Percutaneous Femoral Artery Access: The New Gold Standard For Endovascular Aortic Aneurysm Repair And Its Impact On Arterial Patency

Firas F Mussa¹, Alan B Lumsden², Neil Strickman³, Ali Mortazavi³, Zvonimir Krajcer.^3
1Baylor College of Medicine, Houston, TX; ²Methodist DeBakey Heart Center, Houston, TX; ³St. Luke's Episcopal Hospital and Texas Heart Institute, Houston, TX.

OBJECTIVES: Totally percutaneous endovascular aortic aneurysm repair (EVAR) has been shown to be safe, technically feasible, with low morbidity. We sought to evaluate our experience with this technique and determine its impact on arterial patency as measured by computed tomographic angiography (CTA) and ankle brachial index (ABIs)

METHODS: A retrospective review of a prospectively collected database was performed. All patients who underwent percutaneous closure of large-bore-sheath (>12F) access sites with off-label use of a suture-mediated closure device (Prostar XL, Abbott Vascular Devices, Redwood City, CA) between December 2000 and January 2006 were reviewed. Outcome measures evaluated were rates of technical success, conversion to open femoral arterial repair, and complications. Accessed vessels patencies were assessed with CTA and ABIs measurements both before and 1 month after the procedure. The patient variables were compared by using X2, Fisher exact, and paired and independent samples t test where appropriate. The mean follow-up interval was 38 months (0.2-84).

RESULTS: During the study period, 483 patients (381 men, 102 women, mean age 72.8 years) underwent percutaneous closure of 966 large-bore-sheath access sites. Two hundreds and seventy patients (56%) were morbidly obese (body mass index >35 kg/m2). Successful closure was achieved in 925 (96%) access sites. Percutaneous closures were unsuccessful in 37 (4%) access sites, and were converted to open femoral repair. All conversion occurred after closure of >20F arteriotomy. Total complication rate was 2.6%. Predictors of worse outcomes were morbid obesity and sheath size >20F (P<0.002 and P<0.003, respectively). Upon comparison of preoperative and postoperative CTA, there were no significant differences in minimum intraluminal diameters (7.42 +/- 1.7 vs 7.48 +/- 1.8). Similarly, no significant difference was demonstrated in ABIs between preoperative and postoperative measurements (0.7 +/- 0.1 vs 0.7 +/- 0.2). No thrombotic or infectious complications occurred.

CONCLUSIONS: Percutaneous EVAR has no effect on the luminal diameter or ABIs of the accessed femoral artery or limb. With meticulous technique and good patient selection this approach carries minimal risk and has the potential of converting EVAR to an outpatient procedure.