The Role of Downsizing of Large-Bore Percutaneous Femoral Access for Pelvic and Lower Limb Perfusion in Transfemoral Branched Endovascular Aortic Repair

Abstract

Background: Transfemoral access (TFA) is a valuable alternative to upper extremity access (UEA) for branched endovascular aortic repair (bEVAR). However, TFA requires large introducer sheaths, which can reduce blood flow to lower limbs and the pelvis. This study aimed to evaluate the efficacy of sheath downsizing to maintain lower limb perfusion during TFA–bEVAR. Methods: A single-center retrospective review was conducted including patients managed with TFA-performed bEVAR between December 2020 and May 2021. Intra-operative lower limb perfusion was assessed using non-invasive ankle blood pressure measurements and great toe pulse oximetry, with measurements being taken prior to puncture (baseline), one minute after 10F-sheath insertion, three minutes after the main body delivery system insertion, and three minutes after downsizing to a 14F sheath. Outcomes included the incidence of limb perfusion reduction (LPR), defined as a drop in the ankle–brachial index (ABI) < 0.5 or peripheral oxygen saturation (SpO2) < 90%. Results: Out of 47 patients, 24 met the inclusion criteria. LPR occurred in 4.2% of cases after 10F-sheath placement, and 87.5% after main body delivery system placement, and decreased to 12.6% after downsizing to a 14F sheath. No periprocedural major bleeding occurred. Two patients required revision for inadequate hemostasis post-operatively. SCI occurred in 16% of patients, all recovered by discharge. Pre-operative hypogastric artery occlusion was related to persistent LPR after downsizing (100% vs. 16%, p = 0.009). Conclusions: Downsizing the introducer sheath during bEVAR is feasible and safe to restore lower limb and pelvic perfusion. Further research is needed to clarify the access downsizing value during bEVAR.