Abstract
Introduction
Percutaneous access and closure is commonly performed for patients undergoing endovascular aneurysm repair (EVAR). It has proven to be a safe and successful method of closure associated with fewer complications when compared with the traditional open technique. Fascial closure is an alternative technique that can be used for closure reducing the risks associated with the open technique. The aim of this study was to assess the safety and durability of fascial closure for failed percutaneous closure device following EVAR.
Materials and methods
Over a 12-month period, 49 patients who had undergone EVAR were identified via our EVAR register. Retrospective analysis of the clinical records was undertaken. We identified all the patients who had fascial closure of the groins following a failed percutaneous closure device. Patients had a computed tomography angiogram one month postoperatively, with duplex imaging and clinic follow-up three months later.
Results
Fascial closure was performed in 14 groins. It failed in three groins and these patients had traditional open repair. Fascial closure was successful in 11 groins (7 patients). Of these seven patients, one was female (6%). The mean age was 80 years (range 68–92 years). Two patients died and one was lost to follow-up. One pseudoaneurysms were seen on computed tomography angiogram, which was managed conservatively and had resolved on follow-up imaging.
Conclusions
Fascial closure is a very good alternative to open repair after failure of the closure device.
Keywords: Femoral artery, Endovascular procedures, Aortic aneurysm, Ultrasonography, Blood vessels
Introduction
Percutaneous endovascular aneurysm repair (EVAR) has increased in popularity and has proven to be beneficial over open repair. It is associated with reduced blood loss, pain and infection.1 The success rate is reported at 89–95% but the overall cost of the procedure is higher when compared with the traditional open technique.2
The fascial closure technique, first described by Dietrich in 1997, offers a potential halfway house between percutaneous EVAR and open repair. It is especially useful in calcified vessels, scarred groins, ruptured aneurysms and after failure of the closure device.3,4 This study provides a case series of elective patients who had fascial closure following failure of closure device. Our aim was to assess complications associated with fascial closure.
Fascial closure technique
Ultrasound guidance was used to puncture the common femoral artery inferior to the inguinal ligament. When the procedure (EVAR) had been completed the guidewire and introducer were left in situ. A skin incision of 3–5 cm was made and dissection was performed down to the subcutaneous fat and fascia. A purse-string suture was put around the femoral sheath using only the fascial component and tightened, closing the arteriotomy, while the introducer was removed simultaneously (Fig 1). The guidewire was left in place. If haemostasis was achieved, the guidewire was removed and the sutures tied. If satisfactory haemostasis was not achieved the introducer was reintroduced over the guidewire into the artery and traditional open dissection and closure was performed.
Figure 1.
Fascial closure technique
Materials and methods
Percutaneous EVAR is routinely used at our centre. We retrospectively identified all patients who had undergone fascial closure between January and December 2016 at a regional vascular centre in north-west London, using the hospital’s EVAR register. Inclusion criteria included groins in which the percutaneous closure device had failed. There was one female patient. The mean age of the patients was 80 years (range 68–92 years).
Our primary endpoint was primary success of fascial closure which was identified intraoperatively. Secondary end points included pseudoaneurysm, seroma, wound infection and arterial stenosis.
The procedure was performed by two consultant vascular specialists and was standardised as described above. Patients were followed-up at one month with a routine computed tomography angiogram (CTA), clinic follow-up at three months with a vascular surgeon and a duplex scan at 6–12 months to assess for evidence of pseudoaneurysm or any complications. The data were collected retrospectively using the picture archiving and communication system and clinical notes.
Results
We performed 49 EVARS in 2016. Fascial closure was successful in 7 patients and 11 groins. It was attempted in 14 groins but failed in 3 groins (21%) and these patients had to undergo immediate open repair. Of the 11 groins, there were two deaths within six months and one patient was lost to follow-up. The deaths were unrelated to fascial closure.
Of the nine groins we were able to follow up, one pseudoaneurysm (11%) was seen on CTA at one month post-procedure. This was 6 mm and was treated conservatively. It had resolved on subsequent duplex scan at six months. There were no seromas or stenoses and there were no further complications six months post-procedure.
We have not included the data for the patients in which fascial closure failed immediately and had to undergo immediate open repair.
Discussion
The results of this study show that fascial closure is a safe and durable technique. It is associated with reduced infection and seroma formation as the fascia lata remains intact and is not breached to enter the deeper tissue. Indications for fascial closure that have been documented in the literature are calcified vessels, scarred groins, rupture, after failure of the closure device.3,4
The success rate in this study was 79%, slightly lower than that reported by Larzon et al at 88%.5 Our pseudoaneurysm rate was 11%, which was higher than that reported by Harrison et al and Larzon et al, at 7% and 1% respectively, although our overall numbers were smaller, which account for this difference. The one pseudoaneurysm was small enough to be managed conservatively and on duplex scanning at six months had resolved without any intervention.
Fascial closure is a cheaper alternative to the closure devices. A randomised controlled trial by Larzon et al documented this as a mean difference of €800. The same study also reported a shorter procedure time, with fascial closure at 12.4 minutes compared with 19.9 minutes for the Prostar technique.2 Fascial closure is beneficial over the Perclose technique in the emergency setting. It avoids the need for insertion of the sutures allowing the surgeon to start the procedure quickly, thus saving a significant amount of time.
There were no major wound infections, haematomas, seromas or dehiscence. Similar studies have reported similar low levels of wound complications in fascial closure, which is a benefit of fascial closure over open repair.
The limitations of this study include small numbers, as we only included those groins in which the closure device had failed. The fascial closure technique is a relatively new technique in our department. We did not set a competency level for the surgeons performing the fascial closure or the Perclose technique. Had we have identified a ‘competency level’ the results may have been different. There were three instances in which fascial closure failed and open repair had to be performed. With further work we may be able to identify risk factors for failure.
Conclusion
Fascial closure is a very good alternative to open repair after failure of the closure device.
References
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