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Aggressive Percutaneous Access For Evar & Tevar Is Safe
Graham T. Endler, D.O., Komal Parikh, D.O., Mrinal Shukla, MD, Jennifer R. Dinning, M.D., Marc E. Mitchell, M.D..
University of Mississippi Medical Center, Jackson, MS, USA.
OBJECTIVES: Endovascular aortic repair evolved from open common femoral artery (CFA) exposure to percutaneous. This study aims to review our experience with CFA access requiring sheaths 12 French or larger and identify variables predicting success.
METHODS: A retrospective review of all EVARs or TEVARs was performed at a tertiary care academic medical center by 5 vascular surgeons from July 2022-August 2024. CFA access was categorized as totally percutaneous (perc), planned open, or open conversion after attempted percutaneous access. We included CFA access with 12F or larger sheaths and analyzed BMI, accessed CFA depth, calcification and stenosis. Degree of stenosis was stratified as none, <50%, 50-79%, and critical-occluded. Plaque location was defined as none, posterior, anterior, and circumferential.
RESULTS: This study included 133 consecutive patients (74% male) with a total of 204 CFA access (58% right-sided). Mean age was 64 (range 17-89). With 72% elective aortic repair, indications included aneurysm (75%), dissection, trauma, penetrating aortic ulcer, intramural hematoma, and occlusive disease. EVAR was performed in 62% of patients. Sheath sizes ranged from 12F to 26F. Planned open access was performed in 14 of the 204 accesses (6.9%) at attending surgeon discretion, with indications of CFA aneurysm/dissection, and dense atherosclerotic disease. Perc CFA access using one or two ProGlide/ProStyle perclose devices was attempted 190 times and successful 179 (94%) times. Eleven perc CFA accesses (5.4%) required open conversion. CFA endarterectomy with patch angioplasty was performed in 10 of 11 open conversions (92%), with one simple direct arteriotomy repair. Conversion indications included device failure, bleeding, thrombosis, or occlusion. Ten open conversions occurred during index EVAR/TEVAR. One patient had CFA thrombosis on post-operative day one requiring open repair. There were no long-term access related complications. The 11 patients requiring open conversion had average BMI of 26 and average CFA depth of 3.6cm. Their CFA had posterior or circumferential (55%) plaque and 8 (73%) had <50% stenosis. Open conversions mainly had 20F sheaths (36%) with three 12F (27%), two 18F (18%), and 22F and 26F in one patient each (9%).
CONCLUSIONS: When perc CFA access is attempted but is unsuccessful, conversion to open CFA access and repair can be done at the index operation without short- or long-term complications. An aggressive approach to percutaneous access is safe and justified for EVAR or TEVAR.
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