We sought to evaluate the safety and efficacy of totally percutaneous femoral access (TPFA) for fenestrated–branched endovascular aortic repair (F/B-EVAR) of pararenal–thoracoabdominal aortic aneurysms (PRAs/TAAAs).
We reviewed all consecutive patients enrolled in single-center prospective non-randomized single-arm study to investigate F/B-EVAR for PRAs/TAAAs (2013–2017). Percutaneous approach was selected in all patients when anatomically feasible; otherwise, surgical femoral access (SFA), with or without construction of temporary prosthetic conduit, was selected. Primary outcomes were technical success, mortality, major adverse events (MAEs) and major vascular access complications.
A total of 231 patients were included in the study: TPFA was possible in 163 (70%) with technical success rate of 93%, while 68 (30%) required SFA. Patients with TPFA and SFA had similar mortality rate of 1%. The rate of MAEs for TPFA was 20% versus 38% for SFA (p = .07). The trend was mainly driven by reduced rates of estimated blood loss (EBL) ≥ 1L (6% vs 21%, p = .001) and acute myocardial infarction (2% vs 9%, p = .03). Similarly, TPFA carried a significantly lower rate of major vascular access complications as compared with SFA (6% vs 21%, p < .001; adjusted OR 3.4, 95% CI 1.3–8.9, p = .01).
A percutaneous-first approach for elective F/B-EVAR of PRAs/TAAAs is safe, feasible and effective when proper patient selection is provided. When the presence of hostile iliofemoral anatomy requires open-vessel exposure, higher rates of perioperative major bleeding, cardiac events and access complications may be expected.
Level of Evidence
Level 3 (single-center prospective non-randomized single-arm study).
This is a preview of subscription content, log in to check access.
Buy single article
Instant unlimited access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Wanhainen A, Verzini F, Van Herzeele I, et al. European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2019;57:8–93.
Nelson PR, Kracjer Z, Kansal N, et al. A multicenter, randomized, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial). J Vasc Surg. 2014;59:1181–93.
Oderich GS, Ribeiro MS, de Souza LR, et al. Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts. J Thorac Cardiovasc Surg. 2017;153:S32–41.
Verhoeven ELG, Katsargyris A, Bekkema F, et al. Editor’s Choice—Ten year experience with endovascular repair of thoracoabdominal aortic aneurysms: results from 166 consecutive patients. Eur J Vasc Endovasc Surg. 2015;49:524–31.
Timaran DE, Soto M, Knowles M, et al. Safety and effectiveness of total percutaneous access for fenestrated endovascular aortic aneurysm repair. J Vasc Surg. 2016;64:896–901.
Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg. 2002;35:1048–60.
de Souza LR, Oderich GS, Banga PV, et al. Outcomes of total percutaneous endovascular aortic repair for thoracic, fenestrated, and branched endografts. J Vasc Surg. 2015;62:1442–9.
Malkawi AH, Hinchliffe RJ, Holt PJ, et al. Percutaneous access for endovascular aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg. 2010;39:676–82.
Dwivedi K, Regi JM, Cleveland TJ, et al. Long-term evaluation of percutaneous groin access for EVAR. Cardiovasc Intervent Radiol. 2019;42:28–33.
Siracuse JJ, Farber A, Kalish K, et al. Comparison of access type on perioperative outcomes after endovascular aortic aneurysm repair. J Vasc Surg. 2018;68:91–9.
Eisenack M, Umscheid T, Tessarek J, et al. Percutaneous endovascular aortic aneurysm repair: a prospective evaluation of safety, efficiency, and risk factors. J Endovasc Ther. 2009;16:708–13.
Bechara CF, Barshes NR, Pisimisis G, et al. Predicting the learning curve and failures of total percutaneous endovascular aortic aneurysm repair. J Vasc Surg. 2013;57:72–6.
Mousa AY, Campbell JE, Broce M, et al. Predictors of percutaneous access failure requiring open femoral surgical conversion during endovascular aortic aneurysm repair. J Vasc Surg. 2013;58:1213–9.
Manunga JM, Gloviczki P, Oderich GS, et al. Femoral artery calcification as a determinant of success for percutaneous access for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2013;58:1208–12.
Arthurs ZM, Starnes BW, Sohn VY, et al. Ultrasound-guided access improves rate of access-related complications for totally percutaneous aortic aneurysm repair. Ann Vasc Surg. 2008;22:736–41.
Seto AH, Abu-Fadel MS, Sparling JM, et al. Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access with Ultrasound Trial). J Am coll Cardiol Intv. 2010;3:751–8.
Oguzkurt L, Gurel K, Eker E, et al. Ultrasound-guided puncture of the femoral artery for total percutaneous aortic aneurysm repair. Diagn Interv Radiol. 2012;18:92–5.
Chee YE, Liu SE, Irwin MG. Management of bleeding in vascular surgery. Br J Anaesth. 2016;117:ii85–94.
Bursi F, Barbieri A, Politi L, et al. Perioperative red blood cell transfusion and outcome in stable patients after elective major vascular surgery. Eur J Vasc Endovasc Surg. 2009;37:311–8.
Kougias P, Orcutt S, Pak T, et al. Impact of postoperative nadir hemoglobin and blood transfusion on outcomes after operations for atherosclerotic vascular disease. J Vasc Surg. 2013;57:1331–7.
Obi AT, Park YJ, Bove P, et al. The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery. J Vasc Surg. 2015;61:1000–9.
Osborne Z, Hanson K, Brooke BS, et al. Variation in transfusion practices and the association with perioperative adverse events in patients undergoing open abdominal aortic aneurysm repair and lower extremity arterial bypass in the Vascular Quality Initiative. Ann Vasc Surg. 2018;46:1–16.
Buck DB, Karthaus EG, Soden PA, et al. Percutaneous versus femoral cutdown access for endovascular aneurysm repair. J Vasc Surg. 2015;62:16–21.
Cao Z, Wu W, Zhao K, et al. Safety and efficacy of totally percutaneous access compared with open femoral exposure for endovascular aneurysm repair: a meta-analysis. J Endovasc Ther. 2017;24:246–53.
Tsilimparis N, Dayama A, Perez S, et al. Iliac conduits for endovascular repair of aortic pathologies. Eur J Vasc Endovasc Surg. 2013;45:443–8.
Gupta PK, Sundaram A, Kent CK. Morbidity and mortality after use of iliac conduits for endovascular aortic aneurysm repair. J Vasc Surg. 2015;62:22–6.
Gallitto E, Gargiulo M, Faggioli G, et al. Impact of iliac artery anatomy on the outcome of fenestrated and branched endovascular aortic repair. J Vasc Surg. 2017;66:1659–67.
Maurel B, Delclaux N, Sobocinski J, et al. Editor’s Choice—The impact of early pelvic and lower limb reperfusion and attentive peri-operative management on the incidence of spinal cord ischemia during thoracoabdominal aortic aneurysm endovascular repair. Eur J Vasc Endovasc Surg. 2015;49:248–54.
Rowse JW, Morrow K, Bena JF, et al. Iliac conduits remain safe in complex endovascular aortic repair. J Vasc Surg. 2019;70:424–31.
Hajibandeh S, Hajibandeh S, Antoniou SA, et al. Percutaneous access for endovascular aortic aneurysm repair: a systematic review and meta-analysis. Vascular. 2016;24:638–48.
Conflict of interest
G.S.O. has received consulting fees and grants from Cook Medical, W.L. Gore and GE Healthcare (all paid to Mayo Clinic with no personal income).
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
D’Oria, M., Oderich, G.S., Tenorio, E.R. et al. Safety and Efficacy of Totally Percutaneous Femoral Access for Fenestrated–Branched Endovascular Aortic Repair of Pararenal–Thoracoabdominal Aortic Aneurysms. Cardiovasc Intervent Radiol (2020). https://doi.org/10.1007/s00270-020-02414-8
- Percutaneous access
- Vascular closure device
- Fenestrated and branched endovascular aortic repair
- Pararenal aortic aneurysms
- Thoracoabdominal aortic aneurysms