Endovascular repair or open repair for ruptured abdominal aortic aneurysm: a Cochrane systematic review

Abstract

ObjectivesEmergency endovascular aneurysm repair (eEVAR) may improve outcomes for patients with ruptured abdominal aortic aneurysm (RAAA). The study aim was to compare the outcomes for eEVAR with conventional open surgical repair for the treatment of RAAA.SettingA systematic review of relevant publications was performed. Randomised controlled trials (RCTs) comparing eEVAR with open surgical repair for RAAA were included.Participants3 RCTs were included, with a total of 761 patients with RAAA.InterventionsMeta-analysis was performed with fixed-effects models with ORs and 95% CIs for dichotomous data and mean differences with 95% CIs for continuous data.Primary and secondary outcome measuresPrimary outcome was short-term mortality. Secondary outcome measures included aneurysm-specific and general complication rates, quality of life and economic analysis.ResultsOverall risk of bias was low. There was no difference between the 2 interventions on 30-day (or in-hospital) mortality, OR 0.91 (95% CI 0.67 to 1.22; p=0.52). 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation and respiratory failure. Reporting was incomplete, and no robust conclusion was drawn. For complication outcomes that did include at least 2 studies in the meta-analysis, there was no clear evidence to support a difference between eEVAR and open repair. Longer term outcomes and cost per patient were evaluated in only a single study, thus precluding definite conclusions.ConclusionsOutcomes between eEVAR and open repair, specifically 30-day mortality, are similar. However, further high-quality trials are required, as the paucity of data currently limits the conclusions.

Ruptured abdominal aortic aneurysm: open vs. endovascular repair: literature review

“…The three large multi-centre trials concluded that early mortality rates (30-day mortality or in-hospital mortality) following treatment for rAAAs are no better with EVAR than with OR (Table 1) [21,33,35]. A Cochrane systematic review and metaanalysis involving two of the major RCTs and the one pilot trial found no difference in early mortality between EVAR and OR (pooled odds ratio 0.91, 95% CI: 0.67-1.22; P=0.52) [15]. A further meta-analysis incorporating the data from the three multi-centre RCTs corroborated these findings (pooled odds ratio 0.88, 95% CI: 0.66-1.18; P=0.84) [36].…”

“…More specifically, participants who are haemodynamically stable are often assigned to EVAR, introducing a well-defined selection bias [42]. While there is an accompanying body of observational research failing to reveal any early-mortality benefit in utilising an endovascular approach [15,31,36,40,[43][44][45], there are virtually no literature items reporting EVAR as a more morbid curative approach [37]. So while there is no high-level evidence from randomised trials supporting EVAR over OR from an early mortality perspective [15,36], the trends within observational research favour the former.…”

“…This complex operation often carried a significant level of morbidity and mortality as a result of haemodynamic instability, the co-morbid state of patients, surgical exposure and aortic clamping with associated lower body ischaemic injuries [12][13][14]. However, significant work surrounding patient selection and optimising perioperative care has allowed open repair to demonstrate excellent outcomes in managing these critically ill patients with rAAAs [15,16]. Since its inception in the early 1990's, the arrival of endovascular repair has challenged the supremacy of open repair [8], by offering a number of theoretical benefits Ruptured abdominal aortic aneurysm is a surgical emergency, invariably leading to death without urgent intervention.…”

Endovascular or open repair of ruptured abdominal aortic aneurysms

“…A recent meta-analysis [2] screened for all randomised controlled trials comparing EVAR to open repair in ruptured AAA using the Cochrane central register. Most studies were retrospective case-nested control studies (n = 10) or prospective observational studies (n = 5).…”

“…Although a fi nal conclusion could defi nitely not be drawn yet in elective cases, it has been assumed that the benefi ts of EVAR must become even more obvious in patients with ruptured AAA. This subgroup of patients is usually in a critical clinical condition, suff ering from a high early mortality of about 60 -80 % [1,2]. Therefore, a less invasive procedure should result in more favourable outcomes.…”