Print this pagePercutaneous Access for EVAR: Can Selection Criteria Be Expanded?
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Stephen T Smith, Carlos H Timaran, R James Valentine, Eric Rosero, J Gregory Modrall, Harshal S Broker, Damon S Pierce, G Patrick Clagett, Frank R Arko
University of Texas Southwestern Medical Center, Dallas, TX
Background: Previous reports suggest that percutaneous access for EVAR (P-EVAR) is as safe as open access (O-EVAR) in patients with favorable iliofemoral anatomy. Severe femoral artery calcification, tortuous iliac arteries, and obesity have been considered relative contraindications to P-EVAR, but these criteria have not been evaluated. The purpose of this study was to assess the postoperative anatomic changes associated with P-EVAR versus O-EVAR using 3-D CT reconstruction and to evaluate the overall results of the two procedures in a group of patients with suboptimal iliofemoral anatomy.
Methods: During a recent 15-month period, 173 patients underwent EVAR at our institutions, including 35 P-EVAR. Of these, 22 (63%) had complete pre- and postoperative CT imaging of the femoral arteries. These subjects were compared to 22 matched controls that underwent O-EVAR during the same period. Automated 3-D reconstructions were used to measure iliac tortuosity and the following anatomic femoral artery parameters before and after EVAR: arterial depth, arterial length, calcification score, minimum diameter and area, and maximum diameter and area.
Results: Of the 88 study arteries, 50 underwent open access and 38 percutaneous access (Proglide, n=11; Prostar XL, n=27). Both groups were similar regarding sheath size, number of components, operative time, blood loss and length of stay. Significantly more O-EVAR subjects suffered groin complications (p = 0.017). O-EVAR groin complications include 5 hematomas, 1 wound infection, 2 femoral thromboses, and 1 vessel which required patch repair. In the P-EVAR group there was only 1 hematoma that was managed conservatively. Severe femoral artery calcification (Agatston score > 400) was documented in 10 (45%) P-EVAR and 8 (36%) O-EVAR subjects; significant iliac tortuosity (> 25°/cm) was measured in 10 (45%) P-EVAR and 7 (32%) O-EVAR subjects; and obesity (BMI > 30) was documented in 8 (36%) P-EVAR and 5 (23%) O-EVAR subjects (p=NS). Pre and postoperative CT-derived anatomic data show a significant decrease in the minimal vessel area with O-EVAR compared to P-EVAR (p=0.02).
| Table1. Common femoral artery size changes after EVAR according to type of repair | |||
| Variable | Change in P-EVAR group (median, IQR) | Change in O-EVAR group (median, IQR) | P value* |
| Maximum vessel area (cm2) | 0.0 (-0.7, 0.03) | 0.0 (-0.1 , 0.05) | 0.68 |
| Minimum vessel area (cm2) | 0.0 (-0.04, 0.04) | -0.4 (-0.12 , 0.01) | 0.02 |
| Maximum vessel diameter (mm) | -0.1 (-0.3 , 0.5) | 0.0 (-0.4 , 0.5) | 0.98 |
| Minimum vessel diameter (mm) | -0.05 (-0.5 , 0.4) | -0.3 (-0.9 , 0.2) | 0.19 |
| *Wilcoxon-Mann-Witney test IQR, interquartile range | |||
Conclusions: Postoperative anatomic measurements confirmed that percutaneous access does not compromise the luminal diameter or area of the common femoral artery. This study shows that P-EVAR can be safely performed in patients with obesity, severe femoral calcification, and tortuous iliac arteries with fewer groin complications versus O-EVAR. Selection criteria for P-EVAR can be expanded.
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