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Percutaneous femoral arterial closure in AAA endograft: Advantages and disadvantages

Since Parodi et al. [1] described the technique of endovascular AAA treatment in 1991, great technical development of the endoprosthesis and the interventional technique has been achieved. Sophisticated engineering of aortic endografts has made them easier to handle and deploy. They are lower in profile, more flexible, have greater trackability and pushability, etc. Actually, the implant success and aneurysms exclusion rate are near a hundred percent and in-hospital major complications are low. On the other hand, graft failure at follow-up continues to be relatively common and frequently requires endovascular or surgical reinterventions [2]. For these reasons, the indication of endovascular AAA treatment remains limited to high-risk surgical patients. Consequently, the cohort of candidates for endografting includes a majority of elderly patients with severe comorbid conditions in which a less invasive intervention is desirable. In this population, percutaneous closure of the arterial access should be an important contribution to limit the morbidity of the procedure. In this issue, Howell et al. describe their experience in percutaneous closure of the common femoral artery (CFA) access with the Prostar XL Percutaneous Vascular Surgery Device (PVS) in the endovascular AAA repair. The endograft employed in their experience was the AneuRx (Medtronic, Santa Rosa, CA). Since this prosthesis requires placement of 22 Fr sheath in the CFA and a 16 Fr sheath in the contralateral one, some modifications in the original Preclosure technique (preplacement of the sutures) have been introduced by the authors. Essentially, their innovations include the use of two different-sized PVS at the site of the 22 Fr sheath access (8 and 10 Fr); a 90° rotation of the 10 Fr device in order to prevent the placement of the sutures in the same location; the progressive dilatation of both CFA access with a series of percutaneous dilators to minimize the injury of the artery wall; and the guidewire withdrawal prior to tying the sutures. The authors achieved with this technique a 96% rate of successful repair of both entry sites without local groin complications and blood transfusion requirement. The benefits of the proposed technique include less bleeding, thus avoiding transfusion; less time-consuming intervention; less painful entry site wound; early ambulation; and shortened bed rest and hospital stay. Some surgical complications are abolished. All these benefits are desirable in this special cohort of patients with AAA endovascular treatment indication. Moreover, the percutaneous closure of the arteriotomy implies some intrinsic local complications that must be taken into account. They include local hematoma, pseudoaneurysms, arterio-venous fistula, acute artery or vein thrombosis, and local arterial stenosis at follow-up. Case selection must exclude severe calcified arteries in which the risk of bleeding is increased. A longer follow-up would be necessary to establish securely the incidence of late CFA stenosis and occlusion. A special consideration must be done about closure failure. This situation was uncommon in the present communication but has had a greater incidence in other experiences [3]. Arterial suture, in a situation of failure, must be done in unfavorable conditions (hand-pressure hemostasis and local dilacerations by the big introducer sheath) and the results could be imperfect. The presence of an expert surgeon is necessary at that moment. The catheterization laboratory must offer technical facilities such as a standard surgical suite. This report establishes the feasibility and safety of the common femoral artery closure with the Prostar XL Percutaneous Arterial Suture Device after endoluminal exclusion of AAA with the AneuRex stent graft in a small series of patients. The technique will be of particular benefit in the elderly and multiorganic diseased patients in which the AAA percutaneous intervention is indicated. A less invasive and painful intervention, early ambulation, and minimum blood loss is desirable in this group. The chance of failure and the consequent need of surgical artery repair made necessary the participation of a vascular surgeon in the team. The results need to be validated in a larger series of patients and in a multicenter study to be incorporated to the everyday practice.