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Study flow diagram
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Figure 1

Study flow diagram

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 1 Short‐term mortality rate (30‐day or in‐hospital).
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Analysis 1.1

Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 1 Short‐term mortality rate (30‐day or in‐hospital).

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Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 2 Aneurysm exclusion.
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Analysis 1.2

Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 2 Aneurysm exclusion.

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Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 3 Major complications.
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Analysis 1.3

Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 3 Major complications.

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Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 4 Major complications (6 months).
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Analysis 1.4

Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 4 Major complications (6 months).

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Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 5 Bleeding complications.
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Analysis 1.5

Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 5 Bleeding complications.

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Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 6 Operating time (minutes).
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Analysis 1.6

Comparison 1 Percutaneous vs cut‐down femoral artery access, Outcome 6 Operating time (minutes).

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Summary of findings for the main comparison. Totally percutaneous compared to cut‐down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

Totally percutaneous compared to cut‐down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

Patient or population: people undergoing elective bifurcated abdominal endovascular aneurysm repair
Setting: hospital
Intervention: totally percutaneous
Comparison: cut‐down femoral artery access

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with cut‐down femoral artery access

Risk with totally percutaneous

Short‐term mortality rate

(30‐day or in‐hospital)

See comment

See comment

RR 1.50
(0.06 to 36.18)

181
(2 RCTs)

⊕⊕⊕⊝
MODERATE 1

It was not possible to calculate risk as only one event occurred. Note that although 2 RCTs included, only one contributes to effect estimate (no events in Torsello 2003)

Failure of aneurysm exclusion
(follow‐up 28 days)

Study population

RR 0.17 (0.01 to 4.02)

151
(1 RCT)

⊕⊕⊕⊝
MODERATE 2

20 per 1000

3 per 1000
(0 to 80)

Wound infection rate (30‐day or in‐hospital)

See comment

See comment

not estimable

181
(2 RCTs)

⊕⊕⊕⊝
MODERATE 3

Risk and relative effect were not estimable as no events occurred

Major complications (30‐day or in‐hospital)

Study population

RR 0.91
(0.50 to 1.68)

181
(2 RCTs)

⊕⊕⊕⊝
MODERATE 4

200 per 1000

182 per 1000
(100 to 336)

Long term complications
(follow‐up 6 months)

Study population

RR 1.03
(0.34 to 3.15)

134
(1 RCT)

⊕⊕⊕⊝
MODERATE 5

95 per 1000

98 per 1000
(32 to 299)

Bleeding complications and haematoma

(30‐day or in‐hospital)

Study population

RR 0.94
(0.31 to 2.82)

181
(2 RCTs)

⊕⊕⊕⊕
HIGH

62 per 1000

58 per 1000
(19 to 174)

Operating time (minutes)

The mean operating time was 99 minutes

The mean operating time in the intervention group was 31.46 minutes lower (47.51 lower to 15.42 lower)

‐

181
(2 RCTs)

⊕⊕⊕⊝
MODERATE 6

* The basis for the assumed risk for 'Study population' was the average risk in the comparison group (i.e. total number of participants with events divided by the total number of participants in the comparison group included in the meta‐analysis. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) and calculated where possible from the data provided in the studies.
CI: Confidence interval; mins: minutes; RCT: randomised controlled trial; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 We downgraded by one level due to the low number of events and imprecision (wide confidence intervals include both harm and benefit)
2 We downgraded by one level as event rates were low and data were available from only one study
3 We downgraded by one level due to a low number of events (no wound infections reported)
4 We downgraded by one level due to imprecision (wide confidence intervals include both harm and benefit)
5 We downgraded by one level as data were available from only one study. A loss to follow up for this outcome was detected (9% of participants; 16% of the percutaneous group and 8% of the cut‐down femoral artery access group). We did not downgrade further as there was a clear breakdown of loss to follow‐up and no significant difference in loss to follow‐up between groups was detected
6 We downgraded by one level as the studies reported this outcome as a secondary outcome and were not adequately powered for this outcome.

Figuras y tablas -
Summary of findings for the main comparison. Totally percutaneous compared to cut‐down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair
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Comparison 1. Percutaneous vs cut‐down femoral artery access

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Short‐term mortality rate (30‐day or in‐hospital) Show forest plot

2

181

Risk Ratio (M‐H, Fixed, 95% CI)

1.5 [0.06, 36.18]

2 Aneurysm exclusion Show forest plot

1

151

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.01, 4.02]

3 Major complications Show forest plot

2

181

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.50, 1.68]

4 Major complications (6 months) Show forest plot

1

134

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.34, 3.15]

5 Bleeding complications Show forest plot

2

181

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.31, 2.82]

6 Operating time (minutes) Show forest plot

2

181

Mean Difference (IV, Fixed, 95% CI)

‐31.46 [‐47.51, ‐15.42]
Figuras y tablas -
Comparison 1. Percutaneous vs cut‐down femoral artery access
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