Percutaneous access planning, techniques and considerations for endovascular aortic repair (EVAR)

The Development of Totally Percutaneous Aortic Arch Repair With Inner-Branch Endografts: Experience From 2 Centers

OBJECTIVE

The main objective of this study is to present the experience of 2 centers undertaking total percutaneous aortic arch-branched graft endovascular repair using combination of femoral and axillary routes. The report summarizes the procedural steps, outcomes achieved, and the benefits of this approach, which eliminates the need for direct open surgical exposure of the carotid, subclavian, or axillary arteries, thereby reducing the unnecessary associated surgical risks.

METHODS

Retrospectively collected data of 18 consecutive patients (15M:3F) undergoing aortic arch endovascular repair using a branched device between February 2021 and June 2022 at 2 aortic units. Six patients were treated for a residual aortic arch aneurysm following previous type A dissection with size range of (58-67 mm in diameter), 10 were treated for saccular or fusiform degenerative atheromatous aneurysm with size range of (51.5-80 mm in diameter), and 2 were treated for penetrating aortic ulcer (PAU) with size range of (50-55 mm). Technical success was defined as completion of the procedure and satisfactory placement of the bridging stent grafts (BSGs) in the supra-aortic vessels percutaneously including the brachiocephalic trunk (BCT), left common carotid artery (LCCA), and left subclavian artery (LSA) without the need for carotid, subclavian, or axillary cut down. The primary technical success was examined as primary outcome well as any other related complications and reinterventions as secondary outcomes.

RESULTS

The primary technical success with our alternative approach was achieved in all 18 cases. There was one access site complication (groin haematoma), which was managed conservatively. There was no incidence of death, stroke, or cases of paraplegia. No other immediate complications were noted. Postoperative imaging confirmed supra-aortic branch patency, with satisfactory position of the BSGs and immediate aneurysm exclusion except in 4 patients who had type 1C endoleak (Innominate: 2, LSA 2) detected on the first postoperative scan. Three of them were treated with relining/extension, and 1 spontaneously resolved after 6 weeks.

CONCLUSIONS

Total percutaneous aortic arch repair with antegrade and retrograde inner-branch endografts can be performed with promising early results. Dedicated steerable sheaths and appropriate BSG would optimize the percutaneous approach for aortic arch endovascular repairs.Clinical ImpactThis article provides an alternative and innovative approach to improve the minimally invasive techniques in the endovascular treatment of the aortic arch conditions.

Transaxillary endovascular aortic aneurysm repair using a reverse mounted Gore Excluder endograft for a patient with abdominal aortic aneurysm and severe iliofemoral occlusive disease

Adverse iliofemoral anatomy represents a unique challenge for endovascular aortic aneurysm repair (EVAR). This report describes a transaxillary EVAR in a patient with severe iliofemoral occlusive disease and an infrarenal aortic aneurysm. A reversely mounted Gore Excluder graft was advanced and deployed in the infrarenal aorta using the left axillary artery. Lithoangioplasty and stenting were performed on bilateral iliofemoral anatomy. At the 1-year follow-up, the aneurysm sac revealed regression without endoleaks and the iliofemoral stents remained patent. The transaxillary approach may be a feasible access site for EVAR in patients with a high risk for open repair and prohibitive iliofemoral anatomy.

Transradial-based thoracic branch endograft repair for thoracic aortic aneurysms experience at a suburban community hospital

We present two cases where a transradial-based approach was used to implant thoracic branch aortic endografts to repair aortic aneurysms totally percutaneously. Both procedures were performed electively at a 330-bed suburban community hospital. No complications were associated with either procedure with both patients only requiring overnight observation and being discharged home the next day. With careful patient selection, the transradial through-and-through approach for thoracic endovascular aortic repair using the Gore Thoracic Branch Endoprosthesis provides a totally percutaneous option that can be performed feasibly and safely within a community hospital setting.

Shockwave for peripheral artery disease: an update on trial data

Intravascular lithotripsy (IVL) is fast becoming the vessel preparation tool of choice given its excellent safety profile and associated positive outcomes. In this review, we aim to summarize the most recent trial data as it applies to IVL's utility within the various peripheral arterial beds, including facilitation of large bore vascular access, and elaborate on future directions of this innovative therapy.

The PIGTAIL paradigm for a fast and safe transfemoral transcatheter aortic valve replacement

Transfemoral transcatheter aortic valve replacement is the preferred primary access route whenever possible. Despite advancements in expertise and delivery system profiles, complications associated with the primary femoral access still significantly affect procedural morbidity and outcomes. The current standard for accurate main access planning involves proper preprocedural evaluation guided by computed tomography. Several baseline clinical and anatomical features serve as predictors for the risk of vascular injury occurring during or after transcatheter aortic valve replacement. In this paper, we aimed at reviewing the most up-to-date knowledge of the topic for a safe transfemoral access approach according to a paradigm we have called "PIGTAIL."

Intravascular lithotripsy supported endovascular aneurysm repair

As the use of endovascular aneurysm repair (EVAR) increases, anatomic constraints remain a challenge. In this case report, we describe the use of intravascular lithotripsy to facilitate EVAR in a patient with a severely calcified and stenotic aortic bifurcation. Future applications of intravascular lithotripsy could help expand the use of EVAR to patients with severely stenotic vasculature and optimize outcomes in the treatment of infrarenal abdominal aortic aneurysms.

The Characteristics and Results of Endovascular Devices in Trauma (CREDiT) study: Multi-institutional results

INTRODUCTION

Endovascular techniques are increasingly used to repair major traumatic vascular injuries, but most endovascular implants are not designed/approved for trauma-specific indications. No inventory guidelines exist for the devices used in these procedures. We aimed to describe the use and characteristics of endovascular implants used for repair of vascular injuries to allow for better inventory management.

METHODS

This CREDiT study is a six-year retrospective cohort analysis of endovascular procedures performed for repair of traumatic arterial injuries at five participating US trauma centers. For each treated vessel, procedural and device details were recorded and outcomes assessed with the aim of defining the range of implants and sizes used for these interventions.

RESULTS

A total of 94 cases were identified; 58 (61%) were descending thoracic aorta, 14 (15%) axillosubclavian, 5 carotid, 4 abdominal aortic, 4 common iliac, 7 femoropopliteal, and 1 renal. Vascular surgeons performed 54% of cases, trauma surgeons 17%, IR/CT Surgery 29%. Systemic heparin was administered in 68% and procedures were performed a median of 9 h after arrival (IQR 3-24 h). Primary arterial access was femoral in 93% of cases, 49% were bilateral. Brachial/radial access was used primarily in 6 cases, and secondary to femoral in 9. The most common implant was self-expanding stent graft; 18% used >1 stent. Implants ranged in diameter and length based on vessel size. Five of 94 implants underwent reintervention (1 open surgery) at a median of 4d postop (range 2-60d). Two occlusions and 1 stenosis were present at follow-up at a median of 1 month (range 0-72 m).

CONCLUSIONS

Endovascular reconstruction of injured arteries requires a broad range of implant types, diameters, and lengths which should be readily available in trauma centers. Stent occlusions/stenoses are rare and can typically be managed by endovascular means.

Suture-mediated closure devices for percutaneous endovascular abdominal aneurysm repair

Purpose

Endovascular procedures such as endovascular aneurysm repair or transcatheter aortic valve implantation have become very common because of reduced patient traumatisation and the ability to use shorter or local anaesthesia. In these procedures large-bore sheath devices are used. Access with percutaneous closure is an alternative method to surgical cutdown in groins. The aim of the study was to assess the correlation between sheath size and unsuccessful haemostasis. In addition, the effectiveness of haemostasis after a percutaneous procedure and the number and type of complications were evaluated.

Material and methods

There were 202 patients included in the study. Patients with abdominal aortic aneurysm were qualified to percutaneous aortic stentgraft implantation with Perclose Proglide preclosure technique.

Results

There were 384 access sites performed with 12F to 22F sheaths during aortic stentgraft implantation with Perclose Proglide (Abbott Vascular, Santa Clara, CA, USA) preclosure technique. High effectiveness of haemostasis (98%), low percentage of short- and mid-term complications (2.6%), and infinitesimal number of surgical conversions (n = 5) were stated in the study. There was no correlation between diameter of used introducer sheath and lack of haemostasis observed (Fisher-Freeman-Halton test; p = 0.122). No relationship between diameter of introducer sheath and number of closure devices was observed (c² = 2.436; df = 5; p = 0.786).

Conclusions

Large-bore device percutaneous procedures with closure devices are effective and safe. High effectiveness of haemostasis (98%) was observed in the study group, with a low percentage of complications (2.6%). There was no correlation between size of the vascular access and the lack of haemostasis found in the study.

