Percutaneous Endovascular Aneurysm Repair (PEVAR): A note of CAUTION

I just came back from south Florida where I participated in the excellent ISET 2010 event. One of the concurrent afternoon sessions was devoted to the always-important topic of Vascular Access, including a mini-session on percutaneous aneurysm repair, or PEVAR. In truth, the main topic is not so much whether one can access the aorta via a percutaneous stick of the one or both femoral arteries… because this is of course possible and generally quite easy, always. The real issue is whether and when to repair percutaneously the big arterial hole created by the insertion of the large-caliber (18-25F) delivery system of the endograft device. And I must admit the winds of change are blowing in the EVAR shores as well… with many operators – surgeons included – finding PEVAR increasingly attractive. In my own practice, however, I continue to do a surgical cutdown approach in most cases because I find it easy, effective, and quite straightforward. Additionally, we now perform such an approach – for the majority of patients – using a very short oblique groin incision that heals well and quickly and without complications for the most part. Femoral nerve neuropathy continues to be an issue, though, but it tends to be self-limited and short-lived. That said, I must say I too find PEVAR appealing and it will clearly be the way to go in the future, particularly as endograft devices evolve and become lower profile. However, there are 2 enormously important considerations to make: 1. Proper case selection is paramount, particularly the selection of certain patients who should not be considered for percutaneous access arterial repair, mainly those with circumferential or anterior-wall calcification in the femoral artery. This is the single most significant risk factor and the best predictor of failure. Also, femoral bifurcations that lie high near or at the level of the inguinal ligament, as well as patients with a history of previous vascular surgery with insertion of a synthetic vascular graft at the femoral access site. Pre-operative refined evaluation of access arterial morphology is therefore paramount and best achieved through CT angiography. Obesity has also been cited as a relative contraindication; at the same time, markedly obese individuals tend to be at high risk for healing complications following surgical exposure of the femoral artery so, generally, it would be advantageous to be able to perform PEVAR in some or most such patients. A recently published German study found that obesity was not a predictor for complication after PEVAR, further reinforcing such a concept. 2. No matter how good or careful one might be, the need for surgical “conversion” and open repair of the accessed femoral artery can present itself – powerfully and unpredictably. It is therefore most important to recognize such a potential scenario and make sure that surgical capabilities exist at the institution and/or environment where the endograft procedure is being performed. This is particularly important to think through for operators without a surgical background who may want to do these procedures outside the operating room. In the future, some of the above-described issues may become less relevant if and when aortic stent-grafts evolve into “truly percutaneous” devices that can be delivered in catheters or sheaths that are 14F or smaller in outer diameter. Unfortunately, this is not likely to happen anytime soon. Frank J. Criado, MD, FACS, FSVM Editor-in-Chief Vascular Disease Management ________________________________ Dr. Frank J. Criado is a Board-Certified Vascular Surgeon and Endovascular Specialist at the Union Memorial Hospital-MedStar Health in Baltimore, Maryland – USA. Dr. Criado is widely acknowledged to be a pioneer in endovascular therapy, with a 20-year + interventional experience. He has contributed extensively to the literature, with more than 100 peer-review published articles – mostly on various vascular and endovascular subjects, and is Editor-in-Chief of Vascular Disease Management (VDM). He has also been active in clinical research, with a major focus on aortic stent-graft and carotid interventions, and endovascular technologies in general. He was the National Principal Investigator (P.I.) for the Medtronic Talent AAA clinical trials in the U.S., and a member of the Executive Committee for the Medtronic Valor Thoracic trial. He is a founding member and immediate past President of the International Society of Endovascular Specialists (ISES), founder and current President of the endovascular surgery society of Latin America (CELA), and a member of all major U.S. and international vascular and endovascular societies. He is a Fellow of the American College of Surgeons (FACS) and of the Society of Vascular Medicine (FSVM), and a member of the Board of Directors of the Society for Vascular Surgery (SVS).