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Semin intervent Radiol
DOI: 10.1055/s-0044-1800957
Review Article

Large-Bore Transfemoral Arterial Access: Techniques and Troubleshooting

Amber L. Liles
1   Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health, Ann Arbor, Michigan
,
Geogy Vatakencherry
2   Division of Vascular and Interventional Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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Abstract

Aortic pathologies such as dissection, aneurysm, or blunt aortic injury have historically been treated via open surgical repair; however, the advent of endovascular stent graft technology has allowed for endovascular aortic repair in more and more patients. With improvements in stent graft technology and delivery systems, more patients are now candidates for endovascular aortic repair; however, many will require large-bore transfemoral arterial access. Percutaneous transfemoral arterial access includes the introduction of a large-bore sheath directly into the iliofemoral arterial system for the deployment of aortic stent grafts. Advancements in percutaneous arterial closure and reductions in device delivery profiles have further refined this technique; however, careful preprocedural planning and technical precision are required to minimize complications. This article covers the fundamentals of large-bore transfemoral arterial access as well as technical pearls for successful outcomes.

Keywords

endograft - access - interventional radiology - closure device - femoral


Publication History

Article published online:
18 December 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Yei K, Mathlouthi A, Naazie I, Elsayed N, Clary B, Malas M. Long-term outcomes associated with open vs endovascular abdominal aortic aneurysm repair in Medicare-matched database. JAMA Netw Open 2022; 5 (05) e2212081
    CrossrefPubMedSearch in Google Scholar
  • 2 Lederle FA, Kyriakides TC, Stroupe KT. et al; OVER Veterans Affairs Cooperative Study Group. Open versus endovascular repair of abdominal aortic aneurysm. N Engl J Med 2019; 380 (22) 2126-2135
    CrossrefPubMedSearch in Google Scholar
  • 3 Cao Z, Wu W, Zhao K. et al. Safety and efficacy of totally percutaneous access compared with open femoral exposure for endovascular aneurysm repair: a meta-analysis. J Endovasc Ther 2017; 24 (02) 246-253
    CrossrefPubMedSearch in Google Scholar
  • 4 Nelson PR, Kracjer Z, Kansal N. et al. A multicenter, randomized, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial). J Vasc Surg 2014; 59 (05) 1181-1193
    CrossrefPubMedSearch in Google Scholar
  • 5 Baxter RD, Hansen SK, Gable CE, DiMaio JM, Shutze WP, Gable DR. GREAT Investigators. GREAT Investigators. Outcomes of open versus percutaneous access for patients enrolled in the GREAT Registry. Ann Vasc Surg 2021; 70: 370-377
    CrossrefPubMedSearch in Google Scholar
  • 6 Picel AC, Kansal N. Essentials of endovascular abdominal aortic aneurysm repair imaging: preprocedural assessment. AJR Am J Roentgenol 2014; 203 (04) W347-W357
    CrossrefPubMedSearch in Google Scholar
  • 7 Tran K, Dorsey C, Lee JT, Chandra V. Gender-related differences in iliofemoral arterial anatomy among abdominal aortic aneurysm patients. Ann Vasc Surg 2017; 44: 171-178
    CrossrefPubMedSearch in Google Scholar
  • 8 Bensley RP, Hurks R, Huang Z. et al. Ultrasound guided percutaneous EVAR success is predicted by vessel diameter. J Vasc Surg 2012; 55 (06) 1554-1561
    CrossrefPubMedSearch in Google Scholar
  • 9 Vandy FC, Girotti M, Williams DM. et al. Iliofemoral complications associated with thoracic endovascular aortic repair: frequency, risk factors, and early and late outcomes. J Thorac Cardiovasc Surg 2014; 147 (03) 960-965
    CrossrefPubMedSearch in Google Scholar
  • 10 Seto AH, Abu-Fadel MS, Sparling JM. et al. Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial). JACC Cardiovasc Interv 2010; 3 (07) 751-758
    CrossrefPubMedSearch in Google Scholar
  • 11 Aaron A, El-Hag S, de Grandis E. et al. The superficial femoral artery: an alternative access for percutaneous endovascular aneurysm repair. Ann Vasc Surg 2017; 38: 339-344
