Management of the Femoral Artery After Transluminal Repair of Abdominal Aortic Aneurysms

Abstract

Catheter-based treatment of abdominal aortic aneurysms (AAA), in which an endograft is placed into the aneurysmal aorta through one or more femoral arteriotomies, is gaining acceptance rapidly. This technique has the advantage of avoiding the morbidity and prolonged recovery of conventional repair, but subjects the femoral arteries to significant surgical and catheter trauma that may compromise the outcome of the procedure. We review our experience with management of the femoral arteries following endovascular aneurysmal repair. Thirty patients undergoing endovascular repair of their AAA with the modular bifurcated Aneu Rxg (Medtronic AneuRx, Sunnyvale, CA) endovascular prosthesis had their femoral arteries exposed through bilateral groin incisions to permit insertion of the device. Proximal and distal control of the femoral arteries was achieved, and guidewire passage and sheath access obtained using standard angiographic techniques. The endovascular components, ensheathed in a 22F (primary device) or 16F (secondary device) catheter were positioned and deployed from bilateral common femoral arteriotomies. The 22F insertion system was used in the right femoral artery in 18 and left femoral artery in 12 of the 30 procedures. Repair of the femoral arteriotomies was accomplished following standard vascular surgical principles, and femoral and pedal pulses and ankle-brachial indices (ABI) recorded postoperatively. All 30 patients were men (mean age: 73 ±8 years), and all had evidence of extra-aortic atherosclerosis. The endovascular prosthesis was deployed successfully in 29 of the 30 patients. One limb was lost in the postoperative period secondary to severe pre-existing arterial occlusive disease in the popliteal and tibial arteries, and one patient thrombosed an associated popliteal aneurysm requiring emergent repair on the first postoperative day. No patient experienced a permanent change in the pulse examination or reduction in the ABI. Thirteen of the 60 (22%) arteries required repair other than simple closure of the arteriotomy to restore arterial continuity. Complex repair was more common in the initial 15 (10 of 30 arteries, 33%) patients than in the latter 15 (3 of 30 arteries, 10%, p=0.01) and on the side of the larger, primary device (8 of 30 arteries, p=NS). Technically successful repair was achieved in all vessels.

Although associated with shorter recovery times and brief hospital stays, endovascular repair of AAA, not unexpectedly, may require complex management of the sites of access for the prosthesis. The need for complex repair appears to diminish both with increasing experience with the device and smaller device size. Simplifying management of the femoral artery requires significant advances in the design of the currently available devices.

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References

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