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A Metanalysis on the Long Term Outcomes Comparing Endovascular Repair Versus Open Repair of an Abdominal Aortic Aneurysm. JOSHUA M. CAMOMOT, M.D. Perpetual Succour Hospital -Cebu Heart Institute. INTRODUCTION. ABDOMINAL AORTIC ANEURYSMS (AAAs)

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slide1

A Metanalysis on the Long Term Outcomes Comparing

Endovascular Repair Versus Open Repair

of an Abdominal Aortic Aneurysm

JOSHUA M. CAMOMOT, M.D.

Perpetual Succour Hospital -Cebu Heart Institute

introduction
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

slide3

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%.
  • 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

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

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EVOLUTION OF ANEURYSM REPAIR..

1951

1986

1991

2006

EVAR > Open repair

Minimally invasive surgery

Endovascular repair

(Parodii, et al)

Open repair

Parodi JC,. Ann VascSurg 1991;5:491-9.

Schwarze ML, et alJVasc Surg. 2009;50:722.e2–729.e2.

slide5

Open Repair

  • in hospital and 30 day mortality
  • 6%
  • midterm outcomes
    • equal mortality risk with
    • EVAR
    • lower risk of reintervention
  • EVAR
  • in hospital and 30 day mortality
  • 1-1.7%
  • Midterm outcomes
    • equal mortality risk with
    • open repair
    • increased risk of
    • reintervention
research question
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
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:
    • All cause mortality
    • Rate of reintervention
methodology
METHODOLOGY
  • SEARCH 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
slide9

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
RESULTS

STUDY CHARACTERISTICS

slide12

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

Favor open repair

Favor EVAR

slide14

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

Favor open repair

discussion
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
slide16

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
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
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
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