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Safety and Feasibility of Percutaneous Purse-String-Like Downsizing for Femoral Access During Complex Endovascular
Andrea Melloni1, Alessandro Grandi1, Germano Melissano1
1Division of Vascular Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
Insights
This study introduces a novel purse-string technique for femoral access sheath downsizing during endovascular aortic repair. The method enables early reperfusion of the pelvis and limbs with a 95% success rate in achieving hemostasis.
Area of Science:
- Vascular Surgery
- Endovascular Repair
- Interventional Cardiology
Background:
- Complex endovascular aortic repair (EVAR) often requires large-bore femoral access sheaths.
- Prolonged sheath deployment can lead to extended ischemia of the pelvis and lower limbs.
- Early reperfusion is crucial for patient outcomes during EVAR.
Purpose of the Study:
- To describe a percutaneous purse-string technique for downsizing the femoral access sheath during complex EVAR.
- To evaluate the feasibility and effectiveness of this technique in achieving early reperfusion.
- To maintain sheath access while enabling early limb and pelvic perfusion.
Main Methods:
- Ultrasound-guided femoral artery catheterization followed by pre-closure with two Perclose ProGlide vascular closure devices (VCDs).
- After EVAR component deployment, the large sheath is exchanged for a smaller, non-occlusive sheath (≤10 F).
- The rail suture of the VCDs is then pulled to achieve hemostasis, with final closure using standard techniques.
Main Results:
- The purse-string sheath downsizing technique achieved a 95% (55/58) success rate for hemostasis.
- Median limb ischemic times were 66 minutes for the main access and 65 minutes for the contralateral access.
- While closure success was comparable to a control group, the downsizing group more frequently required an additional ProGlide device (45% vs. 15%).
Conclusions:
- Percutaneous purse-string sheath downsizing is a feasible technique for restoring perfusion during complex EVAR.
- The technique demonstrates high closure success rates.
- Further research is needed to assess the impact on spinal cord injury (SCI) rates within a multimodal approach to spinal cord protection.
Purpose:
To describe a percutaneous "purse-string-like" technique to downsize the femoral access sheath achieving early pelvis and limb reperfusion during complex endovascular aortic repair, while maintaining a sheath in place.
Materials And Methods:
After ultrasound-guided femoral catheterization, two Perclose ProGlide vascular closure devices (VCD) are employed with the pre-close technique. When the deployment of aortic components is complete, the large delivery sheath is exchanged for a smaller non-occlusive one (≤ 10 F) and the rail suture of both VCDs is pulled to achieve hemostasis. At the end of the procedure, the access is closed according to standard technique.
Results:
Fifty-eight femoral accesses were downsized achieving hemostasis with a completion percutaneous closure success of 95% (55/58). The median ischemic time to the limb was 66 min (IQR 31-131) for the main access and 65 min (IQR 30-100) for the contralateral one. When compared to a 1:2 propensity score-matched cohort who did not undergo access downsizing, no differences in closure success were recorded (95% vs. 89%, p = 0.19). However, hemostasis required more frequently an additional ProGlide in the downsizing group (26 cases, 45% vs. 17 cases, 15%; p < .001).
Conclusion:
Percutaneous purse-string-like sheath downsizing to restore perfusion to limbs and pelvis during complex endovascular aortic repair is feasible with high closure success rates, although a third ProGlide is more frequently needed to achieve hemostasis. The impact of this practice on SCI rates requires further evaluation in larger series as part of a multimodal approach for spinal cord protection.
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