title: Femoral artery calcification as a determinant of success for percutaneous access for endovascular abdominal aortic aneurysm repair.
abstract: OBJECTIVE
  This study was conducted to determine the outcomes and predictive factors for success during percutaneous endovascular aneurysm repair (PEVAR) using vascular closure devices (VCDs).
  
  
  METHODS
  The clinical data of patients who underwent PEVAR between 2005 and 2012 were retrospectively reviewed. Patient demographics, body mass index, sheath size, device types, diameter of femoral arteries, and extent and location of femoral artery calcification were recorded. Included were all consecutive patients treated by PEVAR with sheath sizes ranging from 12 F to 24 F. End points were technical success, conversion to open femoral artery repair, and complications.
  
  
  RESULTS
  During this period, 752 patients were treated by EVAR. Of these, 391 femoral arteries in 222 patients (29.5%; 197 men, 25 women), with a mean age of 74.8 years (range, 51-93.7 years), underwent PEVAR (169 bilateral and 53 unilateral percutaneous access). Patients with >50% anterior femoral artery calcifications or those with previous femoral artery reconstructions were not offered PEVAR. Technical success of PEVAR was 96.4% (377 of 391), with an average of two VCDs used per groin. Fourteen intraoperative failures were managed with open femoral conversion using primary repair (five) or patch angioplasty (nine). In nine patients, the procedure was converted from local to general anesthesia. Four patients required a perioperative blood transfusion. There were no significant differences in body mass index (P = .26), femoral artery size preprocedure (P = .33) or postprocedure (P = .37), sheath size (≥ 20 F vs ≤ 18 F), or type of VCD used between the success and failure groups. Pairwise comparisons revealed increased failure rate (P < .001) between patients with <50% anterior wall calcification vs none, <50% anterior wall calcification vs <50% posterior wall calcification, and none vs >50% posterior calcification. There was no significant difference (P = .53) between patients with <50% posterior wall calcification and those with no calcification. The 30-day mortality of the entire group was 0.9% (2 of 222 patients). No deaths occurred after conversion to open femoral closure. At a mean follow-up of 30 months (range, 1-85.2 months), there were no long-term groin complications or iliac limb occlusions.
  
  
  CONCLUSIONS
  PEVAR using VCDs can be performed with high technical success in patients with <50% anterior wall calcification, regardless of the size of the access sheath or the patient's body mass index. Femoral artery calcification, however, is a major determinant of failure.
authors.affiliation: Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, Minn.
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Manunga
authors.forename: Peter
authors.initials: P
authors.lastname: Gloviczki
authors.forename: Gustavo S
authors.initials: GS
authors.lastname: Oderich
authors.forename: Manju
authors.initials: M
authors.lastname: Kalra
authors.forename: Audra A
authors.initials: AA
authors.lastname: Duncan
authors.forename: Mark D
authors.initials: MD
authors.lastname: Fleming
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Bower
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001803:Blood Transfusion; D016009:Chi-Square Distribution; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D004867:Equipment Design; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging; D006489:Hemostatic Techniques / Q000295:instrumentation / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000517:prevention & control; D011677:Punctures; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D061205:Vascular Calcification / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality