Optimizing Femoral Access in EVAR: A Multicentric Comparison of Percutaneous and Surgical Approaches in Elective and Urgent Settings

BACKGROUND: Endovascular aneurysm repair (EVAR) has become the preferred alternative to open repair for infrarenal abdominal aortic aneurysm, offering lower short-term mortality and morbidity. This study investigates the impact of percutaneous femoral access versus surgical cutdown in elective and urgent/emergent EVAR procedures. METHODS: A retrospective study was conducted on all femoral access procedure performed between 2015 and 2023 from 2 referral academic centers. Primary outcomes were technical success, access site complications, and major adverse events rates. Length of intensive care unit (ICU) stay, and hospital stay, bleeding requiring transfusion, and wound infection rates were also collected. Moreover, anatomical and clinical factors potentially influencing the type of access were investigated. RESULTS: The study included 711 EVAR procedures and 1,422 femoral access. One hundred two procedures (14.3%) were performed in an emergent/urgent setting. Percutaneous approach was performed in 636 (44.7%) cases, while surgical exposure was performed in 786 cases (55.3%). Percutaneous access was associated with lower rates of bleeding (P < 0.001), in-hospital mortality (P < 0.001), both in elective and urgent settings, as well as shorter hospital stays (P < 0.001) and less need for ICU (P < 0.001). Age (P < 0.001), body mass index (P < 0.001), and sheath size (Fr > 16) (P < 0.001) were factors that influenced the choice of percutaneous or surgical approach, both in univariate and multivariate analysis. CONCLUSION: The present study suggests that percutaneous approach achieves better short-term outcomes than surgical cutdown. However, these findings should be interpreted in light of the study's limitations, including its retrospective design and potential selection bias in access type allocation. Moreover, the success of percutaneous technique remains highly dependent on operator expertise and anatomical challenges. Therefore, the choice of approach should always be tailored for each patient.