Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Open Access

Peer-reviewed

Research Article

Predictors and Treatments of Proglide-Related Complications in Percutaneous Endovascular Aortic Repair

  • Guohua Hu,

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯
  • Bin Chen,

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯
  • Weiguo Fu ,

    fu.weiguo@zs-hospital.sh.cn

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯
  • Xin Xu,

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯
  • Daqiao Guo,

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯
  • Junhao Jiang,

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯
  • Jue Yang,

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯
  • Yuqi Wang

    Affiliation Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China

    ⨯

Abstract

Purpose

To investigate the predictors and treatment of the 6-Fr Perclose Proglide-related complications (PRC) in percutaneous endovascular aortic repair (pEVAR).

Methods

We retrospectively analyzed the PRC after pEVAR for the treatment of aortic aneurysm or dissection in our center from December 2012 to November 2013. Procedure success was defined as effective functioning of the two devices and local hemostasis. Access-related adverse events included vascular complications and device failures. Operative data and angiographic and computed tomography images were collected to assess the complications and treatment strategy.

Results

A total of 198 patients with 275 puncture sites underwent pEVAR with the 6-Fr Perclose Proglide. The procedure was successful in 178 patients (89.9%), whereas PRC occurred in 20 cases (10.1%), including 10 device failures and 10 vascular complications. An extra manual ancillary compression was conducted in 7 patients, one more device was used in 8 patients, and surgical repair of the femoral artery was performed in 5 patients. PRC had a tendency to occur in patients with body mass index (BMI)>30 kg/m2 (p = 0.021), thoracic stent grafts (p = 0.038), common femoral artery (CFA) calcification (p = 0.001), CFA depth>4 cm (p = 0.001), and sheath size>20Fr (p = 0.005). Device failure-related mortality was zero. None of the access sites had complications during the midterm follow-up.

Conclusions

The pre-close technique with 6-Fr Perclose Proglide devices for pEVAR appears to be safe and effective with low technical failure and complication rates. Careful patient selection and proficiency in device manipulation might reduce the device related complications.

Citation: Hu G, Chen B, Fu W, Xu X, Guo D, Jiang J, et al. (2015) Predictors and Treatments of Proglide-Related Complications in Percutaneous Endovascular Aortic Repair. PLoS ONE 10(4): e0123739. https://doi.org/10.1371/journal.pone.0123739

Academic Editor: Claudio Moretti, S.G.Battista Hospital, ITALY

Received: May 28, 2014; Accepted: March 5, 2015; Published: April 22, 2015

Copyright: © 2015 Hu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: All relevant data are within the paper.

Funding: These authors have no support or funding to report.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Endovascular aortic repair (EVAR) has been an option for the treatment of aortic diseases, such as dissections[1] and aneurysms[2,3]. Arteriotomy of the common femoral artery (CFA) is usually performed to deliver the stent grafts. Since the advent of “pre-close technique” advocated by Haas et al.[4], percutaneous EVAR (pEVAR) has been applied to decrease the morbidity of the groin incisions.

Six-Fr Perclose Proglide (Abbot vascular, Redwood City, USA) is one of these vascular suture devices that consists of one 3–0, unbraided, pre-tied slipknot. A greater than 90% success rate has been reported for this device, and the technique can save procedure time, reduce hospitalization duration, and promote early ambulation[5–7].

However because of inherent limitations and the learning curve involved in its use, several 6Fr Perclose Proglide-related complications (PRC) remain unsolved[8,9]. Accordingly, the current study was conducted to investigate the procedural success rate and predictors of PRC in pEVAR.

Methods

Patient data

The ethics committee of Fudan University approved this clinical observational study. It was a retrospective study and the patients' consent was not obtained. All the data were analyzed anonymously. A retrospective analysis was performed on patients undergoing EVAR in our center from December 2012 to November 2013. Patients were included if they were suitable for percutaneous interventions using the pre-close technique. Patients with previous groin surgery and inguinal arterial prosthesis in the access site, a severely tortuous iliac artery, anterior or posterior plaques (>50% circumference), calcified annulus and narrowed (diameter<6 mm) femoral arteries were excluded.

Medical data for demographics, diagnosis, treatment modalities, outcomes, and follow-ups were retrospectively analyzed. In all subjects, the depth of the puncture sites and CFA calcifications was measured by ultrasonography (US) or computed tomographic angiography (CTA) before the operation.

