Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts, endovascular repair of abdominal aortic aneurysm, thoracic endovascular aneurysm repair and transcatheter aortic valve implantation. The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this is the focus of our review.
We compared the transverse surgical technique (a cut made parallel to the groin crease) versus the vertical groin incision at the inguinal region (classic surgical technique: a cut made across the groin crease) to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective.
Study characteristics and key results
This systematic review includes two studies (most recent search February 2020): one randomized controlled trial and one quasi-randomized clinical trial. Both compared transverse versus vertical inguinal approaches. One study included 149 participants (167 groins) while the second study included 88 participants (116 groins), undergoing inguinal surgery to access the femoral artery.
The outcome 'wound or surgical site infection' was assessed in both studies. The combined analysis showed a lower rate of wound infections for the transverse inguinal incision compared with the vertical inguinal incision. One study assessed lymphatic complications and found no evidence of a difference between the two incision techniques. Other outcomes such as infection of the graft, hospitalization, death and postoperative pain were not reported by the two studies
Certainty of the evidence
We classified the certainty of the evidence as low for surgical site infection due to the high risk of bias because of issues with randomization and the blinding of people assessing the outcomes and the small number of participants in included studies. We considered the lymphatic complications of very low certainty evidence due to the high risk of bias because of issues with randomization and the blinding of people assessing the outcomes, and because there was only one included study with a small number of participants assessing lymphatic complications.
Evidence of low certainty suggests that surgical wound infection in the 28-day period post surgery occurs less frequently in transverse incisions than in vertical incisions to access the femoral artery. Evidence of very-low certainty indicated that there was no evidence of a difference between the two surgical techniques relating to the lymphatic complications' outcome for access to the femoral artery in the 28-day period post surgery.
In this systematic review, we found low-certainty evidence that performing transverse groin incision to access the femoral artery resulted in fewer surgical wound infections compared with performing vertical groin incision. We observed no evidence of a difference between the two surgical techniques for the other evaluated outcomes (lymphocele and lymphorrhea). Other outcomes were not evaluated in these studies.
Limitations of this systematic review are, however, the small sample size, short clinical follow-up period and high risk of bias in critical domains. For this reason, the applicability of the results is limited.
Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts (i.e. bifemoral aortic bypass or infrainguinal bypass), endovascular repair of abdominal aortic aneurysm (EVAR), thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI). The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this will be the focus of our review. We will compare the transverse surgical technique—a cut made parallel to the groin crease—versus the vertical groin incision surgical technique—classic technique: a surgical cut made across the groin crease—to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective.
To evaluate the efficacy and safety of transverse groin incision compared with vertical groin incision for accessing the femoral artery in endovascular surgical procedures and open surgery.
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to 17 February 2020. The review authors searched the IBECS database to 26 March 2020 and reference lists of relevant studies/papers.
We included randomized controlled trials (RCTs) and quasi-randomized trials (qRCTs) that compare transverse and vertical groin incision, during either endovascular or open surgery procedures.
Two review authors (MVCRC, FCN) independently selected the studies, assessed risk of bias, extracted data, performed data analysis and graded the certainty of evidence according to GRADE.
We included one RCT and one qRCT in this review. These two studies had a combined total of 237 participants (283 groins). Infection of the surgical wound was the only outcome that was similar in both studies, and that could therefore be submitted to a combined analysis.
Meta-analysis of the two studies showed low-certainty evidence that transverse groin incision resulted in a lower risk of surgical wound infection in the 10- to 28-day period following surgery (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.08 to 0.76; 2 studies; 283 groin incisions). There was low heterogeneity between the studies. We downgraded the certainty of the evidence for surgical wound infection by one level due to serious limitations in the design (there was a high risk of bias in critical domains). The confidence interval for surgical wound infection is relatively wide, further indicating that the certainty of the effect estimate is low. This is likely due to the small number of studies and participants. We observed no evidence of a difference between the two surgical techniques for the other evaluated primary outcome 'lymphatic complications': lymphocele (RR 0.46, 95% CI 0.20 to 1.02; 1 study; 116 groins); and lymphorrhea (RR 2.77, 95% CI 0.92 to 8.34; 1 study; 116 groins). We downgraded the certainty of evidence for lymphatic complications by one level due to serious limitations in the design (there was a high risk of bias in critical domains); and by two further levels because of imprecision (small number of participants and only one study included).
High-quality studies are needed to enable a comparison of the two surgical techniques with respect to other outcomes, such as infection of the vascular graft (endoprosthesis/prosthesis), prolonged hospitalization, reoperative surgery, death, neurological deficit (e.g. paresthesia), amputation, graft patency, and postoperative pain.