Abstract: Two studies with a total of 181 participants met the inclusion criteria, 116 undergoing the percutaneous technique and 65 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report method of randomisation, allocation concealment or pre-selected outcomes. The second study was a larger study with few sources of bias and good methodology. We observed no significant difference in mortality between groups, with only one mortality occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50; 95% confidence interval (CI) 0.06 to 36.18; 181 participants; moderate-quality evidence). Only one study reported aneurysm exclusion. In this study we observed only one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 151 participants; moderate-quality evidence). No wound infections occurred in the cut-down femoral artery access group or the percutaneous group across either study (moderate-quality evidence). There was no difference in major complication rate between cut-down femoral artery access and percutaneous groups (RR 0.91, 95% CI 0.20 to 1.68; 181 participants; moderate-quality evidence); or in bleeding complications and haematoma (RR 0.94, 95% CI 0.31 to 2.82; 181 participants; high-quality evidence). Only one study reported long-term complication rates at six months, with no differences between the percutaneous and cut-down femoral artery access group (RR 1.03, 95% CI 0.34 to 3.15; 134 participants; moderate-quality evidence). We detected differences in surgery time, with percutaneous approach being significantly faster than cut-down femoral artery access (mean difference (MD) -31.46 minutes; 95% CI -47.51 minutes to -15.42 minutes; 181 participants; moderate-quality evidence). Only one study reported duration of ITU (intensive treatment unit) and hospital stay, with no difference found between groups. This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion, major complications, wound infection and long-term (six month) complications, and high-quality evidence for no difference in bleeding complications and haematoma. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate as a result of the limited number of studies, low event numbers and imprecision. As the number of included studies were limited, further research into this technique would be beneficial. The search identified one ongoing study, which may provide an improved evidence base in the future.

Plain-language summary: This update found two studies comparing the cut-down artery access with the percutaneous technique (current to October 2016). One was a small study with 30 participants, the other a larger more robust study with 151 participants. The large study was found to be of high quality with little risk of bias. The smaller study did not report on the methods of randomisation, how the randomisation was concealed and the pre-selected outcomes of interest. Combined, the studies had 181 participants; 116 underwent the cut-down technique and 65 the percutaneous technique. Both studies compared rates of death, major complications, wound infections, bleeding complications, and length of the operation. Overall, we did not find any difference in the rates of death (moderate-quality evidence), major complications (moderate-quality evidence); or bleeding complications between the percutaneous and cut-down techniques (high-quality evidence). No one developed a wound infection (moderate-quality evidence). The surgery took less time (moderate-quality evidence) in the percutaneous group compared with the cut-down group. Only one study reported if the aneurysm wall was successfully reinforced (checked by a CT scan, moderate-quality evidence), on complications at six months, (moderate-quality evidence); and on how long participants spent in an intensive treatment unit (ITU). We did not find any difference between the cut-down and percutaneous groups. This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion (sealing of the aneurysms), major complications, wound infection and long-term (six months) complications; and high-quality evidence for no difference in bleeding complications. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate due to the small number of studies, overall event rates and imprecision (differences around the level of effect).