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Justification For Aggressive Percutaneous EVAR Access
Julia Kleene, MD, Jeffrey C. Hnath, MD, Benjamin B. Chang, MD, R Clement Darling, III, MD.
Albany Medical College, Albany, NY, USA.

Introduction:
Femoral artery access for endovascular aneurysm repairs (EVAR) has undergone a shift from open cut downs to percutaneous access. Percutaneous access (PEVAR) has been associated with decreased wound complications, shorter hospital stays and shorter operative times. Lowering the threshold for PEVAR, in terms of poorer quality femoral arteries, has led to more open femoral exposures for device failures. The purpose of this study is to determine if there is a difference in outcomes between femoral exposures performed primarily versus exposures performed after PEVAR closure failure.
Methods:
Data from a single groupís database was retrospectively analyzed for EVAR patients between 7/1/2015 and 6/30/2018 comparing patients who underwent primary cut down for EVAR versus those who underwent secondary cut down after PEVAR failure. Demographics, co-morbidities, estimated blood loss (EBL), and return to operating room (RTOR) were collected and compared using standard statistics.
Results:
764 total EVARs with 1528 femoral access sites were performed between 7/1/2015 and 6/30/2018. 263 (17%) femoral arteries were primarily exposed (CEVAR) and 85 (6%) femoral arteries were exposed after percutaneous failure (PEVAR). Demographics were similar CEVAR and PEVAR in terms of age [71 (17-91) v. 71 (28-88)] and sex (104 male, 69.3% vs 46 male, 66.7% P=0.69) and comorbidities were similar for diabetes (27, 18% vs 14, 20.3% P=. 69), current tobacco use (25, 16.7% vs 16, 23.2% P=. 25), and renal insufficiency (6, 4% vs 2, 2.9% P=. 34) respectively. The PEVAR group had significantly more hypertension (76, 50.7% vs 53, 76.8% P=. 0002), coronary disease (30, 20% vs 27, 39.1% P=. 0002), COPD (26, 17.3% vs 23, 33.3% P=. 008), and hyperlipidemia (58, 38.7% vs 44, 63.8% P=. 0005). Primary endpoints of RTOR (10, 6.67% vs 6, 8.7%, P .59) and mean blood loss {383 mL (10 mL - 8000 mL) vs 354mL (20 mL - 1600 mL), P = .75}, showed no statistical difference between CEVAR and PEVAR respectively.
Conclusion:
Percutaneous femoral access for EVAR has been widely adopted, however when applied to less than ideal femoral arteries, has resulted in increased rates of closure device failure. Similar rates of post -operative complications for femoral exposures performed electively versus those performed after closure device failure support a continued aggressive percutaneous approach to EVAR.


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