Multicenter real-life study on access-related outcomes after EVAR: percutaneous is the way

BACKGROUND: Endovascular aortic repair (EVAR) is the first-line treatment for abdominal aortic aneurysms (AAA) in fit patients. Percutaneous vascular access (pEVAR) allows to ulteriorly decrease the invasivity of EVAR in comparison to surgical femoral cutdown (sEVAR). The aim of this multicentric study was to compare the two access techniques and their impact on operative time, hospitalization, short and long-term complications, and mortality. METHODS: Baseline and peripoperative data of consecutive patients undergoing standard EVAR in four Italian vascular academic centers collected in the Italian Collaborators for EVAR (ICE) registry have been retrospectively analyzed. The mortality and complication risk have been calculated with dedicated scores (SVS/AAVS score system, ACS risk calculator). Primary outcomes were technical success of percutaneous access, 30-days mortality and access-related perioperative complications. Operative time, length of hospital stay (LOS), 90-day readmission and type of anesthesia were considered as Secondary outcomes. RESULTS: From January 2018 to February 2021, 608 consecutive patients underwent EVAR: 373 (61.3%) pEVAR and 202 (33.2%) sEVAR; 33 (5.4%) patients who underwent a hybrid approach (one surgical, one percutaneous) were excluded. Operative time (median 80.00 m [IQR 60.00-110.00] vs. 112.50 m [IQR 90.00-144.00], P<0.001), 90-days readmission rate (1.4% vs. 6.9%, P=0.001) and LOS (4.00 days [IQR 3.00-7.00] in pEVAR vs. 5.00 days [IQR 3.25-8.00] in sEVAR, P=0.012) were lower in the pEVAR group. Type of anesthesia (local 71.7%% vs. general 22.8%; P<0.001) was significantly different between the groups. Technical success rate of pEVAR was 97.3% with lower rates of mortality (1.4% pEVAR vs. 6% sEVAR, P=0.004). Early access-related complications had higher rate in sEVAR group, and the difference was significant (5.4% in sEVAR vs. 1.6% in pEVAR, P=0.02). CONCLUSIONS: Percutaneous access for EVAR is safe and feasible when compared with surgical access with high technical success rate and low complication. 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 in hospital readmission.