Utilization of percutaneous closure devices for large bore arterial access in patients with genetic aortopathy does not result in increased rates of access site complications.

Abstract

Objective: Percutaneous closure devices for arterial sheaths of sufficient caliber to deliver aortic endografts have a published success rate of 90-95%. Despite this, they are frequently avoided in patients with genetic aortopathy due to concern for high failure rates and increased complications in the setting of compromised tissue integrity. This study aims to compare rates of access site complications following large bore percutaneous access among patients with and without confirmed genetic aortopathy.

Methods: All patients undergoing endovascular aortic procedures requiring large bore (≥9Fr) femoral sheath access between 2019-2023 were identified. The specific mutation, demographics, comorbidities, and operative details including maximum sheath size were recorded. Outcomes including unplanned femoral cutdown, access site complications and reinterventions were evaluated. These factors were then compared between patients with and without a laboratory confirmed mutation associated with genetic aortopathy. A supplemental analysis was then performed on all patients with genetic aortopathy from 2014-2023.

Results: Among the 404 patients identified, 33 (8%) had confirmed genetic aortopathy. Among these, 7 patients (21%) had Marfan syndrome, 7 (21%) had Loeys-Dietz syndrome, and 3 (9%) had vascular Ehlers-Danlos. Also represented were ACTA2, PRKG1, FOXE3, and LOX mutations. The genetic aortopathy group was significantly younger (median genetic aortopathy: median 52 years; non-genetic aortopathy: 71 years; p<0.001). TEVAR was most frequent in the genetic aortopathy group (52%), followed by Zone II arch replacement with frozen elephant trunk (21%); the most frequent operation among the non-genetic aortopathy group was F/BEVAR(43%), followed by TEVAR (25%). Both groups had a median sheath size of 20 Fr; the patients with genetic aortopathy had higher rates of both prior open (genetic aortopathy: 27%; non-genetic aortopathy: 12%; p=0.015) and prior percutaneous ipsilateral access (genetic aortopathy: 58%; non-genetic aortopathy: 39%; p=0.041). Rates of unplanned cutdowns (genetic aortopathy: 0%; non-genetic aortopathy: 6%) and access site complications (genetic aortopathy: 0%; non-genetic aortopathy: 8%) did not significantly differ between groups (p=0.160 and p=0.096, respectively). In supplementary analysis, there was one patient with genetic aortopathy who required unplanned cutdown, yielding an overall technical success rate of 97% for percutaneous closure over a 10-year period.

Conclusions: Percutaneous access is safe and effective in patients with confirmed genetic aortopathy with similar rates of unplanned cutdown as those in patients without genetic aortopathy. Given the high rates of staged, repeat 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.