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The impact of percutaneous access on the outcomes of endovascular abdominal aortic aneurysm repair
Cassius Iyad N. Ochoa Chaar, MD, MS1, Laura A. Skrip, MPH2, Bart E. Muhs, MD, PhD1, Jeffrey E. Indes, MD1, Bauer E. Sumpio, MD, PhD1, Timur P. Sarac, MD1, Alan Dardik, MD, PhD3.
1Yale School of Medicine, New Haven, CT, USA, 2Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, CT, USA, 3VA Connecticut Healthcare system, West Haven, CT, USA.

OBJECTIVES: Percutaneous access for endovascular abdominal aortic aneurysm repair (EVAR) is increasing in popularity despite controversial advantages derived mostly from case series. This is the first study to compare outcomes after percutaneous and open access for EVAR derived from a national vascular database.
METHODS: The American College of Surgeons NSQIP files targeting EVAR for the years 2011 and 2012 were reviewed. Two groups were selected for comparison based on EVAR access: totally percutaneous (PEVAR) and bilateral surgical cut down (SEVAR). Only procedures performed electively for asymptomatic aneurysm growth were included. Patients with fenestrated grafts were excluded, as well as patients undergoing concomitant procedures such as renal artery stenting. The outcomes of EVAR were examined and statistical comparison between the 2 groups was performed using SAS version 9.3.
RESULTS: There were 918 SEVAR and 360 PEVAR. 5 patients had open cut down after failed percutaneous access. The open conversion rate was 1.4%. There was no statistical difference between the 2 groups in age (p=0.78), sex (p=0.98), or functional status (p=0.42). The comorbidities were comparable with respect to incidence of diabetes (p=0.651), hypertension (p=0.70), heart disease (p=0.99), smoking (0.08), morbid obesity (p=0.21), and renal failure (p=0.99). PEVAR was performed more frequently with local and regional anesthesia (PEVAR =8.1% vs SEVAR 3.7%, p=0.005). The total operating time was significantly decreased with percutaneous access (PEVAR = 124 ± 46 min vs SEVAR = 145 ± 76, p < 0.001). SEVAR patients had significantly more wound complications (SEVAR = 1.85% vs PEVAR =0.28%, p=0.033). There was no difference in mortality (p=0.515), lower extremity ischemia (p=0.999), aneurysm rupture (p =0.484), myocardial infarction (p=0.908), pneumonia (p=0.359), between the 2 groups. The time from operation to discharge (p = 0.391), the length of the ICU stay (0.936), and the discharge destination (p=0.500) were no different. There was no difference in 30-day readmission rate (p=0.969) or return to the OR (p= 0.368). (Table)
CONCLUSIONS: PEVAR is performed with low conversion rate to open access. Percutaneous access decreases operating time and wound complications of EVAR. These results justify the emerging trend of performing PEVAR, but its cost effectiveness remains to be determined.
Outcomes of PEVAR and SEVAR
p - value
wound complications17 (1.85%)1 (0.28%) 0.033
Myocardial infarction12 (1.31%)5 (1.39%)0.908
Aneurysm Rupture1 (0.11%)1 (0.28%)0.484
Low Extremity Ischemia6 (0.65%)2 (0.56%)0.999
Length of ICU Stay (days)1.71 ± 2.321.73 ± 1.800.936
Time from Operation to Discharge (days)2.35 ± 3.27
2.19 ± 2.89
Return to the OR26 (2.83%)7 (1.94%)0.368
Readmission15 (1.66%)6 (1.69%)0.969
Death (within 30 days)7 (0.76%)4 (1.11%)0.515

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