Surgical procedures

All operators were familiar with the use of the Perclose Proglide devices and have undergone training. All operators were experienced and have handled 20 successful sutures using this device.

Patients were operated on under general anesthesia. Prior to puncturing the CFA, we used US or CT data to mark the sites free of ring-shape calcification between the bifurcation and the groin ligament. After a small incision in the skin at the site, we expanded the superficial fascia or fat tissue using a vascular clamp before puncture.

Heparin was intravenously administered at 1 mg/kg dose. Arterial puncture using the modified Seldinger technique (not through the posterior wall of the artery) was performed. Prior to deployment of the first Perclose Proglide device, we performed a femoral angiogram to reconfirm the vessel size, calcium deposits, and tortuosity.

The two devices were deployed in the standard manner according to the protocol of the pre-close technique[10,11], but we rotated the devices left and right from the entrance axis approximately 30° each (60° between them). Stent graft selection was based on the preferences of the surgeons and vascular anatomy.

Prior to the insertion of large-bore stent-graft delivery sheaths, we often perform a progressive pre-dilatation with 6Fr-10Fr sheaths. At the end of the pEVAR procedure, we carefully removed the entire sheath system and allowed the potential blood debris out. We checked the pedal pulses immediately after the closure and ensured that there were no changes compared to the preoperative findings. We administered protamine sulfate after checking for a healthy distal pulse.

Outcome definitions

The primary success is defined as good device performance and femoral arterial hemostasis without any open repair conversion.

Bleeding is defined and classified according to the Bleeding Academic Research Consortium (BARC) criteria[12] at the access site after two device suturing pre-operatively or within 30 days afterwards. Vascular complications also included the access vessel dissection, arteriovenous fistula, and stenosis or stricture that leads to extremity ischemia or severely limited flow confirmed by imaging check.

Device failures involve failure to preload the sutures, suture rupture or tearing out, and insufficient tightening of the knots.

Follow-up

Patients who underwent pEVAR were followed up at 30 days, 3 months and 6 months after discharge. During imaging follow-up, we not only screened the outcome of the aortic stent grafts but also evaluated the access to rule out late PRC events, such as stenosis and pseudoaneurysm.

Statistical analysis

Demographics and background data from patients were descriptive. Continuous data were summarized as the mean ± standard deviation, and categorical data were described as counts and percentages. Differences between the success group and PRC group were analyzed using a combination of Pearson Chi- square test and Student’s t test for categorical and continuous data, respectively. Linear regression analysis was performed on the incidence of PRC. Multivariate analysis was performed to assess the impact of various variables on the PRC. Statistically significant difference was considered at P value<0.05. Statistical Package for Social Sciences for Windows (SPSS 19.0, Chicago, IL, USA) was used for data processing and statistical analyses.

Results

Patient characteristics

We performed EVAR in 216 patients and deployed all stent grafts successfully during the study period, and 18 patients were ineligible for percutaneous access. We assessed 198 consecutive pEVAR patients (160 men and 38 women, mean age 62.2±13.0 years)(see Fig 1). Details of demographics and lesion data before the operation were displayed in Table 1.

thumbnail
Download:
Fig 1. The Flowchart of this study.

The flowchart depicts the inclusion and the exclusion of the study population in this study and the occurrence of Perclose Proglide-related complications.

https://doi.org/10.1371/journal.pone.0123739.g001

thumbnail
Download:
Table 1. Demographics characteristic of the Patients.

https://doi.org/10.1371/journal.pone.0123739.t001

PRC and treatments

Total pEVAR was successful in 178/198 cases (89.9%) and in 255/275 access sites (92.7%). However, 10 vascular complications and 10 device failures occurred in pEVAR patients (10.1%). With the accumulation of manipulating experience, the incidence of PRC linearly decreased (y = -0.0004x+15.898, R2 = 0.78788)(Fig 2).

thumbnail
Download:
Fig 2. The PRC incidence and date.

