Long-term single institution comparison of endovascular aneurysm repair and open aortic aneurysm repair

Quinney, Brent; Parmar, Gaurav; Nagre, Shardul B.; Patterson, Mark A.; Passman, Marc A.; Taylor, Steve M.; Chambers, James G.; Jordan, William D.

doi:10.1016/j.jvs.2011.06.114

Cited by 30 publications

(22 citation statements)

References 17 publications

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“…12 Other groups have reported reintervention rates between 12% and 27%. 21–24 In larger series, reintervention rates were also comparable: Lifeline, 18% at 5 years; OVER, 14% at 1.8 years; and EVAR1, 23% at 5 years. 4,8,25 The increased ARM seen in the reintervention subgroup and the delayed nature of many of these procedures serves to underscore the need for long-term surveillance.…”

Section: Discussionmentioning

confidence: 87%

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry

Chang

Goodney

Tucker

et al. 2013

Journal of Vascular Surgery

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Objective To assess outcomes after endovascular abdominal aortic aneurysm repair (EVAR) in an integrated health care system. Methods Between 2000 and 2010, 1736 patients underwent EVAR at 17 centers. Demographic data, comorbidities, and outcomes of interest were collected. EVAR in patients presenting with ruptured or symptomatic aneurysms was categorized as urgent; otherwise, it was considered elective. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, endoleak status, major adverse events, and reintervention. Results Overall, the median age was 76 years (interquartile range, 70–81 years), 86% were male, and 82% were Caucasian. Most cases (93.8%) were elective, but urgent use of EVAR increased from 4% in the first 5 years to 7.3% in the last 5 years of the study period. Mean aneurysm size was 5.8 cm. Patients were followed for an average of 3 years (range, 1–11 years); 8% were lost to follow-up. Intraoperatively, 4.5% of patients required adjunctive maneuvers for endoleak, fixation, or flow-limiting issues. The 30-day mortality rate was 1.2%, and the perioperative morbidity rate was 6.6%. Intraoperative type I and II endoleaks were uncommon (2.3% and 9.3%, respectively). Life-table analysis at 5 years demonstrated excellent overall survival (66%) and freedom from ARM (97%). Postoperative endoleak was seen in 30% of patients and was associated with an increase in sac size over time. Finally, the total reintervention rate was 15%, including 91 instances (5%) of revisional EVAR. The overall major adverse event rate was 7.9% and decreased significantly from 12.3% in the first 5 years to 5.6% in the second 5 years of the study period (P < .001). Overall ARM was worse in patients with postoperative endoleak (4.1% vs 1.8%; P < .01) or in those who underwent reintervention (7.6% vs 1.6%; P < .001). Conclusions Results from a contemporary EVAR registry in an integrated health care system demonstrate favorable perioperative outcomes and excellent clinical efficacy. However, postoperative endoleak and the need for reintervention continue to be challenging problems for patients after EVAR. (J Vasc Surg 2013;58:324–32.)

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Section: Discussionmentioning

confidence: 87%

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry

Chang

Goodney

Tucker

et al. 2013

Journal of Vascular Surgery

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“…A total of 29 papers were read in full. Eighteen studies were excluded for the following reasons: two were meta‐analyses, two were RCTs with fewer than 200 patients, six non‐randomized studies had fewer than 2000 patients, one study investigated challenging aortic necks, one investigated aortoiliac aneurysms, two investigated high‐risk patients, one was a prospective non‐randomized trial with fewer than 2000 patients, one was a systematic review, one included only patients aged more than 80 years, and one excluded patients aged over 60 years ( Fig . ).…”

