Unselected Percutaneous Access with Large Vessel Closure for Endovascular Aortic Surgery: Experience and Predictors of Technical Success

Metcalfe, Matthew; Brownrigg, Jack; Black, Stephen; Loosemore, T.; Loftus, Ian; Thompson, Matt

doi:10.1016/j.ejvs.2011.12.025

Cited by 29 publications

(33 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…As overall clinical practice evolved and device/sheath technology has improved with respect to both luminal profile reduction and hydrophilic materials, clinicians have become collectively more aggressive in pursuing minimally invasive access 8, 15, 21 . In our own practice, this has translated into a reduction in the number of iliac conduits, once reported to be required in 20% of TEVAR procedures 4 .…”

Section: Discussionmentioning

confidence: 99%

“…Metcalfe et al reported that the success rate of percutaneous aortic endovascular repair in 186 femoral arteries was 95.2% 8 . On univariate analysis, they found that vessel depth, diameter, preoperative renal failure, and operator experience predicted failure of the percutaneous technique.…”

Section: Discussionmentioning

confidence: 99%

“…In addition to shorter operative times 7 , potential advantages of percutaneous access include reduced discomfort, earlier ambulation, and a lower rate of wound complications 8, 9 . Wound complications with open femoral exposure in endovascular aortic repair have been reported in 3–5% of patients, despite efforts to reduce this risk by making limited transverse or oblique incisions 10 .…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients

Zakko

Scali

Beck

et al. 2014

Journal of Vascular Surgery

View full text Add to dashboard Cite

Objectives There is limited data describing the preclose technique with the Perclose Proglide device in thoracic endovascular aortic repair(P-TEVAR), particularly in obese patients, where use of this technique is thought to be relatively contraindicated. The purpose of this analysis is to describe our experience with P-TEVAR and compare outcomes in patients with or without obesity. Methods All TEVAR procedures at a single institution from 2005–2011 were reviewed and P-TEVAR patients were stratified by body mass index(BMI: obesity = ≥ 30 kg/m2). Preoperative CT scans were analyzed for access vessel depth, calcification and morphology. Technical success was defined as the ability to achieve hemostasis and maintain limb perfusion without the need for common femoral artery exposure and/or obligate surgical repair of the vessel within a 30-day postoperative period. Generalized estimating equations and stepwise logistic regression were used to develop prediction models of preclose failure. Results 536 patients were identified, in whom 355(66%) P-TEVAR procedures were completed [366 arteries; N= 40 (11%) bilateral]. Compared to non-obese patients(N = 264), obese patients(N = 91) were typically younger(59±16 vs. 66±16 years; P = .0004) and more likely to have renal insufficiency(28% vs. 17%; P = .05) and/or diabetes mellitus(19% vs. 9%; P = .02). Number of Perclose deployments were similar between groups(P = NS). Mean sheath size(French:25.4 vs. 25.0; P = .04), access vessel inner diameters [8.5±1.9mm vs. 7.9±2.0; P = .02)] and vessel depth(50±20mm vs. 30±13; P < .0001) were greater in obese patients. Adjunctive iliac stents were used in 7% of cases [obese, N = 10(11%) vs. non-obese 16(6%); P = .2]. Overall technical success was 92% [92% non-obese vs. 93% obese patients(P=.7)]. Three patients required subsequent operations for access complications; two obese patients(2%) and one non-obese patient (0.4%)(P = .3). Independent predictors of failure were adjunctive iliac stent(OR 9.5; 95%CI 3.3–27.8, P < .0001), >2 Perclose devices(OR 7.0; 2.3–21, P = .0005), and smaller access vessel/sheath size ratio(OR multiplies by 1.1 for each .01 decrease in ratio; 1.02–1.2, P = .007) (AUC = .75). Conclusion Obesity is not a contraindication to P-TEVAR. P-TEVAR can be performed safely, despite the need for larger diameter sheaths. However, patients predicted to need adjunctive stenting or possessing smaller access vessel diameter to sheath size ratios are at highest risk of preclose failure using the Perclose Proglide device, and selective use of this technique is recommended.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients

Zakko

Scali

Beck

et al. 2014

Journal of Vascular Surgery

View full text Add to dashboard Cite

show abstract

“…24,25 Metcalfe et al 25 used a cutoff of 20 supervised deployments of Prostar to define a proficiency level, and 15 cases constituted the request for "license." In the hands of experienced operators, the complication rate was 4e7%, close to earlier reports for either technique.…”

