Predictors of percutaneous access failure requiring open femoral surgical conversion during endovascular aortic aneurysm repair

Objective: To determine predictors of percutaneous (PEVAR) access failure requiring conversion to an open approach (OEVAR) during endovascular aortic aneurysm repair (EVAR). Methods: A single-center retrospective review of all EVAR patients from January 2009 through June 2011 with multivariate analysis of clinical and anatomic variables that could impact access outcome was conducted. Target vessel calcification was categorized as mild, moderate, or severe based on circumferential calcium arc (<1/3, 1/3 to 1/2, and >1/2 respectively), dyslipidemia (defined as low-density lipoprotein >130 mg/dL or receiving lipid lowering medication), and obesity (defined as body mass index [BMI] > 30). Results: We investigated 400 access sites for 200 patients who underwent EVAR. The study cohort's characteristics included an average age of 72.8 +/- 9.0 years, vessel size of 9.6 +/- 1.8 mm, sheath size of 17.1 +/- 3.0 Fr, BMI of 27.6 +/- 5.3, and estimated glomular filtration rate of 68.5 +/- 24.2 mL/min. Comorbidities included dyslipidemia in 129 patients (64.5%) and diabetes in 54 patients (27%). There were 132 OEVAR (66 patients), two mixed OEVAR with contralateral PEVAR (one patient), and 266 (133 patients) PEVAR approaches. Use of PEVAR increased over time (45.5% [2009], 77.8% [2010], and up to 88.5% [2011]; P = .001) while conversions decreased (24.3% [2009], 8.7% [2010], and 4.3% [2011]; P = .001]. More OEVAR patients (35.8%) stayed longer than 3 days compared with 21.1% for PEVAR (P = .028). For the 266 PEVAR approaches, 32 access sites (12.0%) had to be converted. Severely calcified arteries were most predictive of conversion (odds ratio [OR], 36.4; P < .001). Year of procedure (2010; OR, 0.17; P = .001; 2011, OR, 0.20; P = .049), female gender (OR, 3.1; P = .017), moderately calcified arteries (OR, 2.5; P = .085), and age (OR, 2.3 [per decade]; P = .002) were all also significant. Vessel size, sheath size, and BMI were found to be nonsignificant predictors of conversion. Conclusions: PEVAR was found to be safe, reliable, and feasible. Several factors, including learning curve, vessel calcification, age, and female gender predicted conversion of PEVAR to OEVAR.