Ultrasound-guided percutaneous endovascular aneurysm repair success is predicted by access vessel diameter

Abstract

Objective: Ultrasound scan-guided access allows for direct visualization of the access artery during percutaneous endovascular aortic aneurysm repair. We hypothesized that the use of ultrasound scan guidance allowed us to safely increase the utilization of percutaneous endovascular aortic aneurysm repair to almost all patients and decrease access complications.

Methods: A retrospective chart review of all elective endovascular aortic aneurysm repairs, both abdominal and descending thoracic, from 2005 to 2010 was performed. Patients were identified using International Classification of Disease, 9th Revision, Clinical Modification Codes and stratified based on access type: percutaneous vs cut-down. We examined the success rate of percutaneous access and the cause of failure. Sheath size was large (18-24 F) or small (12-16 F). Minimum access vessel diameter was also measured. Outcomes were wound complications (infections or clinically significant hematomas that delayed discharge or required transfusion), operative and incision time, length of stay, and discharge disposition. Predictors of percutaneous failure were identified.

Results: One hundred sixty-eight patients (296 arteries) had percutaneous access endovascular aneurysm repair (P-EVAR) whereas 131 patients (226 arteries) had femoral cutdown access EVAR. Ultrasound scan-guided access was introduced in 2007. P-EVAR increased from zero cases in 2005 to 92.3% of all elective cases in 2010. The success rate with percutaneous access was 96%. Failures requiring open surgical repair of the artery included seven for hemorrhage and six for flow-limiting stenosis or occlusion of the femoral artery. P-EVAR had fewer wound complications (0.7% vs 7.4%; P = .001), shorter operative time (153.3 vs 201.5 minutes; P < .001), and larger minimal access vessel diameter (6.7 mm vs 6.1 mm; P < .01). Patients with failed percutaneous access had smaller minimal access vessel diameters when compared to successful P-EVAR (4.9 mm vs 6.8 mm; P < .001). More failures occurred in small sheaths than large ones (7.4% vs 1.9%; P = .02). Access vessel diameter <5 mm is predictive of percutaneous failure (16.7% of vessels <5 mm failed vs 2.4% of vessels ≥ 5 mm failed; P < .001; odds ratio, 7.3; 95% confidence interval, 1.58-33.8; P = .01).

Conclusions: Ultrasound scan-guided P-EVAR can be performed in the vast majority of patients with a high success rate, shorter operative times, and fewer wound complications. Access vessel diameters <5 mm are at greater risk for percutaneous failure and should be treated selectively.

Figure 1

Proportion of P-EVAR over time 2005-2010

Figure 2

Change in P-EVAR minimum access vessel diameter over time 2006-2010

Figure 3

Preoperative CT angiogram with 3-dimensional reconstruction showing a patient with heavy plaque burden in the right common femoral and external iliac arteries who experienced percutaneous failure.

Figure 4

Minimum access vessel diameter in millimeters (horizontal axis) with the absolute number of treated arteries within each access vessel diameter (left axis) and the proportion of arteries with percutaneous failure within each access vessel diameter (right axis)

Figure 5

Sheath size (horizontal axis) with the absolute number of sheaths per Fr size (left axis) and the proportion of percutaneous failures per sheath size (right axis)

Figure 6

a. Angiogram showing a patient with small diameter common femoral and external iliac arteries bilaterally where the 7 Fr sheaths are occlusive b and c. Post EVAR angiogram showing improved blood flow through the common femoral and external iliac arteries bilaterally after utilizing the “Dotter” technique during AAA repair.

Figure 6

a. Angiogram showing a patient with small diameter common femoral and external iliac arteries bilaterally where the 7 Fr sheaths are occlusive b and c. Post EVAR angiogram showing improved blood flow through the common femoral and external iliac arteries bilaterally after utilizing the “Dotter” technique during AAA repair.

Figure 6

a. Angiogram showing a patient with small diameter common femoral and external iliac arteries bilaterally where the 7 Fr sheaths are occlusive b and c. Post EVAR angiogram showing improved blood flow through the common femoral and external iliac arteries bilaterally after utilizing the “Dotter” technique during AAA repair.