Comparison of percutaneous and cutdown access‑related minor complications after endovascular aortic repair

The aim of the present study was to compare the open surgical and percutaneous access for thoracic/endovascular aortic repair (T/EVAR) regarding in-hospital and post-hospital minor-complications. Percutaneous (pEVAR) and cutdown (cEVAR) techniques for femoral vessel access for T/EVAR were compared regarding their minor complications. The basic population of this retrospective cohort study consisted of 44 percutaneous and 215 cutdown accesses for endovascular aortic repair (T/EVAR-procedure) conducted between August 2008 and October 2019. The primary outcome consisted of conservatively treatable minor complications until hospital discharge and during follow up. Secondary outcomes comprised postoperative pain and complications requiring invasive treatment. Minor complications were observed in 11.4% (pEVAR) vs. 9% (cEVAR) of cases throughout index hospital stay and 10 vs. 13.7% during follow-up. No significant differences were noticed regarding overall complication rate between pEVAR and cEVAR. Only bleedings treatable through compression occurred significantly more often in the pEVAR-group (6.8 vs. 0.5%; P=0.02). In conclusions, the percutaneous technique represents a safe and quickly executable alternative to cutdown access. A significant difference in overall minor complications could not be observed. In both techniques, complications may occur even months after surgery. In order to demonstrate the superiority of the percutaneous technique compared with cutdown access, possible predictors for the use of the percutaneous technique should be defined in the future.

Use of Percutaneous Cannulation in Robotic Mitral Valve Surgery

Minimally invasive cardiac surgery (MICS) has evolved in its practice over the past several years. Percutaneous cannulation is a technique that can be used during MICS to facilitate cardiopulmonary bypass. This manuscript describes the stepwise approach to percutaneous cannulation and decannulation in robotic mitral valve surgery.

Impact of calcification modeling to improve image fusion accuracy for endovascular aortic aneurysm repair

Since the 1990s, endovascular aortic aneurysm repair (EVAR) has become a common alternative to open surgery for the treatment of abdominal aortic aneurysms (AAAs). To aid the deployment of stent-grafts, fluoroscopic image guidance can be enhanced using preoperative simulation and intraoperative image fusion techniques. However, the impact of calcification (Ca) presence on the guidance accuracy of such techniques is yet to be considered. In the present work, we introduce a guidance tool that accounts for patient-specific Ca presence. Numerical simulations of EVAR were developed for 12 elective AAA patients, both with (With-Ca) and without (No-Ca) Ca consideration. To assess the accuracy of the simulations, the image results were overlaid on corresponding intraoperative images and the overlay error was measured at selected anatomical landmarks. With this approach we gained insight into the impact of Ca presence on image fusion accuracy. Inclusion of Ca improved mean image fusion accuracy by 8.68 ± 4.59%. In addition, a positive correlation between the relative Ca presence and the image fusion accuracy was found (R = .753, p < .005). Our results suggest that considering Ca presence in patient-specific EVAR simulations increases the reliability of EVAR image guidance techniques that utilize numerical simulation, especially for patients with severe aortic Ca presence.

Endovascular Aortic Aneurysm Repair: A Narrative Review

Endovascular aortic aneurysm repair (EVAR) has evolved as minimally invasive method of treating infrarenal abdominal aortic aneurysms (AAA) with perioperatively mortality of less than 1% compared with 5% with open AAA repair as suggested by many randomized control trials. Computed tomography angiography is the imaging of choice for appropriate selection of a patient with EVAR. For patients with unsuitable anatomy, advanced EVARs techniques, such as fenestrated, branch, and chimney EVARs, are also increasingly being offered to patients with equal success. Patients with ruptured AAA are treated with this minimally invasive procedure. Percutaneous EVAR emerged with less of wound-related complications. Endoleaks are the most common complications peculiar to this procedure, and most are preventable by preoperative planning. They are detected on completion angiogram or on the surveillance imaging. This review discusses indications of EVAR, its selection criteria, procedural steps, and common complications associated with this procedure and advanced EVARs.

