Risk Score for Groin Access Complication in Ultrasound-Guided Percutaneous Aortic Procedures
Patric Liang, MD, Thomas F.X. O'Donnell, MD, Andy Lee, MD, Nicholas J. Swerdlow, MD, Chun Li, MD, Alexander B. Pothof, MD, Mark C. Wyers, MD, Allen D. Hamdan, MD, Marc L. Schermerhorn, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Objective:
Ultrasound-guided access for percutaneous endovascular aortic procedures has been increasingly utilized. We developed a prediction model to risk stratify patients for access site complications following ultrasound-guided percutaneous approach.
Methods
We performed a retrospective institutional review of consecutive patients who underwent percutaneous endovascular repair of emergent and elective aortic pathology, from 2014-2016. We excluded patients undergoing initial femoral artery (FA) cutdown, endoleak treatment, or aortic arch reconstruction. Our primary outcome was groin access site complication, which included bleeding, thrombosis, infection, and conversion to femoral cutdown. We created a 15 point risk model for groin access complication using logistic regression.
Results:
We identified 292 FAs from 152 patients undergoing endovascular aortic repair procedures (endovascular aortic aneurysm repair 76.8%, fenestrated endovascular aortic aneurysm repair 7.7%, thoracic endovascular aortic aneurysm repair 15.5%). Surgeons utilized percutaneous access in 97.3% FAs (2.7% underwent planned femoral endarterectomy), with 100% ultrasound use and 100% initial success rate. Superficial FA access was performed in 3 arteries because of prior common FA interposition grafts. 18 (6%) access site complications (8 bleeding, 9 thrombosis, 1 infection) occurred leading to immediate (n = 12) or delayed (n = 5) conversion to cutdown. Factors independently associated with percutaneous access site complication were sheath outer diameter to FA diameter ratio (odds ratio [OR] 58.9 [95% CI, 3.5 - 985.8]; P = .005), morbid obesity with BMI > 40 (OR 16.0 [3.0-84.5]; P = .001), FA stenosis >50% (OR 52.1 [7.7-351.5]; P = <.001), FA stenosis >75% (OR 271.5 [15.1 - 4888.6]; P = <.001), and post-operative anticoagulation (OR 10.5 [2.0-54.0]; P = .005). A risk prediction model based on these criteria produced a C statistic of .91, a Hosmer-Lemeshow goodness of fit of .99, and a Brier score of .03. A risk score of >6 of 15 corresponded to a >10% probability of groin access complication.
Conclusions:
Percutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures, however access site failures still occur. Application of this risk score can help identify patients at high risk for complications following initial FA ultrasound-guided percutaneous access.
| Table 1. Risk score and corresponding access site failure risk, frequency, cumulative frequency | ||||||
| Criteria | Points | Total Points | Predicted risk of access site failure (%) | Frequency (%) | Cumulative Frequency (%) | |
| Sheath:FA diameter < 0.5 0.51-0.65 >0.66 Morbid Obesity (BMI >40) No Yes Degree of FA narrowing <50% >50% >75% Postoperative Anticoagulation No Yes | 0 1 3 0 3 0 4 6 0 3 | 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 | .06 .16 .41 1.0 2.6 6.4 14.9 31.0 53.5 74.6 88.2 95.0 97.9 99.2 99.7 99.9 | 21.3 0.0 21.7 38.6 8.09 0 7.0 2.21 0.4 0 7 0 0 0 0 0 | 21.3 21.3 43.0 81.6 89.7 89.7 96.7 98.9 99.3 100 100 100 100 100 100 100 | |
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