The Percutaneous Approach of Endovascular Aortic Aneurysm Repair

The endovascular treatment of aortic aneurysms is based on stent-graft delivery through the common femoral artery (CFA). The procedure has evolved over the years. Since the development of the percutaneous approach in the late 1990s, several surveys have been performed and have promoted the advantages of this technique. The percutaneous approach was associated with a shorter time to ambulation and fewer complications compared with an open cutdown to the groin vessels, including a reduced risk of events such as wound infection, lymphocele, and hematomas.

All currently available closure devices are approved for use only up to 10-French (10F) sheath sizes. With the introduction of the “preclose” technique, however, it was possible to close access vessels after endovascular aneurysm repair (EVAR), which requires larger-bore sheaths.

The Prostar XL 10F device (Abbott Laboratories. Abbott Park, Illinois, USA) consists of four components ( Fig. 1.1 ). The first two components are a hydrophilic catheter for guiding the system into the aorta and a marker lumen for identification of correct device position in the vessel ( Fig. 1.2 ). The third component is a sheath containing four lancelike nitinol needles, which are connected to two braided sutures ( Fig. 1.3 ). The fourth component is a rotating barrel for dissection and needle capture. The device is advanced into the artery to guide the needle trajectory through the subcutaneous tissue, with the sutures being pulled out from the inside through the arterial wall ( Figs. 1.4 and 1.5 ).

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The Prostar XL 10F device.

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The marker lumen of the Prostar device.

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The lancelike nitinol needles are crossed and connected to two braided sutures.

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Rotating barrel for insertion in the femoral artery. The correct position of the Prostar device in the femoral artery is confirmed by backbleeding.

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The sutures are pulled through the arterial wall.

Preclose Technique

After puncture of the CFA and insertion of an 8F short sheath, and with careful blunt dissection of the subcutaneous tissue down to the vessel wall with a mosquito clamp, the Prostar XL 10F is advanced and deployed. The sutures are fixed loosely with a small clamp, and a 14F sheath replaces the closure system. After deployment of the stent-graft, the sutures are tied to the vessel with a fisherman’s knot ( Fig. 1.6 ).

To avoid major blood loss in case of a failed closure, a guidewire is left in place and maintains access to the vessel. Hemorrhage is controlled during dissection of the groin and exposure of the vessel. If oozing occurs after securing the knots, these should be held against the vessel wall with the knot pusher for several minutes, manually compressing the artery above the puncture site ( Fig. 1.7 ).

If compression is not effective, a polytetrafluoroethylene (PTFE) felt pledget can be sewn with the four vascular sutures of the Prostar device to achieve hemostasis. The wound is closed using a topical liquid skin adhesive.