McCarthy Cullen K, Maqbool Feroz, Gierman Joshua L
Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
Department of Interventional Radiology, Oklahoma City VA Hospital, Oklahoma City, OK.
Ann Vasc Surg. 2020 Jan;62:191-194. doi: 10.1016/j.avsg.2019.06.008. Epub 2019 Aug 23.
Percutaneous endovascular aortic repairs (pEVARs) are associated with access site complications. Two-device technique using 2 Perclose devices has been well established. Combined Perclose and Angioseal technique has been described as well. We sought to determine whether a hybrid Perclose and Angioseal closure technique would safely and effectively establish hemostasis in large-bore arteriotomies up to 20F.
Patients were identified as candidates for percutaneous access based on preoperative computed tomography findings, perioperative ultrasound of femoral vessels, or a combination of the 2 modalities. Prior to sheath insertion, 1 Perclose device was predeployed. At the end of pEVAR, device sheath and introducer were withdrawn over a 0.035″ wire, and partially deployed Perclose was fully deployed. The sheath and introducer were fully withdrawn and the arteriotomy was closed with a 6F Angioseal vascular closure device and completion deployment of the Perclose. Patients were followed at day 1 and day 30 and at least 1 year postintervention.
A composite end point of complications was defined as an access site-related bleed or hematoma that required blood transfusion or an extended hospital stay, pseudoaneurysm, arteriovenous fistula, dissection, or retroperitoneal hematoma. The combined technique was initially successful in 44/45 arteriotomies (97.8%) in 24/25 patients (96.0%) with no conversions to cutdown. Sheath sizes ranged from 10F to 20F outer diameter (OD), with an average of 15.89F OD. The single-device failure was caused by a failure of the footplate to catch during deployment in the Angioseal with a 20F arteriotomy. Consequently, that was the only patient in which this closure was attempted for an arteriotomy larger than 19F. There were no early or late complications in this series.
Large-bore arteriotomies may be safely and effectively closed using a hybrid percutaneous closure technique for sheaths up to 19F OD. Evaluation of this technique in closure of large-bore arteriotomies is ongoing and further investigation is needed to assess the value of this closure in 20F OD sheaths and above.
经皮血管腔内主动脉修复术（pEVAR）与穿刺部位并发症相关。使用2个Perclose装置的双装置技术已得到充分确立。Perclose与Angioseal联合技术也有相关描述。我们试图确定Perclose与Angioseal混合闭合技术能否安全有效地实现高达20F大口径动脉切开术的止血。
根据术前计算机断层扫描结果、股血管围手术期超声或两种方式的组合，将患者确定为经皮穿刺的候选者。在插入鞘管之前，预先部署1个Perclose装置。在pEVAR结束时，将装置鞘管和导引导管通过一根0.035英寸的导丝撤出，部分展开的Perclose装置完全展开。完全撤出鞘管和导引导管，用一个6F Angioseal血管闭合装置闭合动脉切开术，并完成Perclose装置的展开。在术后第1天、第30天以及干预后至少1年对患者进行随访。
并发症的复合终点定义为需要输血或延长住院时间的与穿刺部位相关的出血或血肿、假性动脉瘤、动静脉瘘、夹层或腹膜后血肿。联合技术最初在24/25例患者（96.0%）的44/45例动脉切开术中成功（97.8%），无一例转为切开手术。鞘管外径范围为10F至20F，平均外径为15.89F。单装置失败是由于在使用20F动脉切开术的Angioseal装置展开过程中，踏板未能卡住。因此，该患者是唯一尝试对大于19F的动脉切开术进行这种闭合的患者。本系列中无早期或晚期并发症。
对于外径达19F的鞘管，使用经皮混合闭合技术可安全有效地闭合大口径动脉切开术。目前正在对该技术在闭合大口径动脉切开术中进行评估，需要进一步研究以评估该闭合技术在20F及以上外径鞘管中的价值。
