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Femoral Artery Calcification As a Determinant of Success For Percutaneous Access For Endovascular Abdominal Aortic Aneurysm Repair (PEVAR)
Jesse M. Manunga, Jr., MD, Peter Gloviczki, MD, Gustavo S. Oderich, MD, Manju Kalra, MB BS, Audra A. Duncan, MD, Mark D. Fleming, MD, Thomas C. Bower, MD.
Mayo Clinic, Rochester, Rochester, MN, USA.
OJECTIVES: To determine the outcomes and predictive factors for success during percutaneous endovascular aneurysm repair (PEVAR) using vascular closure devices (VCDs).
METHODS: The clinical data of patients who underwent percutaneous EVAR (PEVAR) between 2005 and 2012 were retrospectively reviewed. Patient demographics, body mass index, sheath size, device types, diameter of femoral arteries, extent and location of femoral artery calcification were recorded. All consecutive patients treated by PEVAR with sheath sizes ranging from 12 F to 24 F were included. End points were technical success, conversion to open femoral artery repair and complications.
RESULTS: There were 752 patients treated by EVAR during this period. Of these, 222 patients (29.5%; 197 males, 25 females with a mean age of 74.8 years, range: 51 to 93.7 years) had 391 femoral arteries accessed percutaneously (169 bilateral and 53 unilateral percutaneous access). Patients with >50% anterior wall calcification were not offered PEVAR. Technical success of PEVAR was 96.4% (377/391) with an average of 2 VCDs per groin. Fourteen intraoperative failures were managed with open conversion using primary repair (5) or patch angioplasty (9). In nine patients, the procedure was converted from local to general anesthesia; 4 patients required perioperative blood transfusion. There were no differences in BMI (p = 0.26), pre or post procedure femoral artery size (P = 0.33 and 0.37), sheath size (≥ 20 F vs ≤ 18F) or type of VCD used between the success and failure groups. Pairwise comparisons revealed increased failure rate (p = <0.001) between patients with <50% anterior wall calcification vs none, <50% anterior wall calcification vs <50% posterior wall calcification, none vs > 50% posterior calcifications. There was no difference (p = 0.53) between patients with < 50% posterior calcification and those with no calcification. Thirty day mortality of the entire group was 0.9% (2/222 patients). There were no deaths following conversion to open femoral closure. At a mean follow up of 30 months (range: 1 to 85.2), there were no long-term groin complications or iliac limb occlusions.
CONCLUSIONS: PEVAR using vascular closure devices can be performed with high technical success in patients with less than 50% anterior wall calcification regardless of the size of the access sheath or patients’ BMI. Femoral artery calcification, however, is a major determinant of failure.
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