Open Femoral Artery Exposure Is Associated with Higher 30-Day Unplanned Readmissions and Wound Complications Than Percutaneous Access for EVAR

A 2017 Cochrane review showed no difference in bleeding/wound infection complications, short-term mortality, and aneurysm exclusion between percutaneous and open femoral artery approach (OFA) with endovascular aortic aneurysm repair (EVAR). In contrast, single-center studies have shown higher readmission rates related to groin wound infections in those undergoing OFA for EVAR. Whether 30-day readmission rates vary by type of access during EVAR procedures is unknown. The goal of this study was to utilize a large national dataset to determine which femoral access approach for EVAR is associated with the lowest risk of 30-day readmission and wound complications. The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing EVAR for aneurysmal disease from 2011 to 2021. Emergency operations were excluded. Patients were stratified by femoral access approach—bilateral OFA, unilateral OFA, failed percutaneous approach converted to OFA, and successful percutaneous access. The primary outcome was 30-day unplanned readmission and wound complications. Wound complications included wound infections and wound dehiscence. Univariate analyses were performed using the χ2 test and the Student t test. Multivariable analysis was performed using logistic regression. From 2011 to 2021, 14,695 patients met study criteria. Most (11,175 [76.0%]) underwent bilateral OFA, 200 (1.36%) underwent unilateral OFA, 53 (0.4%) had a failed percutaneous access that was converted to open, and 3268 (22.24%) had completely percutaneous access. Unplanned 30-day readmission by access strategy included 787 (7.04%) for bilateral OFA, 13 (6.5%) for unilateral OFA, 5 (9.4%) for attempted percutaneous converted to OFA, and 174 (5.3%) for percutaneous access (P = .003) (Figure). Wound complications by access strategy included 126 (1.13%) for bilateral OFA, 4 (2.0%) for unilateral OFA, 1 (1.9%) for attempted percutaneous converted to cutdown, and 16 (0.5%) for percutaneous access (P = .001). After multivariable analysis, using bilateral percutaneous access as the reference, unplanned readmissions by group yielded: percutaneous converted to cutdown (adjusted odds ratio [aOR], 2.03; 95% confidence interval [CI], 0.79-5.19; P = .14); unilateral cutdown (aOR, 1.18; 95% CI, 0.65-2.12; P = .56); and bilateral cutdown (aOR, 1.36; 95% CI, 1.15-1.62; P < .001). Bilateral cutdown was also associated with higher wound complication rate compared to bilateral percutaneous access (aOR, 2.35; 95% CI, 1.39-3.96; P = .001). Patients undergoing bilateral OFA for EVAR are at higher risk for 30-day readmission and wound complications compared to completely percutaneous access. If technically feasible, percutaneous approach should be preferentially utilized over OFA when performing EVAR.