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

Efficacy and Safety of Percutaneous Access Via Large-Bore Sheaths (22-26F Diameter) in Endovascular Therapy

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.

Vascular Access Challenges in Thoracic Endovascular Aortic Repair: A Literature Review

BACKGROUND

This review aims to comprehensively summarize access challenges in thoracic endovascular aortic repair (TEVAR) by describing vascular access routes, associated risks, outcomes, and complications.

METHODS

A literature search was conducted utilizing the PubMed (Medline), Scopus, and Web of Science databases. Qualitative and quantitative data from selected studies are extracted and discussed according to available standards for narrative reviews.

RESULTS

In total, there were 109 eligible studies based on predefined inclusion- and exclusion criteria. There were 39 original articles or reviews and 57 case series or case reports. This article summarizes the evidence from these studies and discusses traditional retrograde access routes and techniques for TEVAR via a femoral or iliac route, with or without the use of conduits. Next, alternative antegrade access routes and techniques via a brachial, axillary, carotid, ascending aorta, transapical, transcaval, or another route are discussed. Vascular access complications are presented with specific attention to the importance of gender and alternative antegrade access routes.

CONCLUSIONS

Multiple access routes and techniques are currently available to overcome access challenges associated with TEVAR, based on low grade evidence from heterogeneous studies. Future research that compares different access routes and techniques might help in the development of a tailored access protocol for specific patients with challenging TEVAR access.

A Novel Plug-Based Vascular Closure Device for Percutaneous Femoral Artery Closure in Patients Undergoing Minimally-Invasive Valve Surgery

Objectives: Surgical exposure of groin vessels to establish cardiopulmonary bypass (CPB) for minimally-invasive valve surgery (MIS) is standard of care but may result in postoperative wound healing disorders or seroma formation. Therefore, adaption of transcatheter techniques for fully percutaneous insertion of CPB cannulae may improve clinical results. We herein analyze a single center experience with a novel plug-based vascular closure device for MIS.

Methods: Between 03/2020 and 02/2021 MIS using the MANTA™ (Teleflex Medical Inc., Wayne, PA, USA) vascular closure device was performed in 28 consecutive patients (58.8 ± 10.6 years, 60.3% male, logEuroSCORE II 1.1 ± 0.8%) receiving mitral and/or tricuspid valve repair/replacement. Concomitant procedures were left atrial appendage occlusion and cryoablation for atrial fibrillation in 21.4% (6/28) and 10.7% (3/28) of patients, respectively. Data were retrospectively analyzed in accordance with standardized M-VARC definitions. MANTA™ device success and early safety was defined as absence of any access site or access related vascular injury and major and life-threatening bleeding complications.

Results: MANTA™ device success with immediate hemostasis and early safety were 96.4% (27/28). In one case, device failure necessitated surgical cut down without further complications. Mean aortic cross clamp time and cardiopulmonary bypass were 96.5 ± 24.2 min and 150.2 ± 33.6 min. Stroke, renal failure or myocardial infarction were not observed. Intensive care unit and total hospital stay were 1.7 ± 0.8 days and 10.1 ± 5.7 days. Overall 30-day mortality was 0%. Post-procedure echocardiography presented one case of residual moderate tricuspid regurgitation and competent valves in all other cases.

Conclusions: The MANTA™ device is safe and effective in MIS. Its ease of use and effectiveness to achieve immediate hemostasis have further simplified MIS.