Percutaneous Thoracic and Abdominal Aortic Aneurysm Repair
Endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) has become a widely accepted treatment modality. The conventional approach of an EVAR involves bilateral groin incisions to expose the femoral arteries followed by introducer sheath placement, which is typically performed with the use of general or epidural anesthesia. As technology trends toward less invasive methods and sheath sizes become smaller, the use of a total percutaneous approach to endovascular repair of aortic pathology is becoming more common. In this review, we present a brief history of percutaneous closure devices for common femoral artery access, factors important in patient selection, the technique of performing a percutaneous EVAR procedure, early and late complications, and overall outcomes of percutaneous approaches for the endovascular treatment of aortic pathology.
Elective endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) has become more commonplace, with early and intermediate outcomes showing reduced operative morbidity and mortality and shorter hospital stays. Currently, four devices approved by the US Food and Drug Administration (FDA) exist for treatment of these aneurysms: AneuRx (Medtronic/AVE, Santa Rosa, CA), Zenith (Cook Inc., Bloomington, IL), the Bifurcated Excluder (W.L. Gore & Associates, Flagstaff, AZ), and the Endologix Endograft (Irvine, CA). Endovascular repair of thoracic aortic aneurysms is also on the rise, especially given the recent FDA approval of the TAG Thoracic Endoprosthesis in March 2005 (W.L. Gore). Given the increasing confidence of providers, the success of these elective repairs, and expanding off-label use of certain devices, endovascular techniques have also been used in the treatment of traumatic thoracic aortic transections, thoracic aortic dissections, and abdominal aortic ruptures.
Traditionally, these endovascular repairs have been conducted through an open cutdown approach on the common femoral artery (CFA), mostly owing to the large sheath sizes of the early devices. However, as technology trends toward less invasive methods and sheath sizes become smaller, the use of a total percutaneous approach to endovascular repair of aortic pathology is becoming more common. Haas and colleagues were the first to describe a total percutaneous approach for the closure of common femoral arteriotomies owing to large sheath sizes in 1999. This percutaneous "Preclose" technique used the Prostar XL Perclose Device (Abbott Industries, Menlo Park, CA), which is a suture-mediated device that deploys two 3-0 braided polyester sutures to close the arteriotomy. Since this original description, the Preclose technique has been used in many institutions, with excellent immediate technical success and short- and long-term outcomes. The benefits of a percutaneous compared with an open approach include a shorter procedure time, avoidance of general anesthesia, improved patient acceptance, and reduced risk of wound complications. However, most investigators have reported experiencing a significant learning curve with the initial use of this device and have continued to caution that even though a percutaneous approach is used, prompt recognition of complications is critical for immediate treatment and prevention of adverse sequela. In this review, we present a brief history of percutaneous closure devices for CFA access, factors important in patient selection, the technique of performing the Preclose procedure, early and late complications, and overall outcomes of percutaneous approaches for the endovascular treatment of aortic pathology.
Abstract and Introduction
Abstract
Endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) has become a widely accepted treatment modality. The conventional approach of an EVAR involves bilateral groin incisions to expose the femoral arteries followed by introducer sheath placement, which is typically performed with the use of general or epidural anesthesia. As technology trends toward less invasive methods and sheath sizes become smaller, the use of a total percutaneous approach to endovascular repair of aortic pathology is becoming more common. In this review, we present a brief history of percutaneous closure devices for common femoral artery access, factors important in patient selection, the technique of performing a percutaneous EVAR procedure, early and late complications, and overall outcomes of percutaneous approaches for the endovascular treatment of aortic pathology.
Introduction
Elective endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) has become more commonplace, with early and intermediate outcomes showing reduced operative morbidity and mortality and shorter hospital stays. Currently, four devices approved by the US Food and Drug Administration (FDA) exist for treatment of these aneurysms: AneuRx (Medtronic/AVE, Santa Rosa, CA), Zenith (Cook Inc., Bloomington, IL), the Bifurcated Excluder (W.L. Gore & Associates, Flagstaff, AZ), and the Endologix Endograft (Irvine, CA). Endovascular repair of thoracic aortic aneurysms is also on the rise, especially given the recent FDA approval of the TAG Thoracic Endoprosthesis in March 2005 (W.L. Gore). Given the increasing confidence of providers, the success of these elective repairs, and expanding off-label use of certain devices, endovascular techniques have also been used in the treatment of traumatic thoracic aortic transections, thoracic aortic dissections, and abdominal aortic ruptures.
Traditionally, these endovascular repairs have been conducted through an open cutdown approach on the common femoral artery (CFA), mostly owing to the large sheath sizes of the early devices. However, as technology trends toward less invasive methods and sheath sizes become smaller, the use of a total percutaneous approach to endovascular repair of aortic pathology is becoming more common. Haas and colleagues were the first to describe a total percutaneous approach for the closure of common femoral arteriotomies owing to large sheath sizes in 1999. This percutaneous "Preclose" technique used the Prostar XL Perclose Device (Abbott Industries, Menlo Park, CA), which is a suture-mediated device that deploys two 3-0 braided polyester sutures to close the arteriotomy. Since this original description, the Preclose technique has been used in many institutions, with excellent immediate technical success and short- and long-term outcomes. The benefits of a percutaneous compared with an open approach include a shorter procedure time, avoidance of general anesthesia, improved patient acceptance, and reduced risk of wound complications. However, most investigators have reported experiencing a significant learning curve with the initial use of this device and have continued to caution that even though a percutaneous approach is used, prompt recognition of complications is critical for immediate treatment and prevention of adverse sequela. In this review, we present a brief history of percutaneous closure devices for CFA access, factors important in patient selection, the technique of performing the Preclose procedure, early and late complications, and overall outcomes of percutaneous approaches for the endovascular treatment of aortic pathology.
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