    CrossrefPubMedSearch in Google Scholar
  • 12 Stone P, Campbell J, Thompson S, Walker J. A prospective, randomized study comparing ultrasound versus fluoroscopic guided femoral arterial access in noncardiac vascular patients. J Vasc Surg 2020; 72 (01) 259-267
    CrossrefPubMedSearch in Google Scholar
  • 13 Torsello GB, Kasprzak B, Klenk E, Tessarek J, Osada N, Torsello GF. Endovascular suture versus cutdown for endovascular aneurysm repair: a prospective randomized pilot study. J Vasc Surg 2003; 38 (01) 78-82
    CrossrefPubMedSearch in Google Scholar
  • 14 de Souza LR, Oderich GS, Banga PV. et al. Outcomes of total percutaneous endovascular aortic repair for thoracic, fenestrated, and branched endografts. J Vasc Surg 2015; 62 (06) 1442-9.e3
    CrossrefPubMedSearch in Google Scholar
  • 15 Georgiadis GS, Antoniou GA, Papaioakim M. et al. A meta-analysis of outcome after percutaneous endovascular aortic aneurysm repair using different size sheaths or endograft delivery systems. J Endovasc Ther 2011; 18 (04) 445-459
    CrossrefPubMedSearch in Google Scholar
  • 16 Barbash IM, Barbanti M, Webb J. et al. Comparison of vascular closure devices for access site closure after transfemoral aortic valve implantation. Eur Heart J 2015; 36 (47) 3370-3379
    CrossrefPubMedSearch in Google Scholar
  • 17 Melloni A, Grandi A, Spelta S. et al. Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair. J Vasc Surg 2021; 73 (01) 81-91
    CrossrefPubMedSearch in Google Scholar
  • 18 Rijkée MP, Statius van Eps RG, Wever JJ, van Overhagen H, van Dijk LC, Knippenberg B. Predictors of failure in closure in percutaneous EVAR using the Prostar XL percutaneous vascular surgery device. Eur J Vasc Endovasc Surg 2015; 49 (01) 45-49
    CrossrefPubMedSearch in Google Scholar
  • 19 Saadi EK, Saadi M, Saadi R, Tagliari AP, Mastella B. Totally percutaneous access using Perclose Proglide for endovascular treatment of aortic diseases. Braz J Cardiovasc Surg 2017; 32 (01) 43-48
    PubMedSearch in Google Scholar
  • 20 Chen IM, Lee TH, Chen PL, Shih CC, Chang HH. Factors in Proglide vascular closure failure in sheath arteriotomies greater than 16 French. Eur J Vasc Endovasc Surg 2019; 58 (04) 615-622
    CrossrefPubMedSearch in Google Scholar
  • 21 Lin SY, Lyu SY, Su TW. et al. Predictive factors for additional ProGlide deployment in percutaneous endovascular aortic repair. J Vasc Interv Radiol 2017; 28 (04) 570-575
    CrossrefPubMedSearch in Google Scholar
  • 22 Krajcer Z, Wood DA, Strickman N. et al. Pivotal clinical study to evaluate the safety and effectiveness of the MANTA Vascular Closure Device during percutaneous EVAR and TEVAR procedures. J Endovasc Ther 2020; 27 (03) 414-420
    CrossrefPubMedSearch in Google Scholar
  • 23 Dumpies O, Jobs A, Obradovic D. et al. Comparison of plug-based versus suture-based vascular closure for large-bore arterial access: a collaborative meta-analysis of observational and randomized studies. Clin Res Cardiol 2023; 112 (05) 614-625
    CrossrefPubMedSearch in Google Scholar
  • 24 van Wiechen MP, Tchétché D, Ooms JF. et al. Suture- or plug-based large-bore arteriotomy closure: a pilot randomized controlled trial. JACC Cardiovasc Interv 2021; 14 (02) 149-157
    CrossrefPubMedSearch in Google Scholar
  • 25 Gemmete JJ, Dasika N, Forauer AR, Cho K, Williams DM. Successful angioplasty of a superficial femoral artery stenosis caused by a suture-mediated closure device. Cardiovasc Intervent Radiol 2003; 26 (04) 410-412
    CrossrefPubMedSearch in Google Scholar
  • 26 Mathisen SR, Nilsson KF, Larzon T. A single center study of ProGlide used for closure of large-bore puncture holes after EVAR for AAA. Vasc Endovascular Surg 2021; 55 (08) 798-803
    CrossrefPubMedSearch in Google Scholar
  • 27 Amponsah MK, Tayal R, Khakwani Z, Sinclair M, Wasty N. Safety and efficacy of a novel “hybrid closure” technique in large-bore arteriotomies. Int J Angiol 2017; 26 (02) 116-120
    Thieme ConnectPubMedSearch in Google Scholar
