Ultrasound-Guided Access Improves Rate of Access-Related Complications for Totally Percutaneous Aortic Aneurysm Repair

Previous experience with totally percutaneous aortic aneurysm repair has identified morbid obesity and larger sheath sizes (≥20F) as complicating factors for percutaneous access closure. We sought to evaluate the impact of ultrasound-guided femoral access on rates of technical success, conversion to open femoral repair, and access-related complications. A retrospective review of a prospectively maintained database was performed. All consecutive patients undergoing totally percutaneous closure of large-bore-sheath (>12F) access sites with a suture-mediated closure device were included. The cohort was stratified into two groups by access technique, standard percutaneous femoral access, and ultrasound-guided femoral access. Patient variables were evaluated, and outcome measures included technical success, requirement for conversion to open repair, and access-related complications. Recorded conversions only included those related to access closure technique. During the study period, 88 consecutive patients underwent percutaneous closure of 152 large-bore access sites after endovascular aneurysm repair. There was no difference in the proportion of morbidly obese patients (body mass index >35kg/m2) between the two cohorts. Access-related complications were significantly reduced in the group undergoing ultrasound-guided access. Despite the lower complication profile with ultrasound guidance, 24 sites (41%) had sheath sizes ≥20F compared to only 21 sites (24%) in the standard access group (p<0.05). Evaluating conversions and technical success of percutaneous closure, a significant benefit was identified for sheath sizes ≥20F (p<0.05). Upon comparing the two cohorts, operative time continued to decrease from 154 (±64) to 101 (±56) min after the addition of ultrasound guidance for access (p<0.05). The addition of ultrasound-guided femoral access to totally percutaneous aortic aneurysm repair continues to increase the technical success rate for vessel closure and has a clinically profound impact on access-related complications. This technical adjunct appears to have the largest impact on patients requiring larger sheath sizes.