title: Percutaneous versus femoral cutdown access for endovascular aneurysm repair.
abstract: OBJECTIVE
  Prior studies suggest that percutaneous access for endovascular abdominal aortic aneurysm repair (pEVAR) offers significant operative and postoperative benefits compared with femoral cutdown (cEVAR). National data on this topic, however, are limited. We compared patient selection and outcomes for elective pEVAR and cEVAR.
  
  
  METHODS
  We identified all patients undergoing either pEVAR (bilateral percutaneous access, whether successful or not) or cEVAR (at least one planned groin cutdown) for abdominal aortic aneurysms from January 2011 to December 2013 in the Targeted Vascular data set from the American College of Surgeons National Surgical Quality Improvement Program database. Emergent cases, ruptures, cases with an iliac conduit, and cases with a preoperative wound infection were excluded. Groups were compared by χ(2) test or t-test or the Mann-Whitney test where appropriate.
  
  
  RESULTS
  We identified 4112 patients undergoing elective EVAR, 3004 cEVAR patients (73%) and 1108 pEVAR patients (27%). Of all EVAR patients, 26% had bilateral percutaneous access; 1.0% had attempted percutaneous access converted to cutdown (4% of pEVARs); and the remainder had a planned cutdown, 63.9% bilateral and 9.1% unilateral. There were no significant differences in age, gender, aneurysm diameter, or prior open abdominal surgery. Patients undergoing cEVAR were less likely to have congestive heart failure (1.5% vs 2.4%; P = .04) but more likely to undergo any concomitant procedure during surgery (32% vs 26%; P < .01) than patients undergoing pEVAR. Postoperatively, pEVAR patients had shorter operative time (mean, 135 vs 152 minutes; P < .01), shorter length of stay (median, 1 day vs 2 days; P < .01), and fewer wound complications (2.1% vs 1.0%; P = .02). On multivariable analysis, the only predictor of percutaneous access failure was performance of any concomitant procedure (odds ratio, 2.0; 95% confidence interval, 1.0-4.0; P = .04).
  
  
  CONCLUSIONS
  Currently, one in four patients treated at Targeted Vascular National Surgical Quality Improvement Program centers are getting pEVAR, which is associated with a high success rate, shorter operation time, shorter length of stay, and fewer wound complications compared with cEVAR.
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Dominique B
authors.initials: DB
authors.lastname: Buck
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Eleonora G
authors.initials: EG
authors.lastname: Karthaus
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Soden
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Klaas H J
authors.initials: KH
authors.lastname: Ultee
authors.affiliation: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Joost A
authors.initials: JA
authors.lastname: van Herwaarden
authors.affiliation: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Frans L
authors.initials: FL
authors.lastname: Moll
authors.affiliation: Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherme@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000379:methods*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D017558:Elective Surgical Procedures; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D005263:Femoral Artery / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D011677:Punctures; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
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