Patients and methods: A total of 201 patients (183 males, 18 females; 66.9±9.9 years; range, 34 to 88 years) who underwent emergency or elective abdominal aortic aneurysm endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR) between September 2014 and June 2021 were included in this single-center retrospective study. Group 1 (n=115) consisted of patients who underwent longitudinal (vertical) femoral incision, whereas Group 2 (n=86) underwent oblique (transverse) femoral incision. Preoperative risk factors connected with wound healing problems, femoral wound healing problem development, onset time of the femoral wound healing issues, types of the wound healing issue, hospital stay, and mortality were assessed.

Results: Femoral wound healing problems were significantly lower in Group 2 (p<0.05). It was observed that wound healing problems started earlier in Group 1. The distribution of diabetes mellitus, chronic kidney disease, and peripheral artery disease rates did not differ significantly (p>0.05). Obesity and chronic obstructive pulmonary disease rates were significantly higher in Group 1 (p<0.05). Postoperative length of hospitalization were borderline statistically significant in Group 1 (p=0.076). The incidence of early mortality was similar.

Conclusion: Femoral wound healing problems were observed more frequently in patients who underwent EVAR with femoral longitudinal incision access. Fewer wound healing problems in the oblique incision group made us routinely prefer the oblique incision in femoral artery access in EVAR cases.

Surgical procedure
Endovascular procedures were performed in the angiography unit with the same surgical team. Anaconda Abdominal Aortic Stent Graft System (Vascutek, Terumo, Inchinnan, Scotland), Medtronic Endurant II Stent Graft System (Medtronic Vascular, Santa Rosa, CA, USA), Medtronic Valiant Thoracic Stent Graft System (Medtronic Vascular, Santa Rosa, CA, USA), and Ankura Abdominal Aortic Stent Graft System (Lifetech Scientific, Shenzen, China) were used as endovascular stent grafts for the procedures. All operations were performed under general anesthesia. Femoral arteries were used for vascular access. Depth and the length of the incisions were similar. Femoral arteries were not excessively explored to avoid further complications. A simple 5-0 Prolene purse-string suture was placed on the anterior side of the femoral artery to control the arterial bleeding during the procedure. The subcutaneous tissue was closed with 1-0 polyglactin (Vicryl) suture. The skin was closed with 3-0 Prolene sutures with a vertical mattress suture technique in all patients. Postoperative routine follow-up was done on the 10th day, at three month and six months, at one year, and annually thereafter following discharge.

Data were collected from the patient files and hospital’s online database. Demographic values, preoperative risk factors connected with abdominal aortic aneurysms and wound healing issues, femoral wound healing issues, onset of the femoral wound healing issue, urgent and elective status, types of the wound healing problem, wound culture tests, intensive care unit and hospital stay, and mortality were assessed. Postoperative early mortality was defined as deaths within 30 days after the operation.

Wound healing problems were determined as follows: wound dehiscence, superficial surgical site infection, deep surgical site infection, and lymphatic leak. There were no cases of organ/space surgical site infection; therefore, this category was excluded from the tables.

Statistical analysis
Data were analyzed using IBM SPSS version 27.0 software (IBM Corp., Armonk, NY, USA). Mean, standard deviation, median, minimum, maximum, frequency, and ratio values were used in descriptive statistics of the data. The distribution of variables was measured with the Kolmogorov- Smirnov test. The independent sample t-test was used to analyze quantitative independent data with normal distribution. The Mann-Whitney U test was used to analyze quantitative independent data with nonnormal distribution. The chi-square test was used in the analysis of qualitative independent data, and the Fischer test was used when chi-square test conditions were not met. A p-value <0.05 was considered statistically significant.

