Treatment of aortic pathologies changed fundamentally during the last two decades: endovascular treatments and especially the use of stentgrafts have become more and more frequent (1). Treatment of the abdominal aorta is commonly referred to as endovascular aortic repair (EVAR), and that of the thoracic aorta as thoracic endovascular aortic repair (TEVAR) (1). With the establishment of thoracic/endovascular aortic repair (T/EVAR), during which stentgrafts are deployed minimally invasive through an arterial access vessel, risky open aortic repair (OAR) can mostly be circumvented. Potential benefits of T/EVAR vs. OAR include reduced perioperative and 1-year mortality, shortening of hospital stay and less periprocedural complications (2-5).

To establish large-bore vessel access in T/EVAR either classic cutdown or percutaneous technique may be performed. cEVAR consists of a skin incision and surgical preparation of the access vessel. In pEVAR, the access vessel is punctured through the skin. After puncture, a suture mediated closure device (SMCD) is used to prepare the sutures for closure of the puncture site (5). Commonly used SMCDs are the systems Perclose ProGlide or Prostar XL (both by Abbott Vascular) (6).

Both access techniques have been compared to a limited extent regarding different parameters (7). A meta-analysis from 2017 comparing both techniques analyzed two randomized controlled trials with 181 patients and suggested equivalence of pEVAR and cEVAR (7). Analyzed parameters included bleeding complications, wound infections and major vessel complications (7). Especially access-related major complications like thrombosis and access-vessel injury were rarely observed in both techniques throughout different studies (8,9).

Current evidence clearly shows a reduction of operation time in pEVAR (10-12). Also technical success rates of more than 90% imply good feasibility of the percutaneous technique (11,13,14). Achieving high success rates presupposes preoperative evaluation of the access vessel, usually the Common Femoral Artery (CFA). Particularly diameter, anterior calcification and possible kinking of the vessel are relevant (15,16). The impact of the CFA calcification level remains uncertain. Starnes et al (17) postulate safe feasibility of pEVAR even in calcified vessels, other studies suggest different results (18,19). Furthermore, routine ultrasound guidance for pEVAR-access seems to reduce incidence of access-site complications, especially hematomas and injuries of the femoral nerve (20,21).

Complications of both techniques frequently have been recorded only for short term outcomes. A randomized controlled trial from 2019 shows no superiority for either approach with wound infection rates between 0 and 1.5% but a reduction of postoperative pain after pEVAR (22). Other studies also included access-related complications, however only until one month after surgery (11,13) or without comparing them to cEVAR (14,23). Nevertheless, overall acquired data shows a clear trend towards reduced access-related complication rates when using the percutaneous technique (9)

The aim of this study was to compare the incidence of short- and long-term minor complications after percutaneous and cutdown groin vessel access for T/EVAR. Because of several previous studies implying a rather low incidence of access-related major complications (8,9), those complications were not considered in the present study.

This study suggests equivalence of percutaneous and cutdown technique for vessel access in T/EVAR regarding minor complications after surgery. Neither postoperative nor follow-up complications occurred significantly more often overall. Nevertheless, the results of the study suggest that despite ongoing development of improved closure systems, the percutaneous access technique does not reach superiority over cutdown access concerning minor complications. Although several studies reported a reduction of single types of complications, a consistent benefit for patients did not become apparent (7-9).

In contrast to complication rates, clearer advantages of percutaneous technique emerged elsewhere: Besides a reduction in the duration of surgery, which was consistently observed in past research, also a significant reduction of postoperative pain is remarkable. Additionally, the possibility of a more frequent use of local compared to general anesthesia represents an important alternative for patients who are limited in undergoing intubation anesthesia because of their multimorbidity. Even though cutdown access is theoretically also possible in local anesthesia, especially for obese and non-compliant patients it is often not feasible.

As complications during follow-up emerge in approximately the same number of cases as during hospital stay, clinical examination of the access site should always be conducted and properly documented on follow-up appointments. Future studies might quantify the period in which access-related complications might be able to appear after T/EVAR.

Besides the retrospective design implying possible selection bias regarding the chosen technique for vessel access, the limitations of this study include a low cohort size mainly in the pEVAR group. The main reason for this lies in incompletely accessible data especially from older cases. Moreover, the fact that ultrasound guidance was not routinely used for vessel access in pEVAR might have had a negative impact on the technical success and complication rates of this subgroup. Lastly, albeit excluding the first five percutaneous accesses to account for possible effects of a learning curve, a lack of experience of the operating surgeons with pT/EVAR might have had a negative impact on the results observed for the technique (25). Further prospective studies are needed to identify which group of patients who may profit from each technique.

As of today, the individual surgeon's decision regarding the vessel access technique is mainly based on own preference and expected technical success. The current German guidelines for treatment of AAA suggest only the degree of calcification of the access vessel and the respective surgeon's experience as factors for the decision (26). Prospectively, this decision process should be complemented by evidence-based data for complication rate of access techniques and the related improvement of patient's quality of life. Factors which are associated with percutaneous access with few complications and high technical success should be investigated and defined in the future. By doing so, the technique for vessel access that potentially achieves the best outcome could be chosen more individually.

In conclusion, the percutaneous technique for vessel access in T/EVAR proved to be a safe and quickly executable alternative to cutdown vessel access. No technique reached superiority in terms of minor complications. For patients being dependent on or wishing for local anesthesia for T/EVAR, the percutaneous technique should be the first choice for groin access if anatomical suitability is given. A thorough clinical examination of the groin access site should not be neglected during follow-up as access-related complications might appear even months after surgery. Future studies and guidelines should aim for investigation and definition of more precise criteria for selection of the individually best fitting access technique.