Section: Resultsmentioning

confidence: 99%

Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm

Stather

Sidloff

Dattani

et al. 2013

British Journal of Surgery

305

127

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Background: Any possible long-term benefit from endovascular (EVAR) versus open surgical repair for abdominal aortic aneurysm (AAA) remains unproven. Long-term data from the Open Versus Endovascular Repair (OVER) trial add to the debate regarding long-term all-cause and aneurysm-related mortality. The aim of this study was to investigate 30-day and long-term mortality, reintervention, rupture and morbidity after EVAR and open repair for AAA in a systematic review.Methods: Standard PRISMA guidelines were followed. Random-effects Mantel-Haenszel meta-analysis was performed to evaluate mortality and morbidity outcomes. Results: The existing published randomized trials, together with information from Medicare and SwedVasc databases, were included in a meta-analysis. This included 25 078 patients undergoing EVAR and 27 142 undergoing open repair for AAA. Patients who had EVAR had a significantly lower 30-day or in-hospital mortality rate (1·3 per cent versus 4·7 per cent for open repair; odds ratio (OR) 0·36, 95 per cent confidence interval 0·21 to 0·61; P < 0·001). By 2-year follow-up there was no difference in all-cause mortality (14·3 versus 15·2 per cent; OR 0·87, 0·72 to 1·06; P = 0·17), which was maintained after at least 4 years of follow-up (34·7 versus 33·8 per cent; OR 1·11, 0·91 to 1·35; P = 0·30). There was no significant difference in aneurysm-related mortality by 2 years or longer follow-up. A significantly higher proportion of patients undergoing EVAR required reintervention (P = 0·003) and suffered aneurysm rupture (P < 0·001). Conclusion:There is no long-term survival benefit for patients who have EVAR compared with open repair for AAA. There are also significantly higher risks of reintervention and aneurysm rupture after EVAR. The aim of this systematic review and meta-analysis was to investigate short-, medium-and long-term outcomes, including morbidity, reintervention and mortality, associated with EVAR and open aneurysm repair. MethodsStandard reporting guidelines set by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Group 7 were followed to identify RCTs and other high-level evidence reporting comparative outcomes of endovascular and open repair of AAA. Study titles and abstracts were searched using MEDLINE, Embase, and Health and Psychosocial Instruments databases, using Ovid Online (version: OvidSP_UI03.04.02.112) in July 2012, with the most recent search carried out on 31 December 2012, separately by two researchers. No language restrictions or filters used to restrict study designs were applied. Reference lists were searched for further studies to be included. Eligibility criteria and study selectionA comprehensive literature search was performed using the search terms 'endovascular AND open AND repair AND abdominal AND aortic AND aneurysm' AND 'randomised OR randomized' AND 'trial' NOT 'thoracic'. Two reviewers individually reviewed potential studies according to a set of eligibility criteria, with discussion of discrepancies. Inclusion criteria were that t...

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“…13–16 . Moreover, it has been shown that a substantial proportion of AAA patients later require non-aortic vascular surgery, 17 which will likely increase as life expectancy is improving. By sparing a second operation, total morbidity, hospitalization and costs may decline.…”

Section: Introductionmentioning

confidence: 99%

The impact of concomitant procedures during endovascular abdominal aortic aneurysm repair on perioperative outcomes

Ultee

Zettervall

Soden

et al. 2016

Journal of Vascular Surgery

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Introduction Concomitant procedures during endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) are performed to either facilitate endograft delivery, simultaneously treat unrelated conditions, or to resolve intraoperative pitfalls. The frequency and perioperative impact of these procedures are not well described. This study aims to assess the frequency and perioperative impact of various concomitant procedures performed at the time of EVAR Methods We included all elective EVARs in the Vascular Study Group of New England between January 2003 and November 2014, and identified those with and those without concomitant procedures. Multivariable logistic regression analysis was used to establish the independent association between concomitant procedures and perioperative outcomes. Results 4033 patients were included in the study, with 1168 (29.0%) patients undergoing one or more additional procedure. Independent risk factors for 30-day mortality were concomitant femoral endarterectomy (OR: 4.8, 95% CI: 2.1–11.2) and renal angioplasty or stenting (3.1, 1.2–8.3). Postoperative bowel ischemia was associated with hypogastric embolization (3.8, 1.1–13.4) and iliac angioplasty or stenting (3.5, 1.3–9.6). Leg ischemia was associated with unplanned graft extension (2.3, 1.02–5.0), other artery reconstruction (5.2, 1.8–15.1), thrombo-embolectomy (5.2, 1.3–20.8), and repair of arterial injury (4.6, 1.2–18.3). Risk factors for deterioration of renal function were ilio-femoral bypass (3.9, 1.3–12.2), other artery reconstruction (2.7, 1.3–5.8), renal angioplasty or stenting (2.5, 1.3–4.6), and repair of arterial injury (4.5, 1.6–12.2). Myocardial infarction was associated with femoro-femoral bypass (3.9, 1.7–8.7), other artery reconstruction (3.9, 1.6–9.2) and repair of arterial injury (6.1, 1.8–21.0). Wound complications were predicted by femoro-femoral bypass (13.4, 5.8–31.1). Conclusions Concomitant procedures during EVAR are associated with increased postoperative morbidity and mortality. The need for performing concomitant procedures should be carefully considered. The morbidity associated with intraoperative complications highlights the importance of avoidance of arterial injury and thrombo-embolic events where possible.

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Long-term single institution comparison of endovascular aneurysm repair and open aortic aneurysm repair

Abstract: EVAR requires more late secondary vascular interventions than open AAA repair, but patients who undergo open repair have more nonvascular long-term morbidity. Long-term survival is better after EVAR compared to open repair in this selected patient group.

Cited by 30 publications

References 17 publications

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry

Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm

The impact of concomitant procedures during endovascular abdominal aortic aneurysm repair on perioperative outcomes

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