Table 1 Demographic and preoperative data comparison of both groups

There was no significant difference between Groups 1 and 2 in terms of the rate of aneurysm, dissection, and rupture diagnoses at the time of intervention (p>0.05; Table 1). Urgent and elective intervention status of the patients resulted similarly and no statistical difference was found (Table 1). The number of patients with femoral wound healing problems was compared for statistical analysis. Three patients had both wound dehiscence and lymphatic leak in one groin in Group 1. As the statistical analysis was based on the number of patients rather than the number of complications, these cases were each counted as a single femoral wound healing problem to avoid duplication (Table 2). Femoral wound healing problems were significantly (p=0.042) lower in Group 2 (7.0% n=6) than in Group 1 (16.5% n=19). Although the onset of postoperative femoral wound healing problems did not differ significantly (p=0.13) between Group 1 (12.8±8.9 days) and Group 2 (19.0±6.3 days), it was observed that wound closure problems started earlier in Group 1. There was no significant difference between the both groups in terms of wound culture results and rates of different wound closure problems (p>0.05; Table 2).

Table 2 Postoperative data between groups

There was no significant difference in the reoperation rate and in terms of intensive care unit length of stay between the both groups (p>0.05). Postoperative length of hospitalization between the both groups were borderline statistically significant (p=0.076). Postoperative early mortality was similar between the groups (Table 2).

Treatment methods used in the wound healing process are summarized in Table 3.

Table 3 Treatment methods used in the wound healing process in patients who had wound closure problems depending on the incision type

According to the classification of the Centers for Disease Control and Prevention (CDC), surgical wound infections are divided into three classes.[11] These were classified as superficial incisional, deep incisional, and organ/space surgical site infections, and this classification was standardized accordingly. In these specific incision types we compared in the femoral region, organ/space surgical site infection was not compared in our study because there was no such deep organ/space level in this region. However, since superficial incisional surgical site infections are classified with a wide range of regions including epidermal, dermal, and subcutaneous tissue, we evaluated patients with wounds that did not reach the subcutaneous tissue and had only a mechanical closure problem in the skin in a separate class as “wound dehiscence.”

The rate of wound healing problems in the longitudinal incision group was statistically significantly higher than in the oblique incision group (p=0.042). In the literature, prospective, randomized controlled, and meta-analysis studies also show that infection and wound healing problems are more common in longitudinal incisions compared to oblique incisions.[4-6] In all patients in whom wound dehiscence was observed, this was encountered as a partial closure problem. When compared according to the CDC’s surgical site infection classification, there was no statistically significant difference between the groups. In addition to the patients with wound dehiscence, three patients with accompanying lymphatic leakage were in the longitudinal incision group and were evaluated under this group. No lymphatic complications were observed in the oblique incision group.

Although there was no statistically significant difference in the timing of the onset of wound healing problems, it was observed that these problems started earlier in the longitudinal incision group. Although the onset time is not discussed in many articles in the literature, in the randomized controlled study of Swinnen et al.,[5] it was mentioned that the infection developed by the 10th day in a significant portion of the patients with wound infection and the infection developed by the 28^th day in a large portion of the remaining patients. In our study, wound healing problems were observed on average on the 12th day in the longitudinal incision group and on the 20th day in the oblique incision group. This suggests that oblique incisions have a lower incidence of healing issues with a later onset of healing complications.

When the duration of hospitalization was analyzed, it was observed that hospitalization in the longitudinal incision group was borderline statistically significant (p=0.076). This result may be attributed to the earlier onset of wound healing problems in the longitudinal incision group and longer hospitalization for this reason. Siracuse et al.[12] also showed that the longitudinal incision access group was hospitalized statistically longer than the oblique incision access group in their study in which they compared the results according to access route differences. Prolonged hospitalization increases both economic costs and the burden of healthcare services. Therefore, fewer wound healing problems will positively contribute to this additional cost-effectiveness analysis and patient bed occupancy rate.

No statistically significant difference was found between the two groups in terms of operative and postoperative mortality. Similarly, no statistically significant difference was observed in the literature according to incision type.[12,13] Similarly, there was no significant difference between the reoperation rates except for surgical wound healing problems.

