Total percutaneous access for aortic endograft placement

Abstracts

O acesso totalmente percutâneo para o implante de endopróteses aórticas, através da preclose technique, é possível mesmo quando utilizadas bainhas introdutoras de elevado perfil. Relatamos sete casos de tratamento endovascular de doenças da aorta, todos realizados de modo percutâneo, e discutimos os principais aspectos desta técnica.

Acesso percutâneo; preclose technique; endoprótese aórtica

CASE REPORT

Total percutaneous access for aortic endograft placement

Felipe Nasser^I; Rodrigo Oliveira Pereira da Silva^II; José Carlos Ingrund^II; Marcelo Calil Burihan^II; Francisco César Carnevale^III; Tiago do Prado Tonial^II; Raimundo Teixeira de Araújo Júnior^II; Adnan Neser^II

^IServiço de Cirurgia Vascular, Hospital Santa Marcelina de Itaquera, São Paulo, SP, Brazil. Serviço de Radiologia Intervencionista, Universidade de São Paulo (USP), São Paulo, SP, Brazil

^IIServiço de Cirurgia Vascular, Hospital Santa Marcelina de Itaquera, São Paulo, SP, Brazil

^IIIServiço de Radiologia Intervencionista, USP, São Paulo, SP, Brazil

Correspondence

ABSTRACT

Total percutaneous access for aortic endograft delivery, using the preclose technique, is feasible even with the use of large-diameter introducer sheaths. We report seven cases of percutaneous approach in endovascular treatment of aortic diseases and discuss the main technical aspects.

Keywords: Percutaneous access, preclose technique, aortic endograft.

Introduction

Aortic endograft delivery systems, used for endovascular repair of aneurysms or aorta dissection, show a high-profile composition, which implies surgical exposure of the femoral artery to facilitate safe device placement.

However, in selected cases, the use of a specific device for suture-mediated arterial closure (Perclose Proglide®, Abbott Vascular) has yielded successful results in percutaneous aortic endograft delivery, even when high-profile delivery systems or large-diameter introducer sheaths are used. This technique, known as preclose technique, consists of an adaptation in the use of homeostatic devices, i.e., the deployment of this device at the time of initial access and before the placement of the introducer sheath, or the endograft delivery system itself, maintaining the sutures outside and tying the knot at the end of the procedure.¹

In the present study, we report seven cases of endovascular treatment of aortic diseases, five thoracic and two abdominal interventions, in which totally percutaneous aortic endograft delivery was performed, using the preclose technique.

Cases

Characteristics of study cases are described in Table 1.

Table 1
- Cases of total percutaneous access for aortic endograft delivery

Patient	Intervention date	Indication	Endograft used	Delivery system profile	Number of percloses used	Intervention success
1	08/04/2008	Dissection of the thoracic aorta	Relay® (Bolton Medical)	25F	2 in the right femoral artery	Yes
2	17/04/2008	Aneurysm of the thoracic aorta	Valiant® (Medtronik)	24F	2 in the right femoral artery	Yes
3	18/04/2008	Aneurysm of the abdominal aorta	Talent® (Medtronik)	22F in the right femoral artery and 18F in the left femoral artery	3 in the right femoral artery (main body) 2 in the left femoral artery (contralateral)	Yes
4	10/04/2008	Dissection of the thoracic aorta	TAG® (Gore)	24F	3 in the right femoral artery	Yes
5	28/04/2008	Pseudoaneurysm of the thoracic aorta	Valiant® (Medtronik)	22F	2 in the right femoral artery	Yes
6	03/06/2008	Aneurysm of the thoracic aorta	TAG® (Gore)	22F	2 in the right femoral artery	Yes
7	19/06/2008	Aortoiliac aneurysm	Excluder® (Gore)	18F bilateral	2 in each femoral artery	Yes

Discussion

Aortic endografts show a high-profile composition, usually larger than 18F, which requires dissection and surgical exposure of femoral arteries for safe device placement, under direct vision and control. Although available in the Brazilian market since 2003, the devices for suture-mediated arterial closure, which were industrially developed to eliminate the need for manual compression and prolonged bed rest after femoral catheterization, are recommended for percutaneous closure of introducer sheaths with maximum diameter of 10 F.^2-5

The technique of percutaneous closure of femoral artery after aortic endograft delivery was firstly described in 1999 by Haas,¹ including the use, although not recommended by the manufacturer, of the 10 F Perclose Prostar XL device (Abbott Vascular). In this technique, the so-called preclose technique, the arterial closure device – Perclose – is inserted before endograft delivery, and repair sutures are maintained outside, the knot being tied at the end of the procedure. Several authors, making subtle modifications to the technique described by Haas, have reported success rates greater than 90%, depending on the profile of the introducer sheath used.^2-5

In all the seven cases reported (Table 1), we used essentially the same technique. Preoperative preparation included meticulous aseptic technique and availability of vascular surgical instrument sets in the event that a surgical conversion was necessary.

Exclusive puncture of the anterior wall of the common femoral artery with a 16-G puncture needle was performed, with the femoral head area previously marked by radioscopy. Punctures above the inguinal ligament indicate high risk of retroperitoneal hemorrhage and procedure failure due to the impossibility of adequate compression.^2,4

Subsequently, a 7 F introducer sheath is implanted in the common femoral artery and soon removed, maintaining the 0.035-inch guide wire inside. The first Perclose is inserted at 30º mesial angulation. The 3-0 polypropylene repair sutures of this device are maintained outside with Kelly tweezers (Figure 1). The 0-inch guide wire is reinserted before removing the first Perclose to allow the placement of a second Perclose, now at 30º lateral angulation, the polypropylene repair sutures being also maintained outside with Kelly tweezers. Before removing the second Perclose, the 0.035-inch guide wire is reinserted and a 12 F introducer sheath is implanted in order to perform predilatation. In patients number 3 and number 6, who were submitted to endovascular repair of abdominal aortic aneurysm, all the steps described were repeated on the other side for the contralateral implant.

At the end of the procedure, the endograft delivery system is removed, maintaining only the 0.035-inch guide wire in the femoral artery. While manual compression is performed on the proximal femoral artery by the operator, the assistant ties both knots previously prepared and maintained repaired outside since the beginning. Manual compression is maintained for 15 minutes. Once adequate hemostasis is achieved, the guide wire is removed, and manual compression is maintained for an additional 10 minutes. We should highlight the importance of maintaining the 0.035-inch guide wire in the femoral artery while the device knots are fixed and manual compression is performed at the access site. This guide wire, in the event of hemostasis failure, allows reinsertion of the endograft sheath, with a consequent cessation in bleeding, and surgical conversion if necessary.³

Some authors believe that time to manual compression should be shorter after removing introducer sheaths and tying the Perclose knots. Lee et al.,^2,3 for example, recommended manual compression time between 5 and 10 minutes, and bed rest for 4 to 6 hours. However, since heparin was not reverted routinely, we maintained a longer manual compression time. In general, manual compression time considered sufficient to achieve adequate hemostasis seems to be similar to that indicated for removal of the 5F introducer sheath used in diagnostic tests. Preserving the integrity of periarterial tissue is likely to contribute significantly to hemostasis at puncture site and the success of the percutaneous technique (Figure 2).³

Percutaneous procedure shows potential advantages, including shorter procedure time, lower risk of surgical wound infection, in addition to higher patient satisfaction (Figure 3).

However, percutaneous access with subsequent closure using puncture-sealing devices is not a risk-free procedure. Acute arterial occlusion with limb ischemia, arterial trauma, suture breakage leading to hemorrhage, arterial dissection, suture infection, pseudoaneurysm formation, and arteriovenous fistula are complications that might result from this technique.⁴ In our sample, there were no complications concerning percutaneous closure, probably due to an appropriate patient selection.

Proper selection of patients undergoing a percutaneous procedure is of utmost importance for intervention success. The existence of coagulopathies, obesity, and the presence of previous inguinal crease or severe calcification of the iliofemoral section are contraindications to this procedure.^2-4

Regarding the anesthetic technique used, it is part of our clinical routine the concomitant use of spinal anesthesia and general anesthesia in all cases of aortic endograft delivery, with the aim of performing liquor drainage, if necessary, thus reducing the incidence of medullary ischemia. We believe that this anesthetic approach also offers the advantage of avoiding patient movement until adequate hemostasis at puncture site is achieved. Additionally, this approach provides both the vascular team and the patient an atmosphere of calm and comfort for surgical conversion if percutaneous technique fails. It is worth mentioning that, although the percutaneous access might appear particularly attractive for an interventionist without vascular surgery specialty training, there is a considerable risk of failure, and a surgical team should be available in the event that a conversion is necessary.

The experience with percutaneous closure of aortic endografts has been growing in several centers worldwide, and the results concerning the feasibility and safety of this method are exciting. Lee et al.^2,3 reported a global success rate of 94.4% with the preclose technique, including a success rate of 92.8% for 18 – 24F introducer sheaths. The same authors obtained a late complication rate (evaluation at 6 months after procedure) less than 2%, confirming the safety of this method.³ Despite the short follow-up period (maximum of 6 months after our first case intervention), there were no complications related to percutaneous access during outpatient follow-up.

The limited number of cases in our experience results from the unavailability of the Perclose device in the public health system, from where most of our patients come. The Brazilian National Health System (Sistema Único de Saúde, SUS), until the present moment, does not contemplate a refund of such material/devices in their endovascular procedure refund list. However, patients could obviously benefit from this technique, and, as previously reported, several studies have attested the feasibility and safety of this method.

References

• 1. Haas PC, Kracjer Z, Dietrich EB. Closure of large percutaneous access sites using the Prostar XL percutaneous vascular surgery device. J Endovasc Surg. 1999;6:168-70.
• 2. Lee WA, Bown MP, Nelson PR, Huber TS. Total percutaneous access for endovascular aortic aneurysm repair ("Preclose" technique). J Vas Surg. 2007; 45:1095-101.
• 3. Lee WA, Bown MP, Nelson PR, Huber TS, Seeger J. Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using Preclose technique. J Vas Surg. 2008;47:919-23.
• 4. Turi ZG. Overview of vascular closure. Endovascular Today. 2008;28-37.
• 5. Starnes BW, Andersen CA, Ronsivalle JA, Stockmaster NR, Mullenix PS, Statler JD. Totally percutaneous aortic aneurysm repair: experience and prudence. J Vasc Surg. 2006;43:270-6.

Publication Dates

• Publication in this collection
  02 Oct 2009
• Date of issue
  June 2009

History

• Accepted
  18 Feb 2009
• Received
  25 June 2008