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

Abstract

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...

Targets to prevent prolonged length of stay after endovascular aortic repair

“…13-18 These patients were unable to perform any physical activity without discomfort and had symptoms of cardiac insufficiency at rest. Because many of these patients receive ACE-I medications as a cornerstone of medical therapy for CHF, seeing the statistical association between preoperative ACE-I and prolonged LOS is not surprising.…”

“…We were not surprised to see that patients requiring hypogastric artery coiling stayed longer, regardless of when the procedure was performed, because this is a marker of AAA complexity. 18 …”

“…This confirms what has been demonstrated in most studies. 13-18 Patients with larger AAAs remained hospitalized longer and are known to have higher complication rates. 13,18 …”

Estimating overdiagnosis in screening for abdominal aortic aneurysm: could a change in smoking habits and lowered aortic diameter tip the balance of screening towards harm?

“…33 The complication rate is about 32% 33 with a 30 day mortality of 4.7% for open repair. 3 Endovascular techniques reduce 30 day mortality to 1.3% 3 but have more long term complications; mortality is similar to that for open surgery after two years. 3 In the two randomised trials that provided data on rupture rate, for every 10 000 men enrolled, 94 more men in the screened group had preventive surgery than in the control group over 13-15 years.…”

“…3 Endovascular techniques reduce 30 day mortality to 1.3% 3 but have more long term complications; mortality is similar to that for open surgery after two years. 3 In the two randomised trials that provided data on rupture rate, for every 10 000 men enrolled, 94 more men in the screened group had preventive surgery than in the control group over 13-15 years. 8 10 Based on the rate of morbidity and mortality from AAA in the control group we estimate that had these 94 men not had surgery 57 would have had a ruptured aneurysm, of whom 44 would have died.…”