A meta-analysis of outcome after percutaneous endovascular aortic aneurysm repair using different size sheaths or...

To determine via a meta-analysis if the success rates for percutaneous EVAR using the "preclose" technique with suture-mediated vascular closure devices (SMCDs) are higher for smaller sheaths [≤ 18-F outer diameter (OD)] than for larger sheaths (≥20-F).

All English-language studies on percutaneous EVAR outcomes related to sheath sizes published between 1999 and August 30, 2010, were searched using MEDLINE and SCOPUS. Randomized trials, retrospective or prospective observational studies, and original articles (including a review) were included. The search identified 32 relevant full-text studies; data on percutaneous EVAR outcomes per sheath size category (≤ 18-F and ≥ 20-F OD) were included in the final meta-analysis of data from 17 studies (1 randomized controlled trial and 8 retrospective and 8 prospective cohort observational studies). The final analysis included 1440 patients and 2447 femoral access sites. Primary success was defined as closure of a common femoral artery arteriotomy without the need for any adjunctive surgical or endovascular procedure.

Pooled data revealed that success rates were significantly better when percutaneous EVAR was performed with ≤ 18-F sheaths than with ≥ 20-F sheaths (odds ratio 1.78, 95% confidence interval 1.24 to 2.54, p = 0.002). This benefit, although not significant, was more pronounced when multiple rather than single pre-applied SMCDs were deployed (odds ratio 2.16 vs. 1.64, respectively; p = 0.353).

When considering primary success, it appears that larger-bore femoral access sheaths (≥ 20-F) introduced for percutaneous EVAR after pre-application of SMCDs are predictors of primary failure and the need for conversion to a femoral cutdown. More advanced large-bore SMCDs are required to further reduce the necessity for conversion. Planned use of multiple SMCDs might be more beneficial when ≤ 18-F sheaths are required.