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Percutaneous Access for Thoracic Aortic Endografts - no Advantage versus Femoral Artery Cut-Down
Burkhart Zipfel, Semih Buz, Robert Hammerschmidt, Volker Düsterhöft, Roland Hetzer.
Deutsches Herzzentrum Berlin, Berlin, Germany.
OBJECTIVE:
To evaluate whether percutaneous access reduces local complications of thoracic endografting related to surgical access to the femoral artery.
METHODS:
Out of 581 thoracic aortic endograft procedures 147 (25 %) were performed through percutaneous access to the common femoral artery (CFA) and 374 (64 %) through CFA cut-down. Exclusion criteria for percutaneous access were (1) external iliac artery diameter less than 7 mm in, (2) calcification of the anterior wall of the CFA, (3) poorly palpable pulses due to obesity and (4) acute Type-B-dissections. Two U-sutures were placed in the femoral artery using a single Prostar® percutaneous suture device, before the delivery sheaths of the endografts with outer diameters of median 24 F were advanced into the artery. The U-sutures were tied at the end of the procedure. All procedures were performed in the operation room.
RESULTS:
All stent-grafts were successfully deployed through the percutaneous approach. In 34 cases (23 %) the femoral artery had to be exposed and repaired because of incomplete sealing by the percutaneous sutures. The table compares femoral access site complications of percutaneous (conversions included) vs. conventional approach. Reoperations through the same femoral artery are included in both groups.
CONCLUSIONS:
In relation to the large delivery catheters the primary effectiveness of the percutaneous technique is impressive, but the results of this retrospective analysis are disappointing. Despite proper selection of the cases and liberal conversion to open repair the need for secondary surgery outweighs the reduction of lymph and nerve complications. Thus overall the technique fails to improve patient comfort of the thoracic endograft procedure.
| Femoral access site complications | Percutaneous n = 147 | Cut down n = 249 |
| Conversion to surgical repair | 34 (23 %) | n.a. |
| Minor hematoma | 5 (3.4 %) | 7 (1.9 %) |
| Surgery for hematoma/false aneurysm | 7 (4.8 %) | 3 (0.9 %) |
| Lymph fistula or lymph cyst | 1 (0.7 %) | 16 (4.3 %) |
| Surgery for lymph complications | 0 | 8 (2.5 %) |
| Femoral nerve impairment | 0 | 4 (1.1 %) |
| Groin infection | 3 (2.0 %) | 6 (1.6. %) |
| Surgery for access site complications | 10 (6.8 %) | 13 (3.5 %) |
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