Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients.
OBJECTIVE
There are limited data describing the preclose technique with the Perclose ProGlide device (Abbott Vascular, Redwood City, Calif) in percutaneous thoracic endovascular aortic repair (P-TEVAR), particularly in obese patients, in whom use of this technique is thought to be relatively contraindicated. The purpose of this analysis was to describe our experience with P-TEVAR and to compare outcomes in patients with or without obesity.


METHODS
All TEVAR procedures at a single institution from 2005 to 2011 were reviewed, and P-TEVAR patients were stratified by body mass index (obesity ≥ 30 kg/m2). Preoperative computed tomography scans were analyzed for access vessel depth, calcification, and morphology. Technical success was defined as the ability to achieve hemostasis and to maintain limb perfusion without the need for common femoral artery exposure or obligate surgical repair of the vessel within a 30-day postoperative period. Generalized estimating equations and stepwise logistic regression were used to develop prediction models of preclose failure.


RESULTS
The review identified 536 patients, in whom 355 (66%) P-TEVAR procedures were completed (366 arteries; n = 40 [11%] bilateral). Compared with nonobese patients (n = 264), obese patients (n = 91) were typically younger (59 ± 16 years vs. 66 ± 16 years; P = .0004) and more likely to have renal insufficiency (28% vs. 17%; P = .05) or diabetes mellitus (19% vs. 9%; P = .02). The number of Perclose deployments was similar between groups (P = NS). Mean sheath size (25.4F vs 25.0F; P = .04), access vessel inner diameters (8.5 ± 1.9 mm vs. 7.9 ± 2.0 mm; P = .02), and vessel depth (50 ± 20 mm vs. 30 ± 13 mm; P < .0001) were greater in obese patients. Adjunctive iliac stents were used in 7% of cases (10 [11%] in obese patients vs 16 [6%] in nonobese patients; P = .2). Overall technical success was 92% (92% for nonobese patients vs 93% for obese patients; P = .7). Three patients required subsequent operations for access complications, two obese patients (2%) and one nonobese patient (0.4%) (P = .3). Independent predictors of failure were adjunctive iliac stent (odds ratio [OR], 9.5; 95% confidence interval [CI], 3.3-27.8; P < .0001), more than two Perclose devices (OR, 7.0; 95% CI, 2.3-21; P = .0005), and smaller access vessel diameter to sheath size ratio (OR multiplies by 1.1 for each .01 decrease in ratio; 95% CI, 1.02-1.2; P = .007) (area under the receiver operating characteristic curve = .75).


CONCLUSIONS
Obesity is not a contraindication to P-TEVAR. P-TEVAR can be performed safely, despite the need for larger diameter sheaths. However, patients predicted to need adjunctive stenting or possessing smaller access vessel diameter to sheath size ratios are at highest risk of preclose failure with the Perclose ProGlide device, and selective use of this technique is recommended.
Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
Jason
J
Zakko
Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla. Electronic address: salvatore.scali@surgery.ufl.edu.
Salvatore
S
Scali
Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
Adam W
AW
Beck
Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla.
Charles T
CT
Klodell
Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla.
Thomas M
TM
Beaver
Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla.
Tomas D
TD
Martin
Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
Thomas S
TS
Huber
Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
Robert J
RJ
Feezor
D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography; D001807:Blood Vessel Prosthesis; D015992:Body Mass Index; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005431:Florida / Q000453:epidemiology; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications*; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome