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.
Keywords: Access; Aneurysm; Downsizing; EVAR; FEVAR; Femoral; Ischemia; Limb; Percutaneous; Spinal cord ischemia; Thoracoabdominal.