, and discharge disposition. Predictors of percutaneous failure were identified.

RESULTS

One hundred sixty-eight patients (296 arteries) had percutaneous access endovascular aneurysm repair (P-EVAR) whereas 131 patients (226 arteries) had femoral cutdown access EVAR. Ultrasound scan-guided access was introduced in 2007. P-EVAR increased from zero cases in 2005 to 92.3% of all elective cases in 2010. The success rate with percutaneous access was 96%. Failures requiring open surgical repair of the artery included seven for hemorrhage and six for flow-limiting stenosis or occlusion of the femoral artery. P-EVAR had fewer wound complications (0.7% vs 7.4%; P = .001), shorter operative time (153.3 vs 201.5 minutes; P < .001), and larger minimal access vessel diameter (6.7 mm vs 6.1 mm; P < .01). Patients with failed percutaneous access had smaller minimal access vessel diameters when compared to successful P-EVAR (4.9 mm vs 6.8 mm; P < .001). More failures occurred in small sheaths than large ones (7.4% vs 1.9%; P = .02). Access vessel diameter <5 mm is predictive of percutaneous failure (16.7% of vessels <5 mm failed vs 2.4% of vessels ≥ 5 mm failed; P < .001; odds ratio, 7.3; 95% confidence interval, 1.58-33.8; P = .01).

CONCLUSIONS

Ultrasound scan-guided P-EVAR can be performed in the vast majority of patients with a high success rate, shorter operative times, and fewer wound complications. Access vessel diameters <5 mm are at greater risk for percutaneous failure and should be treated selectively.

Current status of percutaneous endografting

Significant advances in the technology and techniques in the field of endovascular thoracic and abdominal aortic aneurysm repair have been made since its introduction in the early 1990s. The low incidence of periprocedural complications combined with comparable early outcomes to open surgery have made the endovascular treatment option the first choice of therapy in patients whose aortic anatomy is suitable for endografting. All currently available endografts for aortic aneurysm repair have delivery systems at least 21-French in outer diameter and have traditionally been inserted via surgical cutdowns. More recently, attempts to validate a totally percutaneous approach to the placement of these devices have been introduced by utilizing suture-mediated closure devices. This article will provide an overview of suture-mediated closure devices, our experience with the off-label application of suture-mediated devices for percutaneous closure of arterial access sites during endovascular aneurysm repair, and a review of the literature on this topic.

Vascular access site complications after percutaneous transfemoral aortic valve implantation

BACKGROUND AND PURPOSE

Transcatheter aortic valve implantation (TAVI) is a rapidly emerging treatment option for patients with aortic valve stenosis and high surgical risk. Different access routes have been proposed for TAVI including transapical, transsubclavian and transfemoral, with percutaneous transfemoral being the preferred because least invasive and nonsurgical. However, vascular access site complications due to the large-bore delivery catheters remain an important clinical issue, particularly with respect to the elderly patient collective typically considered for TAVI. In the study, the authors analyzed their 4-year TAVI experience with respect to vascular complications and their management in patients undergoing completely percutaneous transfemoral TAVI procedures.

PATIENTS AND METHODS

Since 2006, TAVI was performed in 101 consecutive patients at the West German Heart Center Essen. 33 patients underwent transapical TAVI, eight patients transfemoral TAVI with surgical access or closure, and 60 patients percutaneous transfemoral TAVI using two commercially available prosthetic valve devices.

RESULTS

Completely percutaneous TAVI was technically successful in all but one patient with malpositioning in the aortic arch during valve retrieval. There was no intraprocedural death and 30-day mortality was 12% (7/60). Vascular access site complications occurred in 19 patients (32%), necessitating surgical repair in six of them (10%). Complications included retroperitoneal hematoma (n = 2), iliac or femoral artery dissection (n = 10), (pseudo)aneurysm formation (n = 3), and closure device-induced vessel stenosis/ occlusion (n = 6). Of these, 13 cases could be managed either conservatively (n = 5) or by contralateral endovascular treatment (n = 8).

CONCLUSION

Completely percutaneous TAVI has a high acute success rate with low intraprocedural and 30-day mortality. The patient collective appears to be prone to vascular complications which remain an important limitation of this novel technique. Although conservative or endovascular management is possible in the majority of cases, further technological developments are obliged to reduce the vascular complication rate.