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A Systematic Review and Meta-Analysis Comparing Total Transfemoral Access to Upper Extremity Access for
Cynthia Florencio de Mesquita1, Dilson da Silva Pimentel Junior2, Braiana Ángeles Díaz Herrera3
1School for Medical Sciences, Federal University of Pernambuco, Recife, Brazil.
Background:
Recent studies have suggested that the use of total transfemoral access reduces the risk of symptomatic cerebrovascular events as compared to upper extremity access in patients treated for complex abdominal and thoracoabdominal aortic aneurysms by fenestrated-branched endovascular aortic repair. We aim to compare the outcomes of fenestrated-branched endovascular aortic repair using total transfemoral versus upper extremity access by a Systematic Review and Meta-Analysis with Trial Sequential Analysis.
Methods:
MEDLINE, Embase, and Cochrane databases were searched for studies until March 2025 that compared total transfemoral and upper extremity access for fenestrated-branched endovascular aortic repair. A total of 800 articles were screened following the Preferred Reported Items for Systematic Review and Meta-Analysis (PRISMA) protocol. End-points were 30-day or in-hospital mortality, stroke, and spinal cord injury (SCI), procedural variables (contrast volume, operative time, estimated blood loss), technical success, and length of hospital stay. A restricted maximum likelihood random-effects model with risk ratios and 95% confidence intervals was employed for binary endpoints, while mean difference was used for continuous endpoints. Heterogeneity was evaluated through Cochrane's Q statistic and Higgins and Thompson's I2 statistic. All tests were two-tailed, and significance was defined as a P-value <0.05. The Grading of Recommendations, Assessment, Development, and Evaluations approach was used to evaluate the quality of evidence.
Results:
We included seven cohort studies with 6,304 patients treated by fenestrated-branched endovascular aortic repair using total transfemoral access in 3,310 (53%) or upper extremity in 2,994 (47%). Patients treated in both groups had similar demographics. The median age of patients was 72.7 years, and 68% were male. Stroke (0.8% vs. 2.6%; RR 0.34; 95% CI 0.21-0.55; P < 0.001; I2 = 0%; Fig. 2A) and SCI (3.2% vs. 9.4%; RR 0.35; 95% CI 0.22-0.56; P < 0.001; I2 = 0%) were significantly less common in patients treated with total transfemoral compared to upper extremity access. Both outcomes remained statistically significant after sensitivity analysis. Mortality was less frequent in the total transfemoral group (3% vs. 4.6%; RR 0.60; 95% CI 0.43-0.82; P = 0.001; I2 = 5.4%). Operative time (OR -69.64 min; 95% CI -77.12 to -62,15; P < 0.001) and estimated blood loss (MD -156.47 milliliters; 95% CI -225.31 to -87.63; P < 0.01; I2 = 75%) favored total transfemoral group. However, technical success was not significantly different between groups. None of the articles reported the results separately by grafts or aneurysm types.
Conclusion:
Total transfemoral access is associated with lower stroke, spinal cord injury, mortality, and improved operative metrics compared to upper extremity access.
