Larger Sheath Size for Infrainguinal Endovascular Interventions does not Increase Major Morbidity but is Associated with Longer Length of Stay
Scott R. Levin, M.D., Alik Farber, M.D., Thomas W. Cheng, M.S., Nkiruka Arinze, M.D., Douglas W. Jones, M.D., Jeffrey A. Kalish, M.D., Denis Rybin, Ph.D., Jeffrey J. Siracuse, M.D..
Boston University, Boston, MA, USA.
OBJECTIVES: Infrainguinal peripheral vascular interventions (PVI) can be performed with a variety of sheath sizes. Our aim was to investigate the effect of sheath size on contemporary outcomes in specifically infrainguinal PVI.
METHODS: The Vascular Quality Initiative (2010-2017) was queried for patients undergoing infrainguinal PVI via retrograde common femoral artery access. Univariate and multivariable methods were performed to compare the effects of 4-7 Fr sheaths.
RESULTS: 36901 infrainguinal PVI procedures were identified. Mean age was 69 and 59% were male. Indications were claudication (42%), rest pain (13%), and tissue loss (45%). Treatment of femoral-popliteal (85%) and tibial (35%) arteries included stenting (39%) and atherectomy (21%). Sheath sizes of 7 Fr, 6 Fr, 5 Fr, and 4 Fr were used in 24541 (66.5%), 5225 (14.1%), 6221 (16.9%), and 914 (2.5%) cases, respectively. Larger sheath sizes were employed in patients who were more often ambulatory, non-diabetic, without ESRD, previously stented in the ipsilateral extremity, non-anemic, not on anticoagulation, less likely presenting with tissue loss; and more often undergoing femoral-popliteal interventions and stenting/atherectomy (P<.001 for all). Overall groin hematoma occurrence increased with the use of larger sheaths (1.2% vs. 2.5% vs. 2.7% vs. 3.5%, P<.001). There were no differences in the rates of hematoma requiring intervention, access site stenosis/occlusion, or 30-day mortality. Multivariable analysis revealed that 5-7 Fr sheaths, compared with 4 Fr sheaths, were independent predictors of overall groin hematomas (OR 2.1, 95% CI 1.1-3.7, P=.02; OR 1.2, 95% CI 1.2-4.0, P=.011; OR 2.9, 95% CI 1.6-5.4, P=.001) and length of stay of 1 day or greater (OR 1.3, 95% CI 1.2-1.5, P<.001; OR 1.2, 95% CI 0.9-1.3, P=.06; OR 1.4, 95% CI 1.2-1.6, P<.001). Groin hematomas requiring intervention and 30-day mortality were not independently associated with sheath size.
CONCLUSIONS: Using larger sheaths during infrainguinal PVI is associated with increased overall groin hematoma occurrence, however, there was no association with hematomas requiring intervention. Patients with larger sheaths were more likely to have a longer length of stay possibly related to conservative treatment of hematomas.
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