A Metanalysis on the Long Term Outcomes A Metanalysis on the Long Term Outcomes Comparing Comparing

Endovascular Repair Versus Open Repair Endovascular Repair Versus Open Repair of an Abdominal Aortic Aneurysmof an Abdominal Aortic Aneurysm

JOSHUA M. CAMOMOT, M.D.Perpetual Succour Hospital -Cebu Heart Institute

INTRODUCTION

ABDOMINAL AORTIC ANEURYSMS (AAAs)

• an increase in size of the abdominal aorta to more than 3.0 cm in diameter

• MC: infrarenal aorta

• overall incidence of AAAs appears to have increased steadily over the past several decades; incidence strongly associates with age

• men 5x > women• strongly associate with cigarette smoking

Braunwald’s 9th Ed

• gradually expand (0.3 to 0.5 cm/year) eventually

RUPTURE

• risk of AAA rupture is closely correlated with aneurysm size; 5-year risk of rupture

• 5%: 3.0 to 4.0 cm • 10% to 20% : 4.0 to 5.5 cm• 30% to 40%: 5.5 to 6.0 cm• > 80%: > 7.0 cm

Estimates..

• 30% to 50% die before reaching a hospital

• 30% to 40% die after reaching a hospital but before operative treatment

• operative mortality rate after rupture is 40% to 50%.

Chaikof EL, Brewster DC, Dalman RL, et al: The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines.  J Vasc

Surg  2009; 50(Suppl):S2

1951 1986 1991

Minimally invasive surgery

Open repair Endovascular repair(Parodii, et al)

2006

EVAR > Open repair

Parodi JC,. Ann Vasc Surg 1991;5:491-9.Schwarze ML, et alJ Vasc Surg. 2009;50:722.e2–729.e2.

EVOLUTION OF ANEURYSM REPAIR..

EVAR• in hospital and 30 day mortality 1-1.7%

•Midterm outcomes• equal mortality risk with open repair • increased risk of reintervention

Open Repair• in hospital and 30 day mortality 6%

• midterm outcomes• equal mortality risk with EVAR• lower risk of reintervention

RESEARCH QUESTION

Is endovascular repair at par with open repair in terms of long term all cause mortality and reintervention in patients with abdominal aortic aneurysms?

OBJECTIVES• To determine the long term outcomes of endovascular repair versus open repair in patients with abdominal aortic aneurysm.

SPECIFIC OBJECTIVES:

• To determine the outcomes at least 3 years after endovascular repair versus open repair in patients with abdominal aortic aneurysm based on:

1. All cause mortality2. Rate of reintervention

METHODOLOGYSEARCH STRATEGY:

Literature search was done through PUBMED, Highwire press, and Clinicaltrials.gov with the following keywords:

• abdominal aortic anuerysm• endovascular repair• long term outcomes• randomized clinical trials

ELIGIBILITY CRITERIA

• clinical trials which randomized patients with non ruptured abdominal aortic aneurysm of at least 5cm in diameter that were suitable to either endovascular or open repair

• study outcomes including all cause mortality and rate of reintervention

• follow up period of at least 3 years

EXCLUSION CRITERIA

• studies dealing with ruptured abdominal aortic aneuryms

• non RCTs

• follow up period of less than 3 years

RESULTS

Trial Study duration

Date published

Population EVAR Open Repair

Becquemin

(ACE)

2003 - 2008 2011 299 150 149

De Bruin

(DREAM)

2000 - 2009 2010 351 173 178

UK EVAR team

(EVAR)

1999 - 2009 2010 1252 626 626

TOTAL 1902 949 953

STUDY CHARACTERISTICS

Trial EndpointRisk Risk Difference

[95% CI] pEVAR group(x/n)

Open repair group(x/n)

Becquemen, et al

2011 Death

11.3%

17/150

8.05%

12/149

0.03

[-0.03; 0.10]

de Bruin et al 2010 Death33.5%

58/173

33.7%

60/178

0.00

[-0.10; 0.10]

UK EVAR Team,

2010 Death

41.5%

260/626

42.2%

264/626

-0.01

[-0.06; 0.05]

35.30%

335/949

35.26%

336/953

0.01

[0.03; 0.05]0.703

heterogeneity: 0.660

Table 2. Death and all cause mortality in the EVAR and open repair group

Figure 1. Risk difference and confidence intervals for the outcome of death and all cause mortality between EVAR and open repair

Favor open repairFavor EVAR

Trial Endpoint

RiskRisk Difference

[95% CI] pEVAR group(x/n)

Open Repair group(x/n)

Becquemen, et al 2011 reintervention16.0%

24/150

2.68%

4/149

0.13

[0.07; 0.20]

de Bruin, et al 2010 reintervention27.7%

48/173

16.9%

30/178

0.11

[0.02; 0.20]

UK EVAR team, et al

2010 reintervention

23.2%

145/626

8.79%

55/626

0.14

[0.10; 0.18]

22.87%

217/949

9.33%

89/953

0.14

[0.11; 0.17]<0.001

heterogeneity: 0.767

Table 3. Reintervention in the EVAR group and open repair group

Figure 2. Risk difference and confidence intervals for the outcome of reintervention after EVAR and open repair

Favor open repair

DISCUSSION

ALL CAUSE MORTALITY

• EVAR 1, DREAM , ACE• no differences were seen in total mortality between the treatment groups (35%)

• most common causes all of mortality• EVAR 1: ischemic heart disease • DREAM: cardiovascular causes (MI, stroke)• ACE: not stated

• Aneurysm related mortality (EVAR1, ACE)• overall risk is low (EVAR 2% – 4% vs open repair 0.4% - 0.6%)• most commonly from graft rupture

REINTERVENTION

• more reinterventions in the EVAR group compared with the open repair group

• Most common causes of reintervention (DREAM,ACE)• Open repair: incisional hernia repairs• EVAR: endoleaks, thrombo occlusive disease

• reinterventions (due to graft occlusions) following endovascular repair shows a trend towards increased aneurysm related mortality (DREAM, ACE)

CONCLUSION

endovascular and open repair of abdominal aortic aneurysm resulted in similar risk of long term survival.

risk of secondary interventions was significantly higher after endovascular repair.

IMPLICATIONS• In our local clinical setting, open repair would still be the more practical choice because

• long term mortality are not significantly different • more experience with open repair• technology and expertise – EVAR is worth trying

• Reintervention• long- term disadvantage in overall survival?? risks associated with reintervention need to be assessed in larger studies

•