Simple linear regression analysis is performed to demonstrate the decline tendency of PRC incidence.

https://doi.org/10.1371/journal.pone.0123739.g002

Bleeding was addressed by manual compression in 4 cases, 3 access sites with vessel stricture or dissection finally induced cut-down conversion, and 7 device failures required another Perclose Proglide (see Table 2). One access artery dissection was indicated by radiography after suturing the access site, and the posterior and anterior arterial walls were sutured together after conversion (see Fig 3). We fixed the intima using the 7–0 Prolene thread and repaired the puncture orifice without a patch.

thumbnail
Download:
Fig 3. Open surgery at the access site.

This series of photographs illustrates the twist shape of CFA when we converted to open surgery. The anterior and posterior artery walls were sutured together, and the CFA was occluded (a). The suture knot was located in the lumina (b).

https://doi.org/10.1371/journal.pone.0123739.g003

thumbnail
Download:
Table 2. Perclose Proglide related complications and treatments during pEVAR.

https://doi.org/10.1371/journal.pone.0123739.t002

PRC and factors

Between the PRC group and the success group, etiology of the lesions, and baseline demographics including age, gender, hypertension, diabetes mellitus, coronary arterial disease, and smoking were similar (P>0.05). However, BMI, stent cover site, CFA calcification, CFA depth, and sheath size showed significant differences between the two groups (P<0.05)(see Table 3).

thumbnail
Download:
Table 3. Factors associated with PRC.

https://doi.org/10.1371/journal.pone.0123739.t003

Further, compared with the other group, the PRC incidence was higher in patients with BMI>30 kg/m2 (P = 0.011), CFA calcification (p = 0.003), thoracic stent grafts (P = 0.021), CFA depth>4 cm (P = 0.038), and sheath size>20Fr (P = 0.019). Multiple logistic regression analysis identified BMI>30 kg/m2 (P = 0.021), CFA calcification (P = 0.003), thoracic stent grafts (P = 0.038), CFA depth>4 cm (P = 0.001), and sheath size>20Fr (P = 0.005) as independent predictors of PRC (see Table 4).

thumbnail
Download:
Table 4. Logistic regression analysis of preoperative classified variables for PRC.

https://doi.org/10.1371/journal.pone.0123739.t004

Late events

During the follow-up, postoperative CTA or US was performed in all patients. One patient died of heart failure in the 3rd month, which was unrelated to the PRC. None of the access sites had stenosis or stricture or other groin complications at 3 and 6 months.

Discussion

Perclose Proglide is the second-generation suture-based vascular closure device that has been used for a decade. We can easily obtain the benefit of reducing hospital stay and improving patients’ early ambulation[11,13]. Further, Proglide has the special superiority of suturing large caliber orifices in vessels, especially when the “pre-close technique” is applied during pEVAR procedures, which usually require a large sheath (range 12Fr to 26Fr profiles) to ensure transporting and deploying the aortic stent graft. The pre-close technique is efficient for achieving hemostasis in the femoral artery[14]. The immediate high success rate (89.9%) in our center is comparable to those reports [8,9,11,14–28]. However, PRC or other events were also reported in 10% to 20% of these patients in the literature[29,30], and 10.1% at our center (Table 5).

thumbnail
Download:
Table 5. PRC and factors referred in recent studies of Perclose Proglide in pEVAR.

https://doi.org/10.1371/journal.pone.0123739.t005

Bleeding is a common vascular complication (6/10) during pEVAR; however, it is not life-threatening and can be successfully treated with manual compression (4/6) leading to successful hemostasis[8,29]. Compared with patients in percutaneous coronary intervention, those in this series were administered an antagonist to heparin at the end of the procedure, which may be one reason that they were free of anticoagulation postoperatively [8,29,31]. Conversion mostly occurred for stricture or stenosis complications, and the incidence in this series is lower than that in the previous report (5/198 vs. 4/78)[8].

We cannot ignore the value of the learning curve during pEVAR, which is likely related to the device failures[9,16,22]. The first multicenter randomized controlled trial indicated that training and experience with the pre-close technique were important for ensuring successful outcomes[16]. In our center, device failure occurred mostly in the early days (see Fig 2). Therefore, we have regular training for vascular surgeons to improve their familiarity with properly deploying the devices, and they have handled 20 cases successfully. However, another larger pEVAR study has produced a different result regarding the relationship between failure and experience[32]. Surgeons with more experience are prone to risking the less favorable anatomy and may have a high failure rate[5].

