The Kaiser Permanente Experience With Ultrasound-Guided Percutaneous Endovascular Abdominal Aortic Aneurysm Repair

Division of Biomedical Sciences, University of California, Riverside, CA
Annals of Vascular Surgery (Impact Factor: 1.17). 04/2012; 26(7):906-12. DOI: 10.1016/j.avsg.2011.09.013
Source: PubMed


This study was conducted to determine the effect of ultrasound (US)-guided percutaneous access for percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) on conversion to open repair by femoral cutdown. We also sought to identify other risk factors associated with failure of percutaneous access and conversion to femoral cutdowns.
This is a single-center, retrospective review of 101 patients who underwent PEVAR between January 1, 2005 and July 31, 2009 (56 months). Risk factors that were evaluated for unsuccessful PEVAR included gender, age (≤65 and ≥66 years), US-guided percutaneous access, mechanical failure, abdominal aortic aneurysm size, and the following comorbidities: diabetes, hypertension, vessel calcification, and obesity (body mass index: ≥30 kg/m(2)).
There were 10 (9.9%) conversions from percutaneous to femoral cutdown, yielding a success rate of 90.1% for a total percutaneous approach. Each converted patient had one groin converted, resulting in a cutdown rate per groin of 10/202 (5%). There were no 30-day mortalities. Univariate analysis showed that hypertension (P = 0.261), age ≥66 years (P = 0.741), current smoking history (P = 0.649), past smoking history (P = .093), diabetes (P = 0.908), vessel calcification (P = 0.8281), and body mass index ≥30 kg/m(2) (P = 0.052) did not significantly predict conversion to endovascular aortic aneurysm repair (EVAR). Mechanical failure significantly predicted conversion to cutdown EVAR (P = 0.0002), whereas US-guided percutaneous access influenced successful PEVAR (P = 0.030). Multivariate analysis showed that mechanical failure significantly predicted conversion to cutdown EVAR (P = 0.003) and US-guided percutaneous access influenced successful PEVAR (P = 0.040) after adjusting for smoking history and obesity.
PEVAR is a viable option for aortic aneurysm repair that may be improved with US-guided percutaneous access by reducing the rate of femoral cutdowns.

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Available from: Jeffrey H Hsu, Oct 09, 2014
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    ABSTRACT: To determine predictors of percutaneous (PEVAR) access failure requiring conversion to an open approach (OEVAR) during endovascular aortic aneurysm repair (EVAR). A single-center retrospective review of all EVAR patients from January 2009 through June 2011 with multivariate analysis of clinical and anatomic variables that could impact access outcome was conducted. Target vessel calcification was categorized as mild, moderate, or severe based on circumferential calcium arc (<⅓, ⅓ to ½, and >½ respectively), dyslipidemia (defined as low-density lipoprotein >130 mg/dL or receiving lipid lowering medication), and obesity (defined as body mass index [BMI] >30). We investigated 400 access sites for 200 patients who underwent EVAR. The study cohort's characteristics included an average age of 72.8 ± 9.0 years, vessel size of 9.6 ± 1.8 mm, sheath size of 17.1 ± 3.0 Fr, BMI of 27.6 ± 5.3, and estimated glomular filtration rate of 68.5 ± 24.2 mL/min. Comorbidities included dyslipidemia in 129 patients (64.5%) and diabetes in 54 patients (27%). There were 132 OEVAR (66 patients), two mixed OEVAR with contralateral PEVAR (one patient), and 266 (133 patients) PEVAR approaches. Use of PEVAR increased over time (45.5% [2009], 77.8% [2010], and up to 88.5% [2011]; P = .001) while conversions decreased (24.3% [2009], 8.7% [2010], and 4.3% [2011]; P = .001]. More OEVAR patients (35.8%) stayed longer than 3 days compared with 21.1% for PEVAR (P = .028). For the 266 PEVAR approaches, 32 access sites (12.0%) had to be converted. Severely calcified arteries were most predictive of conversion (odds ratio [OR], 36.4; P < .001). Year of procedure (2010; OR, 0.17; P = .001; 2011, OR, 0.20; P = .049), female gender (OR, 3.1; P = .017), moderately calcified arteries (OR, 2.5; P = .085), and age (OR, 2.3 [per decade]; P = .002) were all also significant. Vessel size, sheath size, and BMI were found to be non-significant predictors of conversion. PEVAR was found to be safe, reliable, and feasible. Several factors, including learning curve, vessel calcification, age, and female gender predicted conversion of PEVAR to OEVAR.
    Preview · Article · Jun 2013 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
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    ABSTRACT: The evolution of minimally invasive procedures to treat aortic aneurysms has expanded to include access interventions as well. Traditionally, groin exposures have been the standard approach for common femoral artery exposure with open cutdown; however, inherent and related complications to that approach have paved the road to the percutaneous approach. Current available evidence from the literature supports the feasibility and the safety of percutaneous endovascular aneurysm repair (PEVAR); however, predictors of success are not well defined. We should examine all available studies (both prospective and retrospective) in order to draw a conclusion and evidence-based outcome for selecting patients who would benefit the most from PEVAR.
    No preview · Article · Aug 2013 · Vascular and Endovascular Surgery
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    ABSTRACT: Aim: Aim of the study was to report our single-center experience of the ultra-low profile OvationTM Abdominal Stent-Graft System with totally percutaneous endovascular aneurysm repair (PEVAR). Methods: Between December 2010 and March 2013 we electively treated 35 patients (male: 89%, mean age: 73±7 years) with abdominal aortic aneurysm (AAA) using bilateral PEVAR with the OvationTM endograft. Most (77%) cases were characterized by challenging femoral artery anatomy. Patients returned for follow-up visits at 1, 3, 6 months and annually thereafter. Results: Technical success was 97.1%. One type Ia endoleak was identified on final angiography, which was treated with an extension cuff. No groin complications were observed, including lymphocele, hematoma, pseudoaneurysm, dehiscence, or wound infection. Mean follow-up was 10 months (range 1-24 months). No death was registered. One type Ia endoleak was identified at the 12-month follow-up, which resolved with placement of a Palmaz balloon-expandible stent. No type II, III, or IV endoleaks were identified. No migration, AAA enlargement, AAA rupture, or conversion to open surgery was reported. Two patients (5.7%) developed monolateral iliac limb occlusion at 58 and 72 days of follow-up, respectively. In one case a limb kinking was observed and treated with iliac kissing stent. The other limb occlusion was due to external iliac artery severe stenosis and was treated with thrombolysis and iliac artery stenting. Conclusion: PEVAR with the OvationTM endograft is feasible and safe in patients with unfavorable anatomy.
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