  • 28 Rowse JW, Morrow K, Bena JF, Eagleton MJ, Parodi FE, Smolock CJ. Iliac conduits remain safe in complex endovascular aortic repair. J Vasc Surg 2019; 70 (02) 424-431
    CrossrefPubMedSearch in Google Scholar
  • 29 Asciutto G, Aronici M, Resch T, Sonesson B, Kristmundsson T, Dias NV. Endoconduits with “pave and crack” technique avoid open iliofemoral conduits with sustainable mid-term results. Eur J Vasc Endovasc Surg 2017; 54 (04) 472-479
    CrossrefPubMedSearch in Google Scholar
  • 30 Di Mario C, Goodwin M, Ristalli F. et al. A prospective registry of intravascular lithotripsy-enabled vascular access for transfemoral transcatheter aortic valve replacement. JACC Cardiovasc Interv 2019; 12 (05) 502-504
    CrossrefPubMedSearch in Google Scholar
  • 31 Hinchliffe RJ, Ivancev K, Sonesson B, Malina M. “Paving and cracking”: an endovascular technique to facilitate the introduction of aortic stent-grafts through stenosed iliac arteries. J Endovasc Ther 2007; 14 (05) 630-633
    CrossrefPubMedSearch in Google Scholar
  • 32 Koda Y, Yamanaka K, Omura A, Gentsu T, Yamaguchi M, Okada K. Spinal cord ischemia after elective endovascular abdominal aortic aneurysm repair in a patient with multiple occlusions of the intercostal and internal iliac arteries. J Vasc Surg Cases Innov Tech 2022; 8 (03) 447-449
    CrossrefPubMedSearch in Google Scholar
  • 33 Mehta V, Wooster M. Hypogastric artery thrombectomy for spinal cord ischemia following fenestrated endovascular aortic repair. J Vasc Surg Cases Innov Tech 2022; 8 (03) 413-416
    CrossrefPubMedSearch in Google Scholar
  • 34 van Bogerijen GHW, Williams DM, Eliason JL, Dasika NL, Deeb GM, Patel HJ. Alternative access techniques with thoracic endovascular aortic repair, open iliac conduit versus endoconduit technique. J Vasc Surg 2014; 60 (05) 1168-1176
    CrossrefPubMedSearch in Google Scholar
  • 35 Meertens MM, Tenorio ER, Lemmens CC. et al. Safety of percutaneous femoral access for endovascular aortic aneurysm repair through previously surgically exposed or repaired femoral arteries. J Endovasc Ther 2023; 30 (05) 730-738
    CrossrefPubMedSearch in Google Scholar
  • 36 Pecoraro F, Krishnaswamy M, Steuer J. et al. Predilation technique with balloon angioplasty to facilitate percutaneous groin access of large size sheath through scar tissue. Vascular 2017; 25 (04) 396-401
    CrossrefPubMedSearch in Google Scholar
  • 37 Kaki A, Alraies MC, Kajy M. et al. Large bore occlusive sheath management. Catheter Cardiovasc Interv 2019; 93 (04) 678-684
    CrossrefPubMedSearch in Google Scholar
  • 38 Shah Z, Alraies MC, Soud M, Kaki A. Ex-vivo percutaneous bypass: Limb perfusion in the setting of occlusive large bore sheath. Catheter Cardiovasc Interv 2019; 93 (04) 673-677
    CrossrefPubMedSearch in Google Scholar
  • 39 Mathur M, Krishnan SK, Levin DM, Aldea G, Reisman M, McCabe JM. A step-by-step guide to fully percutaneous transaxillary transcatheter aortic valve replacement. Struct Heart 2017; 1 (5–6): 209-215
    CrossrefPubMedSearch in Google Scholar
  • 40 Bertoglio L, Conradi L, Howard DPJ. et al; of the PAXA Collaborators. Percutaneous transaxillary access for endovascular aortic procedures in the multicenter international PAXA registry. J Vasc Surg 2022; 75 (03) 868-876.e3
    CrossrefPubMedSearch in Google Scholar
  • 41 Cheney AE, McCabe JM. Alternative percutaneous access for large bore devices. Circ Cardiovasc Interv 2019; 12 (06) e007707
    CrossrefPubMedSearch in Google Scholar
  • 42 Uflacker A, Lim S, Ragosta M. et al. Transcaval aortic access for percutaneous thoracic aortic aneurysm repair: Initial human experience. J Vasc Interv Radiol 2015; 26 (10) 1437-1441
    CrossrefPubMedSearch in Google Scholar
  • 43 Lederman RJ, Greenbaum AB, Khan JM, Bruce CG, Babaliaros VC, Rogers T. Transcaval access and closure best practices. JACC Cardiovasc Interv 2023; 16 (04) 371-395
    CrossrefPubMedSearch in Google Scholar
  • 44 Lederman RJ, Babaliaros VC, Greenbaum AB. How to perform transcaval access and closure for transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2015; 86 (07) 1242-1254
    CrossrefPubMedSearch in Google Scholar