Pre-operative platelet reactivity is a strong, independent predictor of bleeding complications after branched endovascular thoracoabdominal aortic aneurysm repair

Endovascular aortic repair (EVAR) an alternative to open surgical repair of thoracoabdominal aortic aneurysm (TAAA). The effect of EVAR on platelet reactivity is unknown. We prospectively determined the effect of branched EVAR (bEVAR) on platelet reactivity in patients with TAAA, and evaluated the predictive value of preoperative platelet reactivity for post-operative bleeding in 50 consecutive patients undergoing elective bEVAR (mean age 70.9 ± 5.7 years, 66% male). Blood samples were collected within 24 hours before bEVAR, after bEVAR and at hospital discharge. Platelet reactivity was assessed with impedance aggregometry using ASPI, ADP and TRAP tests. Platelet reactivity decreased within 24 hours after bEVAR compared to the measurement before bEVAR in all tests (p ≤ 0.04), with a further decrease in hospital discharge in the ADP test (p = .004). Twenty-three patients experienced post-operative bleeding complications (transfusion ≥2 red blood cell [RBC] units). Preoperative platelet reactivity below the cutoff value of 30 AUC units predicted post-operative bleeding with 78% sensitivity and 59% specificity (p = .045). In the multivariable analysis, platelet reactivity was the only independent predictor of postoperative bleeding (OR 6.507, 95% CI 1.227-34.506, p = .028). We conclude that platelet reactivity decreases following bEVAR of TAAA and is a strong and independent predictor for postoperative bleeding complications.

Assessment of EVAR Complications using CIRSE Complication Classification System in the UK Tertiary Referral Centre: A ∼6-Year Retrospective Analysis (2014-2019)

PURPOSE

To retrospectively analyse complications in endovascular aortic repair (EVAR) interventions and evaluate if the CIRSE (Cardiovascular and Interventional Radiological Society of Europe) complication classification system is appropriate as a standardized classification tool for EVAR patients.

MATERIALS AND METHODS

Demographic, procedural and complication data in 719 consecutive patients undergoing EVAR at one institution from January 2014 to October 2019 were retrospectively reviewed. Data (imaging reports, procedural reports, nurse notes, discharge summary reports) were collected consulting the electronic patient record system (EPR) of the hospital and cleaned and stored in a Microsoft Excel database. All the procedures were analysed in consensus by two interventional radiology consultants and a resident radiologist and if an intra- , peri- or post-procedural complication occurred, a grade (1-6) was assigned using the CIRSE grading complication classification system.

RESULTS

Twenty-five patients were excluded from the analysis because of invalid or incomplete data. The final population was made up of 694 patients (mean age 75,4 y.o., 616 male/78 female, min age 23 y.o., max age 97 y.o.). Complications emerged in 211 patients (30,4% of cases, 22 female/189 male). The number of patients with CIRSE grade I, II, III, IV, V and VI complications was 36 (17%), 17 (8%), 121 (57,3%), 15 (7,1%), 3 (1,4%), 19 (9%). Nineteen (2,6%) patients succumbed after EVAR. Thirty-four complications (16,1%) were related to vascular access.

CONCLUSION

The CIRSE complication classification system represents a broadly applicable and feasible approach to evaluate the severity of complications in patients following EVAR. However, some deficit may be considered relevant and as starting standing-point for future improvements.

Mid-term follow-up of percutaneous access for standard and complex EVAR using the ProGlide device

OBJECTIVES

Endovascular Aneurysm Repair is an established treatment for abdominal aortic aneurysm which requires arterial access via the groin. Most centres perform percutaneous ultrasound-guided access into the common femoral artery for delivery of the stent graft. The profile of endovascular devices necessitates large sheath sizes, therefore formal closure of the arterial puncture site is required. Various percutaneous devices are available, with data lacking on efficacy and mid-term safety profile. We present outcomes from a single centre with the Perclose ProGlide™ (Abbott Vascular Devices, CA, USA) suture-mediated system, using the well described "pre-close" technique.

MATERIALS & METHODS

Data were collected from operative records and electronic medical records. Patients undergoing standard (EVAR) or complex (F/B-EVAR) aneurysm repair between March 2015 and September 2019 were included. Complications were recorded per-patient and per-groin procedure.

RESULTS

266 patients were included; 182 (68.4%) standard infrarenal EVAR, 84 (31.6%) F/B-EVAR. There were a total of 484 groin procedures performed. Intraoperative Perclose ProGlide™ success was 98.1% (per patient) or 99.0% (per groin procedure). 30-day groin complication rate was 6.1% (per patient) or 3.1% (per groin procedure). There were no pre- or peri-operative factors which predicted the occurrence of groin complications. The rate of groin complications was not related to sheath size.

CONCLUSIONS

Our data support the use of percutaneous access with a pre-close technique for a variety of endovascular aneurysm repair procedures with both large- and small-bore access. The Perclose ProGlide™ system provides excellent mid-term complication-free and reintervention-free outcomes for groin procedures.

