From puncture to closure of the common femoral artery in endovascular aortic repair.

In all fields of surgery there is a trend towards less invasive procedures reducing hospital stay, complications and mortality. Open surgery in the treatment of aortic diseases is gradually less applied, and instead endovascular aortic repair - EVAR - is a widely accepted treatment modality of today. The traditional approach in EVAR involves surgical exposure of the femoral arteries with bilateral groin incisions. Through the groin access, and under fluoroscopy, a special insertion sheath introducer is used to position a stent graft in the desired location with the patient in general or epidural anesthesia. The evolving stent-technology with smaller sheath sizes has broadened the scenario for alternative approaches for access and closure of the common femoral arteries. The following review presents an introduction on technical aspects of puncture of the femoral artery and closure of the arterial wall using percutaneous closure devices. We also aim to discuss three important approaches to expose and close the femoral arteries during endovascular aortic repair: The cut down approach, the true percutaneous technique, and the femoral fascial closure. Finally, factors important in the choice of techniques will be discussed in relation to early and late complications. We suggest that a percutaneous femoral approach should initially be considered for all endovascular aortic procedures, but with a low threshold to convert to traditional cut-down technique when complications such as bleeding, stenosis, ischemia, or femoral artery injury occur. The choice of the optimal femoral approach depends on the unique anatomy of each patient.