Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm

Abstract

Background: Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken.Methods: A systematic review was performed according to PRISMA guidelines. Articles reporting shortand/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival.Results: Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1⋅16 (95 per cent c.i. 0⋅92 to 1⋅39) versus 3⋅27 (2⋅71 to 3⋅83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1⋅01, 1⋅00 and 0⋅98 for 3, 5 and 10 years respectively; P = 0⋅721, P = 0⋅912 and P = 0⋅777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0⋅94, 0⋅91 and 0⋅76 at 3, 5 and 10 years for EVAR, and 0⋅96, 0⋅91 and 0⋅76 respectively for OSR.Conclusion: Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups. Literature search and inclusion criteriaA systematic review of the literature between 1991 and 2018 was undertaken according to PRISMA guidelines 6 . Studies were identified using PubMed, Embase, Web of Science and Cochrane databases. Eligible studies included patients with an intact AAA treated by either EVAR or OSR. Studies that did not compare Publication biasFunnel plots for 30-day and 5-year survival did not show considerable asymmetry (Fig. S2, supporting information).

Long‐term survival following successful abdominal aortic aneurysm repair evaluated using Australian administrative data

“…The administrative data used in in this study provide an alternative perspective of LTS and compare newer techniques of AAA repair with traditional surgical approaches. The calculated LTS using these clinical data are similar to those presented in previous commentaries . However, limitations are recognized in this study that relate to both the use of administrative data in general and the characteristics of the data set used.…”

“…Relative survival as described by Bulder et al . was used to compare AAA‐treated groups and matched controls and contrast outcomes between the first and second periods of this study …”

“…Operations performed for the repair of abdominal aortic aneurysm (AAA) are potentially life‐saving, yet long‐term survival (LTS) following open and endovascular AAA repair (EVAR) is unclear . Studies assessing LTS often focus on comparisons between elective open and endovascular procedures or treated and control populations . However, the higher perioperative mortality associated with open repair can confound both LTS analysis and comparisons of techniques .…”

“…Administrative data are becoming recognized as a useful source of data for the assessment of outcome in a range of surgical domains including vascular surgery . Selection and reporting predispositions are considered lessened and the extent of the data often provides satisfactory longitudinal follow‐up .…”

“…1,2 Studies assessing LTS often focus on comparisons between elective open and endovascular procedures or treated and control populations. [1][2][3][4] However, the higher perioperative mortality associated with open repair can confound both LTS analysis and comparisons of techniques. 1 Englund and Katib reporting the LTS of a personal series of AAA repairs from Australia controlled for this variable and included only those individuals who survived the initial post-operative period.…”