Access Techniques for EVAR: Percutaneous Techniques and Working with Small Arteries

Access is a key component of endovascular aneurysm repair (EVAR.) The femoral artery is the most common site of access and is traditionally exposed via open cutdown. Percutaneous access is possible by placing suture-mediated closure devices before up-sizing to large-bore sheaths. Comparison of open cutdown (n = 2,802) with percutaneous femoral access (n = 1,781) in elective EVAR cases using the American College of Surgeons National Surgical Quality Improvement Program database shows that the main advantage of percutaneous access is decreased operative time (159 ± 63 min v 150 ± 68 min; P < .05.) However, 30-day serious morbidity is more common with percutaneous access (5.8% v 7.2%; P < .05), with a risk-adjusted odds ratio of 1.31 (95% confidence interval, 1.03-1.68). There was no significant difference in either the 30-day mortality rate or the mean length of stay for the femoral exposure cohort (0.8% and 2.9 days) compared with the percutaneous cohort (0.9% and 3.3 days). Iliac exposure was associated with increased morbidity, operative time, intraoperative transfusion, and length of stay, but not 30-day mortality. Therefore, iliac exposure might still be the most appropriate option in cases of inadequately sized external iliac vessels. Alternatively, internal conduits (or endoconduits) can have utility, but the published experience with this technique is limited. Severely stenotic, or even occluded, iliac arteries can often be safely treated with balloon angioplasty if otherwise of adequate caliber. However, with all access options, safeguards, and procedural protocols for promptly treating complications are essential to maintain good outcomes.