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. 2023 Jan 11;1(1):CD010185.
doi: 10.1002/14651858.CD010185.pub4.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

Qi Wang  1 , Jing Wu  2 , Yanfang Ma  3 , Ying Zhu  1 , Xiaoyang Song  4 , Shitong Xie  1   2 , Fuxiang Liang  5 , Madelaine Gimzewska  6 , Meixuan Li  7   8 , Liang Yao  1
Affiliations

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

Qi Wang et al. Cochrane Database Syst Rev. .

Abstract

Background: Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. Therefore, it is critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This Cochrane Review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. However, the technique may be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the previous Cochrane Review published in 2017.

Objectives: To evaluate the benefits and harms of totally percutaneous access compared to cut-down femoral artery access in people undergoing elective bifurcated abdominal endovascular aneurysm repair (EVAR).

Search methods: We used standard, extensive Cochrane search methods The latest search was 8 April 2022.

Selection criteria: We included randomised controlled trials in people diagnosed with an AAA comparing totally percutaneous versus surgical cut-down access endovascular repair. We considered all device types. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for ruptured AAAs and those reporting aorto-uni-iliac repairs.

Data collection and analysis: We used standard Cochrane methods. Our primary outcomes were 1. short-term mortality, 2. failure of aneurysm exclusion and 3. wound infection. Secondary outcomes were 4. major complications (30-day or in-hospital); 5. medium- to long-term (6 and 12 months) complications and mortality; 6. bleeding complications and haematoma; and 7. operating time, duration of intensive treatment unit (ITU) stay and hospital stay. We used GRADE to assess the certainty of evidence for the seven most clinically relevant primary and secondary outcomes.

Main results: Three studies with 318 participants met the inclusion criteria, 189 undergoing the percutaneous technique and 129 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report the method of randomisation, allocation concealment or preselected outcomes. The other two larger studies had few sources of bias and good methodology; although one study had a high risk of bias in selective reporting. We observed no clear difference in short-term mortality between groups, with only one death occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.06 to 36.18; 2 studies, 181 participants; low-certainty evidence). One study reported failure of aneurysm exclusion. There was one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 1 study, 151 participants; moderate-certainty evidence). For wound infection, there was no clear difference between groups (RR 0.18, 95% CI 0.01 to 3.59; 3 studies, 318 participants; moderate-certainty evidence). There was no clear difference between percutaneous and cut-down femoral artery access groups in major complications (RR 1.21, 95% CI 0.61 to 2.41; 3 studies, 318 participants; moderate-certainty evidence), bleeding complications (RR 1.02, 95% CI 0.29 to 3.64; 2 studies, 181 participants; moderate-certainty evidence) or haematoma (RR 0.88, 95% CI 0.13 to 6.05; 2 studies, 288 participants). One study reported medium- to long-term complications at six months, with no clear differences between the percutaneous and cut-down femoral artery access groups (RR 0.82, 95% CI 0.25 to 2.65; 1 study, 135 participants; moderate-certainty evidence). We detected differences in operating time, with the percutaneous approach being faster than cut-down femoral artery access (mean difference (MD) -21.13 minutes, 95% CI -41.74 to -0.53 minutes; 3 studies, 318 participants; low-certainty evidence). One study reported the duration of ITU stay and hospital stay, with no clear difference between groups.

Authors' conclusions: Skin puncture may make little to no difference to short-term mortality. There is probably little or no difference in failure of aneurysm exclusion (failure to seal the aneurysms), wound infection, major complications within 30 days or while in hospital, medium- to long-term (six months) complications and bleeding complications between the two groups. Compared with exposing the femoral artery, skin puncture may reduce the operating time slightly. We downgraded the certainty of the evidence to moderate and low as a result of imprecision due to the small number of participants, low event rates and wide CIs, and inconsistency due to clinical heterogeneity. As the number of included studies was limited, further research into this technique would be beneficial.

Trial registration: ClinicalTrials.gov NCT01070069.

PubMed Disclaimer

Conflict of interest statement

QW: none.

JW: none

YM: none.

YZ: none.

XS: none.

SX: none.

FL: none.

MG: none.

ML: none.

LY: none.

Figures

1
1
Flow diagram
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
1.1
1.1. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 1: Short‐term mortality (30‐day or in‐hospital)
1.2
1.2. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 2: Failure of aneurysm exclusion
1.3
1.3. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 3: Wound infection (30‐day or in‐hospital)
1.4
1.4. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 4: Major complications (30‐day or in‐hospital)
1.5
1.5. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 5: Medium‐ to long‐term complications (6 months)
1.6
1.6. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 6: Bleeding complications (30‐day or in‐hospital)
1.7
1.7. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 7: Haematoma (30‐day or in‐hospital)
1.8
1.8. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 8: Operating time (minutes)
1.9
1.9. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 9: Duration of intensive treatment unit stay (hours)
1.10
1.10. Analysis
Comparison 1: Percutaneous versus cut‐down femoral artery access, Outcome 10: Duration of hospital stay (days)
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Vierhout 2019 {published data only}NTR4257
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    1. Vierhout BP, Saleem BR, Ott A, Dijl JM, Andringa de Kempenaer TD, Pierie ME, et al. A comparison of Percutaneous femoral access in Endovascular Repair versus Open femoral access (PiERO): study protocol for a randomized controlled trial. Trials 2015;16:408. [DOI: 10.1186/s13063-015-0911-y] - DOI - PMC - PubMed

References to studies excluded from this review

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References to other published versions of this review

Gimzewska 2017
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Jackson 2014
    1. Jackson A, Yeoh SE, Clarke M. Totally percutaneous versus standard femoral artery access for elective bifurcated abdominal endovascular aneurysm repair. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No: CD010185. [DOI: 10.1002/14651858.CD010185.pub2] - DOI - PubMed

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