Timaran David E, Soto Marilisa, Knowles Martyn, Modrall J Gregory, Rectenwald John E, Timaran Carlos H
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.
J Vasc Surg. 2016 Oct;64(4):896-901. doi: 10.1016/j.jvs.2016.03.444. Epub 2016 May 27.
Percutaneous femoral vascular access is frequently used for aortic endovascular procedures, with a local access complication rate of 5% to 16%. Fenestrated endovascular aneurysm repair (FEVAR) has recently emerged as a new technique for the repair of short-neck and juxtarenal abdominal aortic aneurysms. The safety and effectiveness of percutaneous access for FEVAR has not been established to date.
Since United States Food and Drug Administration approval of the Zenith fenestrated aortic endograft (Cook Medical, Bloomington, Ind), 94 patients (60 Zenith fenestrated, 6 p-Branch, and 28 custom-made devices) have undergone FEVAR. Percutaneous access was performed using the "preclose" technique with the Perclose Proglide device (Abbott Vascular, Redwood City, Calif). Open access was performed when severely disease or calcified femoral arteries prevented percutaneous access. Patient-based analysis was performed assessing outcomes for the access site used for the larger profile sheath of the main device.
Percutaneous access was used in 90 patients (177 common femoral arteries) and open access in four (11 common femoral arteries). Arm access was used in 41 patients (44%). The median sheath size was 20F (interquartile range [IQR], 20F-22F). Median operative time was 207 minutes (IQR, 160-270 minutes), with a median blood loss of 500 mL (IQR, 300-700 mL). The percutaneous access success rate was 92%. No preoperative factors predicted technical failure. No 30-day deaths occurred. Patients with failed percutaneous closure and who required conversion to open repair had higher estimated median blood loss of 800 (IQR, 600-1200) vs 500 (IQR, 300-600) mL (P = .01) and a longer median time to start ambulation of 4 (IQR, 2-7) vs 2 (IQR, 1-3) days (P = .03). Patients undergoing percutaneous closure had lower median blood loss (500 mL; IQR, 300-600 mL) than patients who underwent open surgical access (800 mL; IQR, 750-800 mL). Postoperative complications related to vascular access occurred in 11 patients (12%).
Percutaneous femoral access is a safe and effective alternative to open access for FEVAR. Operative blood loss and longer time to ambulation are significantly increased after failed percutaneous closure.
经皮股血管穿刺常用于主动脉腔内手术，局部穿刺并发症发生率为5%至16%。开窗腔内动脉瘤修复术（FEVAR）最近已成为一种用于修复短颈和近肾腹主动脉瘤的新技术。迄今为止，FEVAR经皮穿刺的安全性和有效性尚未确立。
自美国食品药品监督管理局批准Zenith开窗主动脉内移植物（库克医疗公司，印第安纳州布卢明顿）以来，94例患者（60例使用Zenith开窗移植物，6例使用p-Branch移植物，28例使用定制装置）接受了FEVAR手术。采用“预闭合”技术，使用Perclose Proglide装置（雅培血管公司，加利福尼亚州红木城）进行经皮穿刺。当严重病变或股动脉钙化妨碍经皮穿刺时，则采用开放穿刺。进行基于患者的分析，评估主要装置较大尺寸鞘管使用的穿刺部位的结果。
90例患者（177条股总动脉）采用经皮穿刺，4例（11条股总动脉）采用开放穿刺。41例患者（44%）采用上肢穿刺。鞘管尺寸中位数为20F（四分位间距[IQR]，20F - 22F）。手术时间中位数为207分钟（IQR，160 - 270分钟），失血中位数为500毫升（IQR，300 - 700毫升）。经皮穿刺成功率为92%。术前没有因素可预测技术失败。未发生30天内死亡。经皮闭合失败且需要转为开放修复的患者，估计失血中位数较高，为800（IQR，600 - 1200）毫升，而成功闭合者为500（IQR，300 - 600）毫升（P = 0.01）；开始行走的时间中位数也较长，分别为4（IQR，2 - 7）天和2（IQR，1 - 3）天（P = 0.03）。接受经皮闭合的患者失血中位数（500毫升；IQR，300 - 600毫升）低于接受开放手术穿刺的患者（800毫升；IQR，750 - 800毫升）。11例患者（12%）发生了与血管穿刺相关的术后并发症。
对于FEVAR，经皮股动脉穿刺是开放穿刺的一种安全有效的替代方法。经皮闭合失败后，手术失血量和开始行走的时间会显著增加。
