A commentary on “Comparison of percutaneous versus cutdown access in patients after endovascular abdominal aortic repair: a randomized controlled trial (SWEET-EVAR trial)”

Dear Editor,

We read with great interest the recent publication titled “Comparison of Percutaneous Versus Cutdown Access in Patients After Endovascular Abdominal Aortic Repair: A Randomized Controlled Trial (SWEET-EVAR Trial)”^[1], which presents a comparative analysis of percutaneous and cutdown access methods in patients undergoing endovascular abdominal aortic repair (EVAR). This study highlights some promising findings regarding recovery times and patient outcomes; however, several concerns and limitations need to be addressed to strengthen the reliability and applicability of the study’s conclusions. We have been assured that the article complies with TITAN Guidelines 2025-governing declaration and use of AI^[2].

First, the study’s sample size is relatively small, which may limit the statistical power of the findings. A small sample size can result in type II errors, where significant differences between groups may go undetected. This limitation could impact the generalizability of the study’s conclusions, especially when considering more complex subgroups or rarer complications that might not be well represented in the study cohort^[3].

Second, while the study effectively assesses short-term recovery and access-related complications, the follow-up period is too short to evaluate long-term outcomes. For instance, long-term complications, such as graft occlusion, vascular injury, or re-interventions, were not sufficiently explored. These are important considerations when assessing the overall success and sustainability of either access method, as complications may emerge months or even years after the procedure^[4]. A longer follow-up would provide a more comprehensive understanding of the long-term impact of the percutaneous and cutdown techniques.

Third, the study primarily focuses on a patient group with non-calcified femoral arteries, which may limit the external validity of the findings. While this cohort is useful for understanding the effects in certain patient populations, the inclusion of patients with calcified arteries and varying comorbidities would be important to assess the universal applicability of the results. Different patient characteristics may affect the outcomes procedure, and the study’s findings may not be directly applicable to other populations^[5].

Additionally, the study was conducted at a single center, which may limit the external validity of the results. Different medical facilities may have varying levels of expertise, patient demographics, and healthcare infrastructure, which can all affect the outcomes of the procedure. A multicenter trial would increase the diversity of the patient population and strengthen the generalizability of the findings across different settings. It would also reduce the potential for bias and improve the reliability of the study’s conclusions.

Moreover, while the authors mention the access-related complications in both groups, they do not provide a comprehensive analysis of all possible complications. It is important to consider other potential complications, such as infections, thrombosis, or arterial dissection, that may occur postoperatively. A more thorough reporting and analysis of all complications would offer a clearer understanding of the risks associated with each access method^[6].

In conclusion, while the SWEET-EVAR trial offers valuable insights into the short-term recovery and patient outcomes associated with percutaneous and cutdown access methods for EVAR, there are several limitations that need to be addressed in future studies. These include a small sample size, short follow-up period, limited patient demographics, lack of multicenter validation, and incomplete reporting of complications. Future research should aim to address these concerns to provide a more robust and comprehensive understanding of the long-term benefits and risks of these access methods.

Ethical approval

Not applicable.

Consent

Not applicable.

Source of funding

Not funding received.

Author contributions

L.L., Z.W. and Y.L.: Conception, design, and writing – original draft; L.L. and Y.L.: Writing – review & editing; L.L. and Z.W.: Investigation, project administration and resources supervision. All authors were involved in the final approval of the manuscript.

Conflicts of interest disclosure

The authors declare that they have no conflicts of interest.

Guarantor

All authors.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Not applicable to this article.