Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL; Division of GI Oncology, Moffitt Cancer Center, Tampa, FL.
Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL.
Ann Vasc Surg. 2024 Sep;106:1-7. doi: 10.1016/j.avsg.2024.02.016. Epub 2024 Apr 8.
A 2023 Cochrane review showed no difference in bleeding/wound infection complications, short-term mortality and aneurysm exclusion between the percutaneous and cut-down approach for femoral access in endovascular aortic aneurysm repair (EVAR). In contrast, single-center studies have shown bilateral cutdown resulting in higher readmission rates due to higher rates of groin wound infections. Whether 30-day readmission rates vary by type of access during EVAR procedures is unknown. The goal of this study was to ascertain which femoral access approach for EVAR is associated with the lowest risk of 30-day readmission.
The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing EVAR for aortic disease from 2012-2021. All ruptures and other emergency cases were excluded. Cohorts were divided into bilateral cutdown, unilateral cutdown, failed percutaneous attempt converted to open and successful percutaneous access. The primary 30-day outcomes were unplanned readmission and wound complications. Univariate analyses were performed using the Fisher's exact test, Chi-Square test and the Student's t-test. Multivariable analysis was performed using logistic regression.
From 2012 to 2021, 14,002 patients met study criteria. Most (7,395 [53%]) underwent completely percutaneous access, 5,616 (40%) underwent bilateral cutdown, 849 (6%) underwent unilateral cutdown, and 146 (1%) had a failed percutaneous access which was converted to open. Unplanned readmissions by access strategy included 7.6% for bilateral cutdown, 7.3% for unilateral cutdown, 7.8% for attempted percutaneous converted to cutdown, and 5.7% for completely percutaneous access (P < 0.001, Figure 1). After multivariable analysis, unplanned readmissions compared to percutaneous access yielded: percutaneous converted to cutdown adjusted odds ratio (AOR): 1.38, 95% CI [0.76-2.53], P = 0.29; unilateral cutdown AOR: 1.18, 95% CI [0.92-1.51], P = 0.20; bilateral cutdown AOR: 1.26, 95% CI [1.09-1.43], P = 0.001. Bilateral cutdown was also associated with higher wound complications compared to percutaneous access (AOR: 4.41, CI [2.86-6.79], P < 0.001), as was unilateral cutdown (AOR: 3.04, CI [1.46-6.32], P = 0.003).
Patients undergoing cutdown for EVAR are at higher risk for 30-day readmission compared to completely percutaneous access. If patient anatomy allows for percutaneous EVAR, this access option should be prioritized.
2023 年 Cochrane 综述显示，在血管内主动脉瘤修复（EVAR）中，经皮和切开两种股动脉入路在出血/伤口感染并发症、短期死亡率和动脉瘤排除方面没有差异。相比之下，单中心研究表明，双侧切开导致更高的再入院率，因为腹股沟伤口感染的发生率更高。在 EVAR 手术过程中，哪种股动脉入路方式的 30 天再入院率不同尚不清楚。本研究的目的是确定哪种 EVAR 股动脉入路方式与最低的 30 天再入院风险相关。
从 2012 年至 2021 年，美国外科医师学院国家外科质量改进计划的靶向血管模块被查询，以确定接受主动脉疾病 EVAR 的患者。所有破裂和其他紧急情况均被排除。队列分为双侧切开、单侧切开、经皮尝试失败转为开放和经皮成功入路。主要的 30 天结局是计划外再入院和伤口并发症。使用 Fisher 确切检验、卡方检验和学生 t 检验进行单变量分析。多变量分析使用逻辑回归进行。
2012 年至 2021 年，符合研究标准的患者有 14002 例。大多数（7395 [53%]）接受了完全经皮入路，5616 例（40%）接受了双侧切开，849 例（6%）接受了单侧切开，146 例（1%）经皮入路失败，转为开放。根据入路策略，计划外再入院率包括双侧切开为 7.6%，单侧切开为 7.3%，经皮尝试失败转为切开为 7.8%，完全经皮入路为 5.7%（P<0.001，图 1）。多变量分析后，与经皮入路相比，计划外再入院包括：经皮尝试失败转为切开的校正优势比（AOR）：1.38，95%置信区间 [0.76-2.53]，P=0.29；单侧切开 AOR：1.18，95%置信区间 [0.92-1.51]，P=0.20；双侧切开 AOR：1.26，95%置信区间 [1.09-1.43]，P=0.001。与经皮入路相比，双侧切开还与更高的伤口并发症相关（AOR：4.41，CI [2.86-6.79]，P<0.001），单侧切开也是如此（AOR：3.04，CI [1.46-6.32]，P=0.003）。
与完全经皮入路相比，接受切开入路的 EVAR 患者 30 天再入院风险更高。如果患者的解剖结构允许经皮 EVAR，则应优先选择这种入路方式。
