LAUSR

BACKGROUND Access issues are one of the most common complications of endovascular aneurysm repair (EVAR). However, contemporary rates as well as risk factors for complications and the subsequent impact of access complications on mortality are poorly described. METHODS We studied all EVAR for intact AAA without prior aortic surgery in the Vascular Quality Initiative between 2011 and 2018. We studied factors associated with access complications (thrombosis, embolus, wound infection, hematoma, conversion to cutdown), as well as the interaction with female sex and the impact on survival using multilevel logistic regression and propensity weighting. Multiple imputation was used for missing data. RESULTS There were 33,951 EVAR during the study period (91% elective, 9% symptomatic); most cases (70%) involved an attempt at percutaneous access on at least one side, with 30% bilateral cutdowns and 0.1% iliac conduits. 1,553 patients (4.6%) experienced at least one access complication. Access complications were almost twice as common in female patients (7.5% vs 3.9%, P<.001). The factors associated with access complications included female sex (OR 2.7 [2.0-3.6], P<.001), age (OR 1.05 per 5 years [1.02-1.1], P<.01), aortouniiliac device (OR 1.6 [1.1-2.3], P<.01), smoking (OR 1.4 [1.1-1.7], P<.01), BMI < 16 (OR 1.8 [1.3-2.5], P=.001), dual antiplatelet therapy (1.3 [1.02-1.6], P=.03), prior infrainguinal bypass (OR 1.8 [1.3-2.7], P<.01), and beta blocker usage (OR 1.2 [1.03-1.4], P=.02). Conversion from percutaneous access to open cutdown was associated with higher rates of complications than planned open cutdown (8.6% vs 2.9%, P<.001). In propensity-weighted analysis, percutaneous access was associated with significantly lower odds of access complications in women (OR 0.6 [0.4-0.96], P=.03). Patients who experienced an access complication had over four times the odds of perioperative death (OR 4.2 [2.5-7.1], P<.001), and 60% higher risk of long-term mortality (HR 1.6 [1.2-2.1], P=.001). In addition to death, patients with access site complications had higher rates of other major complications, including reoperation during the index hospitalization (19% vs 1.2%, P < .001), myocardial infarction (3.5% vs 0.7%, P < .001), stroke (0.8% vs 0.2%, P < .001), acute kidney injury (12% vs 3%, P < .001), and reintubation (5.7% vs 0.8%). CONCLUSION Although access complications are infrequent in the current era, they are associated with both perioperative and long-term morbidity and mortality. Female patients in particular are at high risk of access complications but may benefit from percutaneous access.