Access-related Outcomes After Infrarenal Endovascular Aortic Aneurysms Repair: A Multicenter Retrospective Cohort Study

Endovascular aortic repair (EVAR) is the first-line treatment for abdominal aortic aneurysms (AAAs) in fit patients. Percutaneous vascular access (pEVAR) allows to ulteriorly decrease the invasivity of EVAR procedures in comparison to femoral cutdown (sEVAR); however, controversies remain regarding postoperative complications and mortality. The aim of this study is to compare the outcomes of these techniques and their impact on operative time, hospitalization, short-term complications, and mortality. This is a retrospective, observational cohort study from four tertiary referral university hospitals. Baseline and peripoperative data of all patients undergoing EVAR procedures were collected in a prospectively managed dataset at each institution and merged in the Italian Collaborators for EVAR (ICE) registry. Study cohort included standard EVAR interventions between January 2018 and February 2021. Mortality and complication risks have been calculated with dedicated scores (Society for Vascular Surgery/American Association for Vascular Surgery score system, American College of Surgeons [ACS] risk calculator). Primary outcomes were pEVAR technical success (absence of surgical conversion), 30-day mortality, and access-related complications. Operative time, length of hospital stay (LOS), 90-day readmission rate, and type of anesthesia were considered secondary outcomes. During the study time, 608 consecutive patients underwent standard EVAR procedures: 373 (61.3%) pEVAR and 202 (33.2%) sEVAR; 33 (5.4%) patients with one surgical and one percutaneous access were excluded from the final analysis. A higher estimated ACS risk for surgical site infection (0.80% ± 0.65% vs 0.65% ± 0.53%; P = .008) and death (1.66% ± 3.55% vs 0.76% ± 1.60%; P = .001) was found in the pEVAR group. Operative time (median, 80.00 minutes [interquartile range (IQR), 60.00-110.00 minutes] vs 112.50 minutes [IQR, 90.00-144.00 minutes]; P < .001), 90-day readmission rate (1.4% vs 6.9%; P = .001), and LOS (4.00 days [IQR, 3.00-7.00 days] in pEVAR vs 5.00 days [IQR, 3.25-8.00 days] in sEVAR; P = .012) were lower among pEVAR group. Higher rates of local anesthesia were observed in the percutaneous group (71.7% vs 22.8%; P < .001). Technical success rate of pEVAR was 97.3% with lower rates of 30-day mortality (1.4% pEVAR vs 6% sEVAR; P = .004). Early access-related complications showed a higher rate in sEVAR group (5.4% in sEVAR vs 1.6% in pEVAR; P = .02). Percutaneous access for EVAR is safe and feasible when compared with surgical access with a high technical success rate and low complication rate. The results of our analysis demonstrate that percutaneous access was associated with decreasing operative time, length of hospital stay, the use of general anesthesia, and readmission rate. The lower mortality rate, despite a higher estimate, is certainly a promising factor; however, further studies are needed to assess the significance of this results.