1. Tokuda Hospital Sofia Vascular Surgery and Angiology Department Dr. A. Daskalov, Assoc. Proff. V. Chervenkov

2. Carotid Artery Stenting (CAS) Endovascular Aortic Repair (EVAR);(TEVAR);(TAVI)

3. aortic arch “Unfavorable” anatomy

4. Bovine arch Tortuosity

5. Absence of accessible common femoral artery Abdominal aortic occlusion Present Aorto-bifemoral bypass Pulseless disease (Takayasu's arteritis)

6. Radial or brachial access Transseptal access Alternative Vascular access

7. Percutaneous transcervical carotid puncture. Surgical access:  Transcervical access under reversed flow (with arteriovenous shunt in most cases).  Small cervical cutdown to perform a direct single wall cannulation of common carotid artery. Transcervical access

8. Recent retrospective analysis included 12 issues reporting the results of 579 CAS procedures: Two techniques were used: direct CAS with percutaneous transcervical access in 250 patients and CAS with open cervical access under reversed flow in 489 patients. The incidence of stroke was 1.2% (3 of 250) in direct CAS with transcervical access and 1.02% (5 of 489) in CAS under reversed flow (P >.05). Local complications were encountered in 17 of 579 CAS (2.9%), comprising 15 hematomas (13 direct CAS) and two hematomas and two patients with transient laryngeal palsy (surgical cutdown). No randomized trials

9. Major advantage of the transcervical access when compared to transfemoral access is that the aortic arch is not passed through, which eliminates the risk of atheroembolisation at the time of catheter and wire navigation through the aortic arch and supra-aortic trunks. Surgery provides a safe access to the artery with secure surgical closure of artery puncture. Cervical access to CCA -advantages

10. Major drawbeck of direct carotid puncture is the possability of developing a postprocedural cervical haematoma. In most cases this procedure demands the use of closure devices (Angio Seal).

11. In patients who are unsuitable for transfemoral access a direct transcervical approach with a small cervical cut down can be useful for the endovascular treatment of carotid artery disease. This technique allows the achievement of haemostasis in a controlled fashion at the end of the procedure, despite the use of anticoagulation. It is a safe and effective alternative method in cases in which a distal arterial access cannot be used.

12. EVAR;TEVAR Arterial access- (CFA). Three important approaches to expose and close the CFA when using large instruments:  exposure of the artery via bilateral open surgical cutdown in the groin.  truly percutaneous approach.  minimally invasive fascia suture technique.

13. Surgical Cutdown: Complications Literature Range: 5-15% Infection 8% Wound necrosis 6.5% Lymphocele 4.8% Re-exploration for hematoma 1% Dalainas et al, EJVES 2004;27:319.

14. Fascial Suture: Complications 23 complications in 182 patients (13.7%) 12 bleeding 4 vessel thrombosis 5 vessel stenosis 1 intimal dissection 1 pseudoaneurysm Larzon et al, J Endo Ther 2006;13(2):152-7.

15.  Percutaneous suture-mediated closure devices (Prostar XL, Proglide)  The constant pursuit to lower device profile: 27fr 24fr 21fr 14fr 18fr 1995 1997 2002 2008 2010

16. Potential advantages of p/c EVAR reduced operative time reduced blood loss reduced length of hospital stay

17. Device Specific Complications Case related factors: Size of sheaths Obesity Scar tissue Vessel disease: calcification and aneurysm Operator related factors: Learning curve

18. Torsello et al. performed a prospective randomized study that compared the endovascular suture technique with conventional cutdown access. The complication rates were similar and included 1 arterial thrombosis in each group, 3 lymphoceles in group with surgical cutdown, and 1 conversion to cutdown because of bleeding in percutaneous group. Mean surgery time (86.7 +/- 27 minutes vs 107.8 +/- 38.5 minutes; P <.05) and time to ambulation (20.1 +/- 4.3 hours vs 33.1 +/- 18.4 hours; P <.001) were significantly shorter in the group treated percutaneously.

19. Minion and Davenport compared open cutdown (n=2,802) with percutaneous femoral access (n=1,781) in elective EVAR cases using the American College of Surgeons National Surgical Quality Improvement Program database, and showed that the main advantage of percutaneous access was a shorter operative time (159±63 min v 150±68 min; p<0.05.). However, they reported that 30-day morbidity was more common in the group with percutaneous access, with no significant differences either in the 30-day mortality rate or the mean length of stay between the two groups.

20. In a more recent report a comparison between surgical cut-down vs. percutaneous femoral approach for transcatheter aortic valve implantation (TAVI) was made: single centre experience. No difference in the length of the procedure in both groups, but the incidence of major vascular complications was significantly higher in the percutaneous group (p=0.006). Contrary to other papers published in literature that concluded that surgical arteriotomy has several disadvantages, the authors concluded that surgical cut-down was safer and more cost-effective in comparison to the femoral percutaneous approach.

21. Brachial access in complex EVAR The authors found significantly higher incidence of pseudoaneurism formation in PA (11%) versus OCD (3.3%); (P<.004). There was no difference in hematomas, arterial injury, nerve injury between two groups.

22. Summary Complete percutaneous treatment is technically feasible in most cases Complications can be minimized by careful case selection, training and appropriate device deployment. Complication rate using bigger devices (over 18 fr.) is still high. The cost-effectiveness is an aspect that has to be considered.

23. The decision whether to use percutaneous approach or open cut-down for endovascular therapies should not rely on the idea to avoid surgeons’ interface, but on patient’s benefit and appropriate use of public resources.

24. THANK YOU FOR YOUR ATTENTION!