RS24 - Utilization of percutaneous closure devices for large bore arterial access in genetic aortopathy patients does not result in increased rates of femoral cutdown or access site complications

Objectives: Percutaneous closure devices for arterial sheaths of sufficient caliber to deliver aortic endografts have a published success rate of up to 96%. Despite this, they are frequently avoided in patients with genetic aortopathy due to longstanding dogma and concern for high failure rates and increased complications in the setting of compromised tissue integrity. However, the safety and feasibility of total percutaneous access in this population has not been widely described. This study aims to quantify access site complications following large bore percutaneous access among patients with confirmed genetic aortopathy.

Methods: All patients undergoing endovascular aortic procedures requiring large bore (≥9Fr) femoral sheath access between 2019-2023 were identified. Only patients with a laboratory confirmed genetic aortopathy were included. The specific mutation, demographics, comorbidities, and operative details including maximum sheath size were recorded. Outcomes including unplanned femoral cutdown following percutaneous access, pseudoaneurysm, limb complications and reinterventions were evaluated.

Results: 33 patients were identified for whom the mean age was 45 (Table I). The cohort were mostly male (79%) and White (94%). 10 patients (30%) had Marfan, 7 (21%) had Loeys-Dietz, 3 (9.1%) had vascular Ehlers-Danlos. Also represented were MYH11, ACTA2, PRKG1, FOXE3 and LOX mutations; 6 individuals had a mutation identified in more than one culprit aortopathy gene. The most frequent procedure was TEVAR (63.3%) followed by F/BEVAR (13.3%), open Zone II arch repair with frozen elephant trunk (13.3%) and thoracic branched grafts (6.7%). The mean sheath size was 17Fr; 18% of patients had prior femoral cutdown on the groin being accessed and 45% had prior ipsilateral percutaneous access. Successful percutaneous access was achieved for 29 out of 30 (97%) patients; with the 3 non-percutaneous access cases resulting from planned cutdowns on reoperative, previously challenging groins. There was one unplanned cutdown (3.3%) resulting from inability to fire a ProGlide device in a scarred, reoperative groin. On routine postoperative ultrasound, there were no access site pseudoaneurysms or dissections identified. Two small hematomas were identified; however neither required reintervention or evacuation. There were no limb complications or unplanned reinterventions.

Conclusions: Percutaneous access is safe and effective in patients with confirmed genetic aortopathy with similar rates of unplanned cutdown as has been reported in the general literature. Given the high rates of staged aortic procedures in this patient population, percutaneous closure should be attempted to avoid an obligate femoral incision, thereby reducing the potential for wound complications and increasing the ease of future procedures.