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Utilization Of Percutaneous Closure Devices For Large Bore Arterial Access In Genetic Aortopathy Patients Does Not Result In Increased Rates Of Access Site Complications
Rebecca Sorber, MD, Sasha Smerekanych, BS, Haley J. Pang, BS, Blake E. Murphy, MD, Kirsten Dansey, MD MPH, Matthew P. Sweet, MD MS, Sara L. Zettervall, MD MPH.
University of Washington, Seattle, WA, USA.
Objective:Percutaneous closure devices for arterial sheaths of sufficient caliber to deliver aortic endografts have a published success rate of 90-95%. Despite this, they are frequently avoided in patients with genetic aortopathy(GA) due to concern for high failure rates and increased complications in the setting of compromised tissue integrity. This study aims to compare rates of access site complications following large bore percutaneous access among patients with and without confirmed GA.
Methods:All patients undergoing endovascular aortic procedures requiring large bore (≥9Fr) femoral sheath access between 2019-2023 were identified. The specific mutation, demographics, comorbidities, and operative details including maximum sheath size were recorded. Outcomes including unplanned femoral cutdown, access site complications and reinterventions were evaluated. These factors were then compared between patients with and without a laboratory confirmed mutation associated with GA. A supplemental analysis was performed on all GA patients from 2014-2023.
Results:Among the 404 patients identified, 33(8%) had confirmed GA. Among those with confirmed GA, 7 patients(21%) had Marfan, 7(21%) had Loeys-Dietz, and 3(9%) had vascular Ehlers-Danlos. The GA group was significantly younger(median GA:52 years; non-GA:71 years; p<0.001). TEVAR was most frequent in the GA group(52%), followed by Zone II arch replacement with frozen elephant trunk(21%); the most frequent operation among the non-GA group was F/BEVAR or PMEG(43%), followed by TEVAR(25%). Both groups had a median sheath size of 20 Fr; the GA group had higher rates of both prior open(GA:27%; non-GA:12%; p=0.015) and prior percutaneous ipsilateral access(GA:58%; non-GA: 39%; p=0.041). Rates of unplanned cutdowns(GA:0%; non-GA:6%) and access site complications(GA:0%; non-GA:8%) did not significantly differ between groups(p=0.160 and p=0.096, respectively). There was one GA patient who required unplanned cutdown for the extended 10-year study period, yielding an overall technical success rate of 97% for percutaneous closure in this group.
Conclusions: Percutaneous access is safe and effective in patients with confirmed GA with similar rates of unplanned cutdown as those in patients without GA. Given the high rates of staged aortic procedures in this patient population, percutaneous closure should be attempted to avoid an obligate femoral incision, thereby reducing the potential for wound complications and increasing the ease of future procedures.
| | | | |
| Genetic Aortopathy (N=33) | Non-Genetic Aortopathy (N=371) | p-value |
| Clinically significant CFA stenosis – N (%) | 0 (0%) | 12 (3%) | 0.294 |
| Clinically significant CFA calcification – N (%) | 0 (0%) | 39 (11%) | 0.050 |
| Largest Sheath Size, Fr – median (IQR) | 20 (9-22) | 20 (18-22) | 0.304 |
| Operation Type – N (%) | | | | |
| TEVAR | 17 (52%) | 94 (25%) | <0.001 |
| F/BEVAR/PMEG | 5 (15%) | 161 (43%) | |
| Zone II Arch/FET | 7 (21%) | 34 (9%) | |
| TBE | 3 (9%) | 35 (9%) | |
| EVAR | 0 (0%) | 38 (10%) | |
| Other | 1 (3%) | 9 (2%) | |
| Percutaneous Access – N (%) | | 28 (85%) | 358 (96%) | 0.002 |
| Prior Open Ipsilateral Access – N (%) | | 9 (27%) | 44 (12%) | 0.015 |
| Prior Perc Ipsilateral Access – N (%) | | 19 (58%) | 143 (39%) | 0.041 |
| Type of Closure – N (%) | | | | |
| Perclose Proglide | 26 (79%) | 334 (90%) | 0.103 |
| Open | 5 (15%) | 18 (5%) | |
| Prostar XL | 1 (3%) | 11 (3%) | |
| Manual Pressure | 1 (3%) | 8 (2%) | |
| Planned Cutdown – N (%) | | 5 (15%) | 21 (6%) | 0.033 |
| Unplanned cutdown – N (%) | | 0 (0) | 21 (6%) | 0.160 |
| Any access site complication – N (%) | | 0 (0) | 29 (8%) | 0.096 |
| Reintervention for complication – N (%) | | 0 (0) | 3 (1%) | 0.604 |
| CFA, common femoral artery; Fr, French; TEVAR, thoracic endovascular aortic repair; F/BEVAR/PMEG, fenestrated/branched endovascular aortic repair/physician-modified endovascular graft; Zone II Arch/FET, Zone II arch replacement with frozen elephant trunk; TBE, thoracic branch endoprosthesis; EVAR, endovascular aneurysm repair; Perc, percutaneous. |
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