title: Percutaneous endovascular aneurysm repair in morbidly obese patients.
abstract: OBJECTIVE
  Endovascular aneurysm repair (EVAR) with percutaneous femoral access (PEVAR) has several potential advantages. Morbidly obese (MO) patients present unique anatomical challenges and have not been specifically studied. This study examines the trends in the use of PEVAR and its surgical outcomes compared with open femoral cutdown (CEVAR) in MO patients.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program files for the years 2005 to 2013 were reviewed. The study included all MO patients (body mass index [BMI] ≥40 kg/m2) undergoing EVAR. Patients were categorized as having CEVAR if they had any one of 11 selected Current Procedural Terminology (American Medical Association, Chicago, Ill) codes describing an open femoral procedure. The PEVAR group included any remaining patients who had only codes for EVAR and endovascular procedures. Linear correlation was used to evaluate temporal trends in the use of PEVAR among MO patients. Baseline comorbidities and surgical outcomes were compared between the PEVAR and CEVAR groups using χ2tests or t-tests.
  
  
  RESULTS
  There were 833 MO patients (470 CEVAR and 363 PEVAR) constituting 3.0% of all patients undergoing EVAR. The use of PEVAR in MO patients significantly increased from 27.3% of total EVARs in the years 2005 to 2006 to 48.6% in 2013 (P = .039). The two groups had similar baseline characteristics, including age, BMI, comorbidities, and emergency procedures, except for history of severe chronic obstructive pulmonary disease (29.6% CEVAR vs 22.6% PEVAR; P = .024). PEVAR patients had shorter duration of anesthesia (244 vs 260 minutes; P = .048) and shorter total operation time (158 vs 174 minutes; P = .002). PEVAR patients had significantly decreased wound complications (5.5% vs 9.4%; P = .039). There was a trend towards PEVAR patients being more likely to be discharged home than to a facility (93.6% vs 87.8%; P = .060). There was no difference in any other complication or mortality. A subgroup analysis of 109 superobese patients with BMI ≥50 kg/mg2(59 CEVAR and 50 PEVAR) demonstrated no significant differences in outcomes between groups.
  
  
  CONCLUSIONS
  PEVAR is increasingly used in MO patients and decreases operating time and rates of wound infection compared with CEVAR. The advantages of PEVAR seem to be lost in the superobese patients.
authors.affiliation: Section of Vascular Surgery, Yale University School of Medicine, New Haven, Conn.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Chin
authors.affiliation: Yale School of Public Health, New Haven, Conn.
authors.forename: Laura
authors.initials: L
authors.lastname: Skrip
authors.affiliation: Section of Vascular Surgery, Yale University School of Medicine, New Haven, Conn.
authors.forename: Bauer E
authors.initials: BE
authors.lastname: Sumpio
authors.affiliation: Section of Vascular Surgery, Yale University School of Medicine, New Haven, Conn.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Cardella
authors.affiliation: Section of Vascular Surgery, University of Connecticut School of Medicine, Farmington, Conn.
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Indes
authors.affiliation: Section of Vascular Surgery, Yale University School of Medicine, New Haven, Conn.
authors.forename: Timur P
authors.initials: TP
authors.lastname: Sarac
authors.affiliation: Section of Vascular Surgery, Yale University School of Medicine, New Haven, Conn.
authors.forename: Alan
authors.initials: A
authors.lastname: Dardik
authors.affiliation: Section of Vascular Surgery, Yale University School of Medicine, New Haven, Conn. Electronic address: cassius.chaar@yale.edu.
authors.forename: Cassius I
authors.initials: CI
authors.lastname: Ochoa Chaar
mesh_terms: D000328:Adult; D000783:Aneurysm / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000639:trends; D016009:Chi-Square Distribution; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000639:trends; D005260:Female; D005263:Femoral Artery / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications* / Q000175:diagnosis; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D011677:Punctures; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014945:Wound Healing