Percutaneous access for endovascular abdominal aortic aneurysm repair: can selection criteria be expanded?

Previous reports suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (P-EVAR) is as safe as open access (O-EVAR) in patients with favorable femoral anatomy. Severe femoral artery calcification and obesity have been considered relative contraindications to P-EVAR, but these criteria have not been evaluated. The purpose of this study was to assess the postoperative anatomic changes associated with P-EVAR versus O-EVAR using three-dimensional (3-D) computed tomographic (CT) reconstruction and to evaluate the overall results of the two procedures in a group of patients with suboptimal femoral anatomy. During a recent 26-month period, 173 patients underwent EVAR at our institutions, including 35 P-EVARs. Of these, 22 (63%) had complete pre- and postoperative CT imaging of the femoral arteries. These subjects were compared to 22 matched controls who underwent O-EVAR during the same period. Automated 3-D reconstructions were used to measure the following anatomic femoral artery parameters before and after EVAR: arterial depth, calcification score, minimum diameter and area, and maximum diameter and area. Of the 88 study arteries, 50 underwent open access and 38 percutaneous access (Proglide, n=11; Prostar XL, n=27). Both groups were similar regarding sheath size, number of components, operative time, blood loss, and length of stay. Significantly more O-EVAR subjects suffered groin complications (p=0.02), including five hematomas, two wound infections, two femoral thromboses, and one vessel which required patch repair. In the P-EVAR group there was only one hematoma, which was managed conservatively. There was no difference between the P-EVAR and O-EVAR groups with respect to femoral artery calcification (Agatston scores 667+/-719 vs. 945+/-1,248, p=0.37). Obesity (body mass index >30) was documented in six (27%) of both the P-EVAR and O-EVAR groups (p=nonsignificant). Pre- and postoperative CT-derived anatomic data showed a significant decrease in the minimal vessel area with O-EVAR compared to P-EVAR (p=0.02). This study demonstrates that patients with obesity or severely calcified femoral arteries can be successfully treated percutaneously with fewer minor groin complications.