Obesity represents a risk factor that is significantly associated with the incidence of complications during pEVAR[33,34], other than in conventional surgical access to the femoral site. We found that the incidence of PRC in the BMI>30 kg/m2 group was relatively high (18.3%). Therefore, Jean-Baptiste et al. [6] chose patients with moderate obesity (BMI <35 kg/m2) for pEVAR. However, several negative results in the literature revealed that BMI was not related to PRC[9,17,26]. In fact, the general state of weight or BMI was not the main reason, but rather, the depth of the subcutaneous tissue in the groin was important[15,17], which is another risk factor for PRC revealed in our study. Zakko et al. [17] reported that the CFA depth was significantly greater in obese patients (50±20 mm vs. 30±13 mm; P <. 0001). If patients have thick fat tissue at the puncture sites (depth of CFA>4 cm), pushing down of the slipknot is usually difficult and may result in loosening of the knots.

Numerous previous studies have mentioned that the success rate is significantly related to the caliber of the sheath[5,11,17,18,29]. Lee et al. [15] concluded that large sheaths had low technical success rates among the subset of sheath sizes. Kim et al. [14] also found 7 of 8 closure procedure failures in cases involving sheaths over 16Fr and believed that procedural failure might be related to large sheath sizes. To date, we consider the sheath size>20Fr as a predictor of PRC in pEVAR, and it is reasonable to infer that PRC occurs more often in thoracic stent grafts, which usually use delivery sheaths larger than 18Fr[17,18]. In the reviewed articles[17,19,20], the CFA diameter was considered another predictor of PRC, which implied that sheath size and vessel diameter might co-contribute to the result.

In one meta-analysis, the quality of the artery was found to be a greater predictor of failure than the sheath size itself[5]. The use of the Proglide device is not considered when the CFA has a large plaque (>50% circumference) or ring-shape calcification. Manunga et al. [35] found that cases of patients with >50% anterior wall calcification had a higher failure rate than calcification-free patients. We also found that even the patients with <50% CFA calcification tend to develop PRC, compared with patients who are free of CFA calcification. In the case of severe calcification, we would most likely perform a CFA endarterectomy instead.

During midterm follow-up, late PRC such as infection, thrombosis, stricture, or occlusion are rare[15]. One of our patients died of heart failure at 3 months in this study. The mortality of the pEVAR procedure was low (<0.2%) and was usually related to the underlying comorbidities of the patients but not the devices themselves[28,34,36]. However, clinical long-term follow-up is imperative for pEVAR patients.

Conclusions

The pre-close technique with two 6F Perclose Proglide devices for pEVAR appears to be safe and effective. Obesity (BMI>30 kg/m2), thoracic stent grafts, deep CFA (>4 cm), CFA calcification, and large sheath size (>20Fr) predict the risk for technical failure and vascular complications. Careful patient selection and proficiency in device manipulation might reduce the device related complications.

Limitations

This study is limited by its retrospective nature. We did not compare the efficacy between Perclose Proglide and other devices. Furthermore, different criteria for PRC may alter the incidence of the adverse event and thereby impair the results.

Author Contributions

Conceived and designed the experiments: GHH WGF. Performed the experiments: GHH. Analyzed the data: GHH WGF. Contributed reagents/materials/analysis tools: GHH BC XX DQG JHJ JY YQW WGF. Wrote the paper: GHH WGF.

