A Cochrane review[Abstract] 1 included 5 studies with a total of 3 194 subjects. Four studies (n=2 790) compared endovascular aneurysm repair (EVAR) with open surgical repair (OSR) and one study (n = 404) compared endovascular aneurysm repair (EVAR) with no intervention in subjects considered unfit for OSR.
In individuals considered fit for surgery short-term mortality with EVAR was significantly lower than with OSR (table T1). Using intention-to-treat analysis (ITT) there was no significant difference in mortality at intermediate follow-up. There was also no significant difference in long-term mortality. Similarly, there was no significant difference in aneurysm-related mortality between groups, either at the intermediate- or long-term follow up. The long-term reintervention rate was significantly higher in the EVAR group than in the OSR group. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between the EVAR and OSR groups. However, there was a slightly higher incidence of pulmonary complications in the OSR group compared with the EVAR group (OR 0.36, 95% CI 0.17 to 0.75; 2 studies, n=650).
| Outcome | OR (95% CI) | EVAR | OSR | Participants (studies) |
|---|---|---|---|---|
| * including 30-day or inhospital mortality, excluding deaths prior to intervention | ||||
| Short-term mortality* | 0.33 (0.20 to 0.55) | 1.4% | 4.2% | 2 723 (4 studies) |
| Intermediate-term mortality (up to 4 years) | 0.92 (0.75 to 1.12) | 15.8% | 17% | 2 783 (4 studies) |
| Long-term mortality (beyond 4 years) | 0.98 (0.83 to 1.15) | 37.3% | 37.8% | 2 484 (3 studies) |
| Long-term reintervention rate | 1.98 (1.12 to 3.51), statistical heterogeneity I2 = 85% | 23.4% | 13.1% | 2 484 (3 studies) |
In individuals considered unfit for conventional OSR, the one included trial found no difference between the EVAR and no-intervention groups with regard to all-cause mortality at final follow up, with 21.0 deaths per 100 person-years in the EVAR group and 22.1 deaths per 100 person years in the no-intervention group (adjusted HR with EVAR 0.99, 95% CI 0.78 to 1.27). Aneurysm-related deaths were, however, significantly higher in the no-intervention group than in the EVAR group (adjusted HR 0.53, 95% CI 0.32 to 0.89).
A systematic review 2 incuding 7 studies was abstracted in DARE. 4 studies compared open repair with endovascular elective repair of large (mean diameter 5.2 to 6.5 cm) abdominal aortic aneurysms (AAAs) in patients who were candidates for both procedures (n=1532). Endovascular treatment was associated with lower 30-day post-operative all-cause mortality (1.6% vs. 4.8%; RR 0.33, 95% CI 0.17 to 0.64) and mid-term (up to 4 years) AAA-related mortality (RR 0.53, 95% CI 0.31 to 0.92), while the mid-term all-cause mortality was comparable (RR 0.95, 95% CI 0.76 to 1.19). There was no statistical heterogeneity for any of these outcomes. These findings were unchanged after correcting for age, AAA diameter, renal function and gender. Endovascular repair seemed to shorten the period of hospitalisation (pooled weighted median 6.2 days versus 11.5 days), but increases in the rate of re-interventions (2-3 times as many patients in the endovascular repair group as in the open repair group required reintervention) and adverse events were reported. The endovascular approach also seemed to improve short-term quality of life whereas no differences were found after 1 to 3 months. The authors state that endovascular repair requires periodic imaging for the remainder of the patient's life.
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