Retrospective Evaluation of Percutaneous Access for TEVAR and EVAR: Time to Make it the Standard Approach?

Abstract

Introduction To evaluate the safety of percutaneous endovascular aortic repair and the relationship of access site characteristics to complications

Materials and Methods All patients undergoing percutaneous TEVAR, EVAR and FEVAR procedures from January 2010 to May 2016 were retrospectively analysed for incidence of complications and their relationship to various access site characteristics like access artery size, degree of vessel calcification, skin to artery distance and sheath to artery ratio. Hemostasis occurring within 15 min after suture closure with or without manual compression was defined as primary hemostasis.

Results 92 patients with 142 femoral access sites were included in the study. Median follow-up was 28.13 months (range 2.5 – 76.7 months, Mean 32.39, SD – 21.66 months). Introducer system size ranged from 12F to 25F. Primary haemostasis was achieved in 97.1 % (138/142) of the total femoral access sites. Four access sites (2.8 %) had to be closed surgically; in all 4 cases the introducer systems was ≥ 18F. Two of these access sites had been operated upon previously. Late complications including inguinal hematoma (n = 7), wound infection (n = 1), scrotal hematoma (n = 1), pseudoaneurysm (n = 4) and late bleeding (n = 4) occurred in 17 access sites (11.9 %), of which 13 were managed conservatively. On account of the low complication rate, no correlation between the evaluated variables and observed complications could be established.

Conclusion Percutaneous endovascular aortic repair is feasible and safe irrespective of the size of the introducer sheath and the nature of aorto-iliac pathology. The technical success rate is high and the incidence of complications is low. Early complications are most often associated with sheath sizes ≥ 18 F. The majority of the late complications can be treated conservatively.

Key points: 

• Percutaneous endovascular aortic repair is feasible and safe.

• Technical success rate is high and complication rate is low.

• Vascular closure device failure in the occasional patient may necessitate surgical intervention.

Citation Format

• Thomas RP, Kowald T, Schmuck B et al. Retrospective Evaluation of Percutaneous Access for TEVAR and EVAR: Time to Make it the Standard Approach?. Fortschr Röntgenstr 2017; 189: 347 – 355

Zusammenfassung

Zielsetzung Überprüfung der Sicherheit von perkutanen endovaskulären aortalen Prozeduren und des Einflusses von Zugangscharakteristika auf Komplikationen.

Material und Methoden Alle Patienten, welche sich von Januar 2010 bis Mai 2016 einer perkutanen TEVAR, EVAR und FEVAR Prozedur unterzogen haben, wurden retrospektiv ausgewertet in Bezug auf die Komplikationshäufigkeiten unter Berücksichtigung der Zugangs-charakteristika wie Gefäßdurchmesser, Ausmaß vorhandener Gefäßverkalkungen, Abstand Hautoberfläche zum Zugangsgefäß sowie des Verhältnisses von Gefäßdurchmesser zum Einführbesteck. Hämostase mit oder ohne manuelle Kompression innerhalb von 15 Minuten nach Gefäßnahtverschluss wurde als primäre Hämostase definiert.

Ergebnisse Insgesamt wurden 92 Patienten mit 142 femoralen Zugängen in die Studie eingeschlossen. Die Mediane Nachbeobachtungszeit betrug 28,13 Monaten (range 2,5 – 76,7 Monate; Mittel 32,39, SD 21,66 Monate). Die Größe des Einführsystems variierte zwischen 12 und 25F. Eine primäre Hämostase wurde in 97,1 % (138/142) der femoralen Zugänge erreicht; vier Zugänge (2,8 %) mussten chirurgisch verschlossen werden; bei allen 4 Zugängen waren die Einführbestecke ≥ 18F, zwei der vier Leisten waren voroperiert. Spätkomplikationen waren Leistenhämatome (n = 7), Wundinfekt (n = 1), Skrotalhämatom (n = 1), Pseudoaneurysmen (n = 4) sowie Nachblutungen (n = 4), diese wurden bei 17 Zugangswegen (11,9 %) beobachtet, wovon 13 rein konservativ behandelt werden konnten. Auf Grund der niedrigen Komplikationsrate ergaben sich keine Zusammenhänge zwischen den Zugangscharakteristika und den stattgehabten Komplikationen.

Zusammenfassung Perkutane Stentgraftimplantationen sind unabhängig von der Größe des verwendeten Einführsystems und der vorliegenden Aortenpathologie sicher durchführbar. Es besteht eine hohe technische Erfolgsrate bei einer niedrigen Komplikationsrate. Ein Versagen des Nahtverschlusssystems ist häufiger bei verwendeten Einführsystemen ≥ 18F. Die Mehrzahl der Spätkomplikationen kann konservativ behandelt werden.

Kernaussagen: 

• Perkutane Stentgraftimplantationen sind sicher durchführbar

• Die technische Erfolgsrate ist hoch und die Komplikationsrate niedrig

• Ein Versagen des Nahtverschlusssystems im Einzelfall bedarf der chirurgischen Intervention

Key words

endovascular aortic repair - EVAR - TEVAR - percutaneous access

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