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OBJECTIVES:
Percutaneous femoral vascular access has become a common means of vascular access for aortic endovascular procedures, with a local complication rate in contemporary data of 9%. Recently, fenestrated endovascular aortic aneurysm repair (FEVAR) has emerged as a new technique for the repair of short-neck and juxtarenal aneurysms. The investigation of the use of percutaneous access in FEVAR has not been investigated to date.
METHODS:
Since FDA approval, 57 patients (51 Zenith fenestrated [Zfen], 6 p-branch) underwent FEVAR at a single institution. Percutaneous access was performed using a “preclose” technique using the Proglide device (Abbott Vascular, Redwood City, Calif.). The total number of access sites was 124 (110 percutaneous, 4 open, and 10 brachial). The median femoral access size was 20F (IQR: 18-20) for percutaneous and 20F (IQR: 18.5-21.5) for open access. The most common configuration was a Zfen with a scallop for the SMA (n=31), Zfen with fenestration for the SMA (n=20) and p-branch (n=6). Median operative time was 210(IQR:174-277.5) minutes. Ten patients had a history of previous aortic surgery, and 8 had a history of previous groin surgery. There were 5 conduits performed at surgeon’s discretion: 4 endoconduits and 1 open retroperitoneal.
RESULTS:
The percutaneous access success rate was 95.4%. There were 8 groin access site complications: 3 open (3/4;75%) and 5 percutaneous (5/110;4.5%)(P=.0009). The 3 open complications were a wound infection of a retroperitoneal conduit incision requiring percutaneous drainage and a bilateral groin infection with lymph leak. The 5 percutaneous complications were 2 tears with the device and hemorrhage, a backwall injury with flap, and an embolization requiring thrombectomy and fasciotomy. Previous aortic or groin surgery was not found to increase the risk of access site complications. The median operative time in the complication group was 308(IQR:210-395) minutes compared to 210(IQR:166-250) minutes in those without complication (P=.004). Use of an endoconduit for percutaneous access was associated with an increased complication rate (4/10 vs 0/100 access sites;p<.0001). Neither previous groin or aortic surgery influenced the complication rate.
CONCLUSIONS:
Despite the increased operative time and complexity, percutaneous femoral access appears to be a safe alternative to open access in FEVAR patients. Cases with higher complexity, as manifested by the need for endoconduits and longer operative time, appear to have a higher percutaneous complication rate.