Conventional EVAR procedures are performed through
the cut-down of both femoral arteries. Postoperative
patient discomfort and surgical site infections are
critical predictors of postoperative morbidity. Given
the fact that these patients are more likely to have
repeated transfemoral interventions, groin site cutdown
may be risky for the further procedures.[
10]
Novel vascular closure devices may solve this problem
and decrease postoperative morbidity during EVAR
procedures.
The success rates of vascular closure devices are
highly dependent on patient volume and selection.[11]
Primary suspects of failure are obesity, femoral artery
calcification, groin scarring and iliac artery tortuosity.
The success rate of utilization of the Prostar closure
device has been closely associated with the learning curve. Pozzi et al.[4] reported that the success rate
increased from 80% in the first 50 cases to 98.8% in
the following cases. In our series, the success rate was
80% showing consistency with reported series due to
high failure in the learning curve.[4] On the contrary,
McDonnell et al.[12] reported a success rate of 71%
regardless of the level of experience.
In addition, Thomas et al.[1] reported 93.6%
primary success and 10.3% major complication rates
with Prostar XL in their series of 50 patients who
underwent endovascular aortic and iliac procedures.
Pseudoaneurysms were detected in 6.4% of the operated
groins (five patients) in the first three months after
the procedure and two of them healed conservatively.
Manual compression for continuing bleeding was
necessary in six patients (12.0%) and five patients
(10.0%) required immediate surgical cut-down. The
authors found that the difference of complication rates
were not statistically significant in small and large
profile systems. Inconsistent with these findings,
Starnes et al.[13] reported higher complication rates
using sheaths larger than 20F. However, we did not
use such high profile systems in our patient population.
Furthermore, Eisenack et al.[14] analyzed the risk
factors of procedure failure in 500 patients. They
demonstrated that anterior calcification of femoral
artery and fibrosis at the access site were possible
predictors of failure and operator experience was
a predictor for success. They found no correlation
of obesity or sheath size with the success rate. In
another study, although Starnes et al.[13] reported
higher complication rates in morbid obese patients,
they did not show any correlation of obesity with
conversion to open repair. However, Teh et al.[15]
reported a significant association between obesity
and groin fibrosis and device failure. Similarly, in our
series, obese patients had higher rates of complications
and the difference was strongly marked for hematoma
formation (Table 3b).
Table 3: Postoperative complications according to the patient groups
In general, the rate of general anesthesia is high in
our EVAR experiences; however, surgical conversion is
a serious complication for aortic procedures. To avoid
possible complications, general anesthesia was preferred
for primary cases. Of note, as the EVAR experience
increased, the use of general anesthesia decreased.
To the best of our knowledge, only one study on
the use of percutaneous systems which included seven
patients is available in Turkey.[16] Although the authors
reported their initial experience in the published
paper; they failed to address the technique and device
of vascular closure. Therefore, our report is the largest
series of percutaneous experience in Turkey for the
time being.
On the other hand, there are some limitations to
our study. The primary limitation is the retrospective
design of the study. The conclusions, therefore, were
drawn more hesitantly. Second, the patients were not
randomized in both groups; however, the preoperative
data comparison did not show significant differences
between the two groups. Third, anatomical analysis
was not made in detail. However, the primary goal
was to evaluate the outcomes in patients with various
risk factors reported in the literature such as diabetes
and obesity.
In conclusion, pre-close technique is a successful
way of performing EVAR procedures. Inherent
limitations such as open repairs may be challenging
which can be solved with increasing experience. In
addition, although wound infections are less common,
obese patients show higher rates of complications
with percutaneous technique. We believe that further
studies are required to identify the optimal access
technique in this patient population.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.