Section: Comparison With Other Studiesmentioning

confidence: 99%

Editor's Choice - A Randomized Controlled Trial of the Fascia Suture Technique Compared with a Suture-mediated Closure Device for Femoral Arterial Closure after Endovascular Aortic Repair

Larzon

Roos

Gruber

et al. 2015

European Journal of Vascular and Endovascular Surgery

View full text Add to dashboard Cite

show abstract

“…Operator experience is a strong predictor of technical success for SMCD, 3 and excellent results have been reported for experienced operators. 4 In the present study, experience of 15 cases was used to define the basic level, and of 60 procedures the experienced level.…”

mentioning

confidence: 94%

Commentary on ‘A Randomized Controlled Trial of the Fascia Suture Technique Compared with a Suture-mediated Closure Device for Femoral Arterial Closure After Endovascular Aortic Repair’

Wanhainen

2015

European Journal of Vascular and Endovascular Surgery

View full text Add to dashboard Cite

Several techniques exist for EVAR access closure: 1) open surgical technique with cutdown onto the femoral artery, 2) modified open technique with fascia suture technique (FST), and 3) strictly percutaneous pre-suturing technique with suture-mediated closure device (SMCD). There is no consensus on which technique should be used. In Sweden, cutdown was used in 21% of all EVAR in 2013, FST in 37%, and SMCD in 42%. 1 In this issue, Larzon and colleagues present the results of a randomized controlled trial comparing FST with SMCD (Prostar XL) for femoral artery closure after EVAR. 2 Based on achievability, time was chosen as the primary outcome. Consequently, the main finding was that FST is faster compared with Prostar. With a median difference of 7 minutes in favor of FST, the clinical relevance of this finding can be questioned. A more desirable and relevant study design would have been technical failure and major complications as primary outcome, with time and cost as secondary endpoints. The authors argue, however, that such a study is not feasible because of the large sample size required.Operator experience is a strong predictor of technical success for SMCD, 3 and excellent results have been reported for experienced operators. 4 In the present study, experience of 15 cases was used to define the basic level, and of 60 procedures the experienced level. Notably, experienced operators had a technical failure rate of 4% for FST and 7% for Prostar, while corresponding rates for the basic level operators were 27% and 30%, respectively. This indicates that the learning curve is of great importance in both techniques.Prostar was until recently the only available SMCD for large access sites. ProGlide (Abbot Vascular, Redwood City, CA, USA) is a simplified SMCD recently approved for closure of up to 21F vascular access sites. Ultimately, a complete percutaneous approach is desirable, and with easier-tolearn closure devices and delivery systems getting ever smaller, this is a likely development.Although FST is more invasive than SMCD, the lack of preclosure preparation of the access site is an advantage, particularly in the emergency situation. Furthermore, as demonstrated by this investigation, FST can work as a bailout procedure for a failed Prostar XL suture, and may be a cheaper option than Prostar XL. REFERENCES1 Swedvasc yearly report. 2014 [in Swedish], http://www.ucr.uu. se/swedvasc/index.php/arsrapporter. 2 Larzon T, Roos H, Gruber G, Henrikson O, Magnuson A, Falkenberg M, et al. A randomized controlled trial of the fascia suture technique compared with a suture-mediated closure device for femoral arterial closure after endovascular aortic repair. Eur J Vasc Endovasc Surg 2014 [in press]. 3 Metcalfe MJ, Brownrigg JRW, Black SA, Loosemore T, Loftus IM, Thompson MM. Unselected percutaneous access with large vessel closure for endovascular aortic surgery: experience and predictors of technical success. Eur J Vasc Endovasc Surg 2012;43: 378e81. 4 Skagius E, Bosnjak M, Björck M, Steuer J, Nyman R, Wanhainen A. P...

show abstract

Unselected Percutaneous Access with Large Vessel Closure for Endovascular Aortic Surgery: Experience and Predictors of Technical Success

Cited by 29 publications

References 10 publications

Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients

Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients

Editor's Choice - A Randomized Controlled Trial of the Fascia Suture Technique Compared with a Suture-mediated Closure Device for Femoral Arterial Closure after Endovascular Aortic Repair

Commentary on ‘A Randomized Controlled Trial of the Fascia Suture Technique Compared with a Suture-mediated Closure Device for Femoral Arterial Closure After Endovascular Aortic Repair’

Contact Info

Product

Resources

About