title: Safety and Effectiveness of a "Percutaneous-First" Approach to Endovascular Aortic Aneurysm Repair.
abstract: BACKGROUND
  Percutaneous endovascular aneurysm repair (PEVAR) has been increasingly used in the endovascular treatment of abdominal aortic aneurysms. Furthermore, the percutaneous approach can be used with minimal sedation and local anesthesia in most cases. The purpose of this study was to assess the safety and effectiveness of a "percutaneous first" approach to femoral access for EVAR.
  
  
  METHODS
  From 2012 to 2014, PEVAR has been the preferred approach to femoral access for EVAR at our institution. Retrospective review of institutional vascular quality initiative data was used to compare outcomes with elective PEVAR to a contemporary institutional series of elective EVAR via open femoral exposure. These 2 patient groups were compared with assess perioperative outcomes, procedural details (including anesthesia modality, procedure time, and length of stay [LOS]) and access-related complications between groups.
  
  
  RESULTS
  One hundred two consecutive patients underwent attempted PEVAR and were compared with 98 patients undergoing surgical femoral exposure. Demographics and comorbidities were similar between groups, although there was a greater proportion of smokers in the PEVAR group (76.5% vs. 63.3%; P = 0.04). PEVAR was associated with an increased utilization of local anesthesia (67.6% vs. 12.2%; P < 0.001). PEVAR was associated with shorter postoperative LOS (mean 1.7 vs. 3.0 days; P = 0.035), shorter procedure times (137 vs. 222 min; P < 0.001), and significantly less blood loss (169 vs. 481 mL; P < 0.001). There were 5 access-site complications (4.9%) in the PEVAR group requiring conversion to open femoral exposure, compared with 2 patients (2.0%) with access-related complications after open femoral exposure (P = 0.09). There were significantly more hematomas in the PEVAR group (9.8% vs. 2.0%, P = 0.02). However, there were no significant differences in overall postoperative complications, wound infection, or ICU LOS.
  
  
  CONCLUSIONS
  A "PEVAR first" approach proved feasible in the overwhelming majority of patients. Conversion to open transfemoral exposure was rare. PEVAR facilitated endovascular abdominal aortic aneurysm repair under local anesthesia in most patients and resulted in decreased procedural morbidity and resource utilization.
authors.affiliation: Division of Vascular Surgery, New York-Presbyterian/Weill Cornell Medical Center, New York, NY. Electronic address: Cha2010@nyp.org.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Agrusa
authors.affiliation: Division of Vascular Surgery, New York-Presbyterian/Weill Cornell Medical Center, New York, NY.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Meltzer
authors.affiliation: Division of Vascular Surgery, New York-Presbyterian/Weill Cornell Medical Center, New York, NY.
authors.forename: Darren B
authors.initials: DB
authors.lastname: Schneider
authors.affiliation: Division of Vascular Surgery, New York-Presbyterian/Weill Cornell Medical Center, New York, NY.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Connolly
mesh_terms: D000368:Aged; D000772:Anesthesia, Local; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D016063:Blood Loss, Surgical / Q000517:prevention & control; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D009519:New York City; D061646:Operative Time; D011183:Postoperative Complications / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome