Percutaneous Endovascular Aneurysm Repair: Current Status and Future Trends

Abstract

Endovascular aneurysm repair (EVAR) is a common, safe, and effective method of treating abdominal aortic aneurysms. Traditionally treated via surgical cutdown over the common femoral arteries, many recent studies demonstrate percutaneous access techniques to avoid the surgical cutdown. Developing familiarity with these percutaneous techniques, including risks, complications, adjuncts, and alternative accesses, can help improve the outcomes and availability of EVAR. As these techniques become increasingly common, it is not unlikely that they can be practiced safely in select patients in an outpatient setting.

Keywords: alternative access; outpatient EVAR; percutaneous EVAR.

Fig. 1

( a ). Demonstration of “Preclose technique” using the snare knot pusher devices from two previously deployed Perclose Proglide devices (Abbott Medical, Abbott Park, IL). ( b ) An image of bilateral large bore access sites for percutaneous endovascular aneurysm repair immediately after successful closure with the “Preclose technique.”

Fig. 2

A 74-year-old man presents with an enlarging abdominal aortic aneurysm (AAA) and a pelvic kidney with the renal artery arising from the aortic bifurcation ( a ). Contrast injection demonstrates a large infrarenal aortic aneurysm ( b ). A patent renal artery is noted to arise just to the left of the aortic bifurcation ( c ). Percutaneous ultrasound-guided left brachial artery access was obtained and a 7-Fr sheath was placed ( d ). A wire was snared from via the brachial access ( e ) to achieve through and through wire access. The renal artery was selected from above with a wire and directional catheter ( f ). Final image demonstrates exclusion of the AAA with continued patency of the aberrant renal artery via use of a “snorkel” technique using VBX balloon-expandable stent grafts and a VIABAHN self-expanding stent graft (W.L. Gore, Newark, DE) ( g ). The brachial artery access was closed with “Preclose technique” in a similar fashion to the CFA access sites ( h ). The position of the footplate was monitored throughout the closure process with real-time ultrasound. The patient had mild asymptomatic ecchymosis the following day, but no hematoma or pseudoaneurysm on follow-up duplex ultrasound. Follow-up CT imaging 6 months later ( i ) demonstrates effective exclusion of the aneurysm with continued patency of the renal artery and brisk renal enhancement. The patient's serum creatinine remained stable.