References

  1. 1. Steuer J, Eriksson MO, Nyman R, Bjorck M, Wanhainen A. Early and long-term outcome after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection. Eur J Vasc Endovasc Surg. 2011; 41: 318–323. pmid:21194985
  2. 2. Jonker FH, Trimarchi S, Verhagen HJ, Moll FL, Sumpio BE, Muhs BE. Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm. J Vasc Surg. 2010; 51: 1026–1032, 1032 e1–1032 e2. pmid:20347700
  3. 3. Harkin DW, Dillon M, Blair PH, Ellis PK, Kee F. Endovascular ruptured abdominal aortic aneurysm repair (EVRAR): a systematic review. Eur J Vasc Endovasc Surg. 2007; 34: 673–681. pmid:17719809
  4. 4. Haas PC, Krajcer Z, Diethrich EB. Closure of large percutaneous access sites using the Prostar XL Percutaneous Vascular Surgery device. J Endovasc Surg. 1999; 6: 168–170. pmid:10473335
  5. 5. Georgiadis GS, Antoniou GA, Papaioakim M, Georgakarakos E, Trellopoulos G, Papanas N, et al. A meta-analysis of outcome after percutaneous endovascular aortic aneurysm repair using different size sheaths or endograft delivery systems. J Endovasc Ther. 2011; 18: 445–459. pmid:21861729
  6. 6. Jean-Baptiste E, Hassen-Khodja R, Haudebourg P, Bouillanne PJ, Declemy S, Batt M. Percutaneous closure devices for endovascular repair of infrarenal abdominal aortic aneurysms: a prospective, non-randomized comparative study. Eur J Vasc Endovasc Surg. 2008; 35: 422–428. pmid:18166490
  7. 7. Morasch MD, Kibbe MR, Evans ME, Meadows WS, Eskandari MK, Matsumura JS, et al. Percutaneous repair of abdominal aortic aneurysm. J Vasc Surg. 2004; 40: 12–16. pmid:15218455
  8. 8. Jabori S, Jimenez JC, Gabriel V, Quinones-Baldrich WJ, Derubertis BG, Farley S, et al. Is heparin reversal required for the safe performance of percutaneous endovascular aortic aneurysm repair? Ann Vasc Surg. 2013; 27: 1049–1053. pmid:24011808
  9. 9. Bechara CF, Barshes NR, Pisimisis G, Chen H, Pak T, Lin PH, et al. Predicting the learning curve and failures of total percutaneous endovascular aortic aneurysm repair. J Vasc Surg. 2013; 57: 72–76. pmid:23127982
  10. 10. Kahlert P, Eggebrecht H, Erbel R, Sack S. A modified "preclosure" technique after percutaneous aortic valve replacement. Catheter Cardiovasc Interv. 2008; 72: 877–884. pmid:19006257
  11. 11. Malkawi AH, Hinchliffe RJ, Holt PJ, Loftus IM, Thompson MM. Percutaneous access for endovascular aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg. 2010; 39: 676–682. pmid:20185341
  12. 12. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011; 123: 2736–2747. pmid:21670242
  13. 13. Dosluoglu HH, Lall P, Blochle R, Harris LM, Dryjski ML. Ambulatory percutaneous endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2014; 59: 58–64. pmid:23978571
  14. 14. Kim WH, Shin S, Ko YG, Hong MK, Jang Y, Choi D. Efficacy and safety of the preclose technique following percutaneous aortic stent-graft implantation. J Endovasc Ther. 2013; 20: 350–355. pmid:23731308
  15. 15. Lee WA, Brown MP, Nelson PR, Huber TS. Total percutaneous access for endovascular aortic aneurysm repair ("Preclose" technique). J Vasc Surg. 2007; 45: 1095–1101. pmid:17398056
  16. 16. Nelson PR, Kracjer Z, Kansal N, Rao V, Bianchi C, Hashemi H, et al. A multicenter, randomized, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial). J Vasc Surg. 2014; 59: 1181–1193. pmid:24440678
  17. 17. Zakko J, Scali S, Beck AW, Klodell CT Jr., Beaver TM, Martin TD, et al. Percutaneous thoracic endovascular aortic repair is not contraindicated in obese patients. J Vasc Surg. 2014; 60: 921–928. pmid:24845111
  18. 18. Ye P, Chen Y, Zeng Q, He X, Li Y, Zhao J. [Long-term follow-up of the femoral artery after total percutaneous endovascular aortic repair with preclose technique using a vascular closure device]. Nan Fang Yi Ke Da Xue Xue Bao. 2014; 34: 747–750 pmid:24849451
  19. 19. Bensley RP, Hurks R, Huang Z, Pomposelli F, Hamdan A, Wyers M, et al. Ultrasound-guided percutaneous endovascular aneurysm repair success is predicted by access vessel diameter. J Vasc Surg. 2012; 55: 1554–1561. pmid:22360918