Advanced age, female sex, DM, obesity, cigarette smoking, dialysis-dependent CKD, PAD, COPD are considered factors that increase the risk of developing surgical site infection in previous studies.[7,14,15] When we analyzed our preoperative demographic data, there was no significant difference in terms of patient age and sex. Diabetes mellitus in itself is a risk factor in the development of atherosclerosis and leads to adverse effects on wound healing with inadequate angiogenesis, impaired cellular response, and increased oxidative stress.[16] In terms of DM, the data were similar between the two groups, and there was no statistically significant difference. Obesity is another factor that increases the risk of surgical wound infection not only in EVAR procedures but also in all other surgeries.[17] Although the mechanism has not been fully explained, impaired microcirculation and immune system response, increased lymphedema, and negative effects on respiratory functions appear to be obesity-related factors in impaired wound healing.[18] It should again be emphasized that DM and atherosclerosis are more common in obese patients, and these have negative effects on the wound healing process. In our study, the rate of obesity in the longitudinal incision group, in which wound healing problems were observed more frequently, was statistically more significant than the other group (p=0.020). Peripheral artery disease, which adversely affects micro- and macrocirculation of the extremity and thus causes diminished tissue oxygenation, was borderline statistically significant in the longitudinal incision group (p=0.058), where wound healing problems were more common. Finally, the incidence of COPD, which is also associated with an increased risk of wound infection, was statistically significantly higher in the same group (p=0.014). In this context, tissue hypoxia caused by impaired respiratory functions in patient groups with COPD is interpreted as the main relationship.[17]

Treatment modalities used in the wound healing process were classical wound debridement and healing with simple suturization, healing with vacuum-assisted closure devices, and, finally, suturization of the wound. In some patients, secondary healing with local dressing applications was applied. Skin grafting or skin flap application methods were not required in any patient who developed wound healing problems.

Wound healing is an important postoperative complication and requires attention as it requires additional surgical intervention, prolongs hospitalization, and may sometimes lead to limb loss and mortality. In previous studies, EVAR was compared to open surgery were shown to be effective and safe in the early period,[19] which increased the preference for endovascular procedures in appropriate patients. However, in the current era of advanced surgical techniques, new approaches are being explored to minimize possible wound healing complications. Nowadays, percutaneous methods have also started to be used in femoral access, and studies in the literature comparing open surgical and percutaneous access in the femoral access route[20] will contribute to the practice in terms of surgical interventions with less femoral wound closure issues, at least for endovascular procedures in the future.

This study had some limitations. Although most of the risk factors were similar in the preoperative group comparison, the fact that risk factors such as obesity, COPD, and to a lesser extent PAD (borderline statistically significant in this study), which may have a negative effect on femoral wound healing, were higher in the longitudinal incision group, raises additional questions as to whether adverse wound healing occurred only due to the type of incision or also with the effect of these risk factors. The retrospective design is another limiting factor, and comparing different incisions with prospective randomized controlled studies would provide more robust results. The number of patients is relatively sufficient; nonetheless, a larger number would provide more statistically significant results.

In conclusion, femoral wound healing problems were observed more frequently in patients who underwent EVAR with longitudinal incision access from the femoral region in our study. Furthermore, wound healing problems started earlier, and hospitalization was longer in the longitudinal incision group. This prolongs treatment, leads to additional interventions, and ultimately increases treatment costs and patient bed occupation time. Therefore, surgical procedures that cause less femoral wound healing problems should be selected. The fact that the oblique incision group had fewer wound healing problems resulted in us routinely preferring the oblique incision for femoral access in EVAR.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Idea/concept, design, control/ supervision, analysis, processing, literature review, writing the article, critical review, materials: H.S.; Idea/concept, data collection, analysis, idea/concept, data collection, analysis: H.İ.E; Materials, interpretation: B.P.; Materials, data collection, literature review: B.Ö.; Idea/concept, interpretation, critical review: İ.K.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

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