Totally percutaneous aortic aneurysm repair: experience and prudence.
OBJECTIVE
Totally percutaneous aortic aneurysm repair has been shown to be technically feasible, with low morbidity. Complications from percutaneous arterial closure are not insignificant, however, and can be fatal. We sought to evaluate our experience with this technique, compare it with the published literature, and identify factors associated with conversion to open repair and complications.


METHODS
A retrospective review of a prospectively collected database was performed. All patients who underwent percutaneous closure of large-bore-sheath (>12F) access sites with off-label use of a suture-mediated closure device (Prostar XL) between December 2002 and August 2005 were reviewed. Outcome measures evaluated were rates of technical success, conversion to open femoral arterial repair, and complications. Axial diameter measurements of the accessed vessels were assessed with computed tomographic (CT) angiography both before and after the procedure. Patient variables were compared by using chi2, Fisher exact, and paired and independent samples t tests where appropriate. The mean follow-up interval was 1.5 years.


RESULTS
During the study period, 49 patients underwent percutaneous closure of 79 large-bore-sheath access sites after successful endovascular aneurysm repair. Seven patients (14%) were morbidly obese (body mass index >35 kg/m2). Successful closure was achieved in 74 access sites (93.7%). Percutaneous closure was unsuccessful in five access sites (6.3%), all of which required open femoral repair at the same setting. Two converted patients experienced complications (4.1%): one retroperitoneal hematoma requiring transfusion of blood products and one iliac artery injury leading to death from myocardial infarction. Both of these patients were morbidly obese. Both complications occurred after closure of larger than 20F sheath sites. Morbid obesity and sheath size greater than 20F were associated with a significantly increased complication rate (P = .02 and P = .01, respectively). No thrombotic or infectious complications occurred in this series. Upon comparison of preoperative and postoperative CT angiograms, one (1.3%) small pseudoaneurysm was detected. No arteriovenous fistulas or hematomas larger than 3 cm were detected. The pseudoaneurysm occurred after closure of a 20F sheath access site. There were no significant differences in minimum intraluminal (7.38 +/- 1.8 vs 7.48 +/- 1.8) or maximum extraluminal (11.25 +/- 2.8 vs 12.02 +/- 2.7) diameters between preoperative and postoperative CT angiograms, respectively.


CONCLUSIONS
Totally percutaneous aortic aneurysm repair is technically feasible in most cases, with no effect on the luminal diameter of the accessed femoral artery. Complications occur more often in morbidly obese patients and with sheaths larger than 20F. These complications can be minimized with meticulous technique and good patient selection. The capability for expeditious open femoral arterial repair is mandatory with this approach.
Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431-1100, USA. bwtarnes@comcast.net
Benjamin Ware
BW
Starnes
Charles A
CA
Andersen
Joseph A
JA
Ronsivalle
Neal R
NR
Stockmaster
Philip S
PS
Mullenix
John D
JD
Statler
D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D002404:Catheterization / Q000009:adverse effects* / Q000295:instrumentation; D019992:Databases as Topic; D004867:Equipment Design; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000601:surgery; D005500:Follow-Up Studies; D006488:Hemostasis, Surgical / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications; D011677:Punctures; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013536:Suture Techniques / Q000295:instrumentation; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014861:Washington