  20. 20. Al-Khatib WK, Zayed MA, Harris EJ, Dalman RL, Lee JT. Selective use of percutaneous endovascular aneurysm repair in women leads to fewer groin complications. Ann Vasc Surg. 2012; 26: 476–482. pmid:22437069
  21. 21. Wei R, Xiong J, Guo W, Liu X, Zhang H, Jia X. Effectiveness comparison between double Perclose ProGlide crossing suture and traditional suture for closure of puncture sites in endovascular aortic repair. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2012; 26: 968–971 pmid:23012933
  22. 22. Ni ZH, Luo JF, Huang WH, Liu Y, Xue L, Fan RX, et al. Totally percutaneous thoracic endovascular aortic repair with the preclosing technique: a case-control study. Chin Med J (Engl). 2011; 124: 851–855 pmid:21518591
  23. 23. Krajcer Z, Nelson P, Bianchi C, Rao V, Morasch M, Bacharach J. Percutaneous endovascular abdominal aortic aneurysm repair: methods and initial outcomes from the first prospective, multicenter trial. J Cardiovasc Surg (Torino). 2011; 52: 651–659 pmid:21796092
  24. 24. Zhang HP, Guo W, Liu XP, Yin T, Jia X, Xiong J, et al. Total percutaneous endovascular abdominal aortic aneurysm repair. Zhonghua Wai Ke Za Zhi. 2010; 48: 1855–1858 pmid:21211267
  25. 25. Grenon SM, Gagnon J, Hsiang YN, Chen JC. Canadian experience with percutaneous endovascular aneurysm repair: short-term outcomes. Can J Surg. 2009; 52: E156–160 pmid:19865546
  26. 26. Smith ST, Timaran CH, Valentine RJ, Rosero EB, Clagett GP, Arko FR. Percutaneous access for endovascular abdominal aortic aneurysm repair: can selection criteria be expanded? Ann Vasc Surg. 2009; 23: 621–626. pmid:18954964
  27. 27. Lee WA, Brown MP, Nelson PR, Huber TS, Seeger JM. Midterm outcomes of femoral arteries after percutaneous endovascular aortic repair using the Preclose technique. J Vasc Surg. 2008; 47: 919–923. pmid:18328666
  28. 28. Dosluoglu HH, Cherr GS, Harris LM, Dryjski ML. Total percutaneous endovascular repair of abdominal aortic aneurysms using Perclose ProGlide closure devices. J Endovasc Ther. 2007; 14: 184–188. pmid:17484534
  29. 29. Applegate RJ. Vascular closure device failure: we are getting better but not there yet. JACC Cardiovasc Interv. 2012; 5: 845–847. pmid:22917456
  30. 30. Derham C, Davies JF, Shahbazi R, Homer-Vanniasinkam S. Iatrogenic limb ischemia caused by angiography closure devices. Vasc Endovascular Surg. 2006; 40: 492–494. pmid:17202097
  31. 31. Griese DP, Reents W, Diegeler A, Kerber S, Babin-Ebell J. Simple, effective and safe vascular access site closure with the double-ProGlide preclose technique in 162 patients receiving transfemoral transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2013; 82: E734–741. pmid:23765732
  32. 32. Eisenack M, Umscheid T, Tessarek J, Torsello GF, Torsello GB. Percutaneous endovascular aortic aneurysm repair: a prospective evaluation of safety, efficiency, and risk factors. J Endovasc Ther. 2009; 16: 708–713. pmid:19995109
  33. 33. Howell M, Villareal R, Krajcer Z. Percutaneous access and closure of femoral artery access sites associated with endoluminal repair of abdominal aortic aneurysms. J Endovasc Ther. 2001; 8: 68–74. pmid:11220473
  34. 34. Starnes BW, Andersen CA, Ronsivalle JA, Stockmaster NR, Mullenix PS, Statler JD. Totally percutaneous aortic aneurysm repair: experience and prudence. J Vasc Surg. 2006; 43: 270–276. pmid:16476600
  35. 35. Manunga JM, Gloviczki P, Oderich GS, Kalra M, Duncan AA, Fleming MD, et al. Femoral artery calcification as a determinant of success for percutaneous access for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2013; 58: 1208–1212. pmid:23830310
  36. 36. Krajcer Z, Gregoric I. Totally percutaneous aortic aneurysm repair: methods and outcomes using the fully integrated IntuiTrak endovascular system. J Cardiovasc Surg (Torino). 2010; 51: 493–501 pmid:20671633