Percutaneous Endovascular Aneurysm Repair: Current Status and Future Trends

Endovascular aneurysm repair (EVAR) is a common, safe, and effective method of treating abdominal aortic aneurysms. Traditionally treated via surgical cutdown over the common femoral arteries, many recent studies demonstrate percutaneous access techniques to avoid the surgical cutdown. Developing familiarity with these percutaneous techniques, including risks, complications, adjuncts, and alternative accesses, can help improve the outcomes and availability of EVAR. As these techniques become increasingly common, it is not unlikely that they can be practiced safely in select patients in an outpatient setting.

Access Type for Endovascular Repair in Ruptured Abdominal Aortic Aneurysms Does Not Affect Major Morbidity or Mortality

BACKGROUND

There are limited data on access type when treating ruptured abdominal aortic aneurysms (AAAs) with endovascular aneurysm repair (EVAR). Our study's objective was to evaluate if the type of access in ruptured AAAs affected outcomes.

METHODS

The Vascular Quality Initiative was queried from 2009 to 2018 for all ruptured AAAs treated with an index EVAR. Procedures were grouped by access type: percutaneous, open, and failed percutaneous that converted to open access. Patients with iliac access, both percutaneous and open access, and concurrent bypass were excluded. Baseline characteristics, procedure details, and outcomes were collected. Univariable and multivariable analyses were performed.

RESULTS

There were 1,206 ruptured AAAs identified-739 (61.3%) was performed by percutaneous access, 416 (34.5%) by open access, and 51 (4.2%) by failed percutaneous that converted to open access. Percutaneous access, compared with open access and failed percutaneous access, respectively, had the shortest operative time (min, median) (111 vs. 138 vs. 180, P < 0.001) and was most often performed under local anesthesia (16.7% vs. 5% vs. 9.8%, P < 0.001). The amount of contrast used was similar between the approaches. Univariable analysis comparing percutaneous access, open access, and failed percutaneous access showed differences in 30-day mortality (19.9% vs. 24.8% vs. 39.2%, P = 0.002), postoperative complications (33.7% vs. 40.2% vs. 54%, P = 0.003), and cardiac complications (18.2% vs. 19.8% vs. 34.7%, P = 0.018). However, multivariable analysis did not show access type to have a significant effect on cardiac complications, pulmonary complications, any complications, return to the operating room, or perioperative mortality. Open access was independently associated with a prolonged length of stay (means ratio 1.17, 95% confidence interval (CI) 1.04-1.33, P = 0.012). Factors independently associated with failed percutaneous were prior bypass (odds ratio (OR) 9.77, 95% CI 2.44-39.16, P = 0.001) and altered mental status (OR 2.45, 95% CI 1.17-5.15, P = 0.018).

CONCLUSIONS

Access type for ruptured AAAs was not independently associated with major morbidity or mortality but did have a differential effect on length of stay. Access during these emergent procedures should be based on surgeon preference and experience.

Use of a balloon-expandable sheath for transfemoral complex endovascular aortic repair

Authors' Note: On April 30, 2019, Terumo Medical Corporation issued a voluntary product recall for and discontinued manufacturing of the SoloPath Balloon Expandable Sheath System, the device used for the procedures outlined in this article. Data collection, data analysis, and manuscript submission occurred prior to notice of this recall. The authors of this article were unaware of adverse events associated with this device and the 15 procedures reviewed for this series were free of events related to the reason for this device recall. Management of iliac artery disease remains a challenging problem in the setting of complex endovascular aortic procedures. In spite of the nonavailability of the device outlined in this article, the authors feel that the value of innovative solutions to this clinical problem (including the use of a balloon expandable sheath) merits public review of this technique and its results. Vascular access complications contribute to the morbidity of fenestrated endovascular aneurysm repair (FEVAR). As the ability to perform these procedures progresses, new techniques emerge to overcome difficult peripheral vascular anatomy and to minimize these complications. We describe our use of a balloon-expandable sheath to accommodate the multiple accesses needed for bridging stent placement during FEVAR in patients with highly calcified, tortuous, or small-diameter access vessels. We used this sheath for successful completion of FEVAR in 15 patients with challenging iliofemoral disease. There was one iliofemoral complication and no limb loss. Given the significant source of morbidity that vascular access complications contribute to endovascular procedures, we believe that a balloon-expandable sheath is a useful adjunct in FEVAR with complex iliac anatomy.