title: Selective use of percutaneous endovascular aneurysm repair in women leads to fewer groin complications.
abstract: BACKGROUND
  Endovascular aneurysm repair (EVAR) in women is often technically limited by smaller access vessel anatomy, particularly at the femoral and iliac artery levels. Percutaneous femoral artery access and closure using the "Preclose" technique (PERC) is a less invasive alternative to open surgical femoral arterial exposure and has been reported to be technically feasible, particularly in male cohorts. The purpose of this study was to evaluate the efficacy and access-related outcomes of PERC in women undergoing EVAR.
  
  
  METHODS
  We identified female patients in a prospectively maintained EVAR database from 2000 to 2009. An all-percutaneous approach was adopted in 2007 if technically feasible, based on preoperative computed tomography angiogram criteria including a femoral diameter >7 mm, <25% posterior plaque and lack of circumferential calcification/disease. All percutaneous EVAR procedures were performed using two Perclose Proglide devices in a standardized manner for sheath sizes ranging between 12F and 26F.
  
  
  RESULTS
  In period 1 (2000-2006), most cases were performed with open femoral exposure. In period 2 (2007-2009), our group adopted a percutaneous-first approach. Of 736 EVARs performed during the study period, 120 (16.3%) were in women, leading to 178 femoral arteries requiring large sheath access. Period 1 included 90 women and period 2 included 30 women who were evaluated for percutaneous access. During period 2, of the 47 eligible femoral arteries for possible PERC, 24 (51%) met appropriate criteria, and the Preclose technique was employed. The remaining 23 femoral arteries during period 2 were accessed with surgical exposure (OPEN). Technical success rate of PERC in period 2 was 96%, with one device pulling through a thin anterior arterial wall requiring open femoral conversion. During period 2, the OPEN cohort had a higher rate of total wound complications compared with PERC (34.8% vs. 8.3%, P = 0.02), including hematomas (8.7% vs. 0%), wound breakdowns (8.7% vs. 0%), and pseudoaneurysms (4.3% vs. 0%). There were two cases of femoral artery thrombosis in the PERC group requiring repair in the immediate postoperative period; however, this was not significantly different compared with the OPEN group (8.7% vs. 8.3%).
  
  
  CONCLUSIONS
  Selective percutaneous access of the femoral arteries for EVAR is safe and effective in the female population, with fewer wound complications than open exposure. Approximately one-half of femoral arteries in women are eligible for PERC access, and complications can be limited with careful selection based on preoperative imaging.
authors.affiliation: Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA 94305, USA.
authors.forename: Weesam K
authors.initials: WK
authors.lastname: Al-Khatib
authors.forename: Mohamed A
authors.initials: MA
authors.lastname: Zayed
authors.forename: E John
authors.initials: EJ
authors.lastname: Harris
authors.forename: Ronald L
authors.initials: RL
authors.lastname: Dalman
authors.forename: Jason T
authors.initials: JT
authors.lastname: Lee
mesh_terms: D000368:Aged; D000783:Aneurysm / Q000175:diagnosis / Q000601:surgery*; D000792:Angiography; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods / Q000706:statistics & numerical data*; D002140:California / Q000453:epidemiology; D057510:Endovascular Procedures / Q000379:methods / Q000706:statistics & numerical data*; D005240:Feasibility Studies; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D005500:Follow-Up Studies; D006119:Groin; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D015994:Incidence; D011183:Postoperative Complications / Q000453:epidemiology* / Q000517:prevention & control; D011446:Prospective Studies; D013536:Suture Techniques / Q000706:statistics & numerical data*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome