Meta-analysis confirms lower mortality with EVAR up to two years with convergence in the long term

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A meta-analysis of randomised trials involving 2,899 patients has concluded that endovascular repair of abdominal aortic aneurysms yields lower perioperative, short- and intermiate-term mortality, but long-term survival converges between the EVAR and open repair groups. The analysis has also confirmed that endovascular repair was associated with higher re-intervention rates.

The meta-analysis was led by George Dangas and published in the October 2012 issue of the Journal of the American College of Cardiology. “Endovascular stent graft placement for abdominal aortic aneurysm has gained broad acceptance as an alternative to open surgical repair due to a lower perioperative morbidity and mortality. The intermediate- and long-term all-cause and aneurysm-related mortality vary among studies. Thus, we sought to perform a meta-analysis of open versus endovascular repair for treating abdominal aortic aneurysm,” the authors wrote.

In the study, which sought to evaluate the short-, intermediate-, and longer-term outcomes after EVAR versus open repair, including both aneurysm-related and all-cause mortality, electronic databases were queried for identification of prospective, randomised trials of open surgery versus endovascular stent graft repair of abdominal aortic aneurysm. A total of 10 published papers reporting on six studies (EVAR 1, DREAM, OVER, ACE, Lottman, Soulez) at different follow-up intervals were identified; they involved 2,899 patients with abdominal aortic aneurysm repair procedures, of whom, 1,470 underwent EVAR and 1,429 were treated by open repair.

At 30 days, the pooled relative risk of all-cause mortality was lower in the EVAR group than in the open surgery group (14 vs. 55, p=0.0006). At intermediate follow-up, the all-cause mortality had a non-significant difference (84 vs. 110, p=0.14), the aneurysm-related mortality was significantly lower (23 vs. 51, p=0.002) and re-intervention rates were higher (142 vs. 91, p=0.02) in the EVAR group than in the open surgery group.

At long-term follow-up, there was no significant difference in all-cause mortality (234 vs. 238, p=0.87) or aneurysm-related mortality (32 vs. 39, p=0.67), whereas the significant difference in the rate of re-interventions persisted, with 197 events in the EVAR group and 81 in the open repair group (p=0.0001).

The authors concluded that, “in patients randomised to open or endovascular abdominal aortic aneurysm repair, all-cause perioperative mortality, as well as aneurysm-related mortality at short- and intermediate-term follow-up are lower in patients undergoing endovascular stent graft placement. This was associated with greater reintervention in the endovascular group noted at intermediate follow-up. Long-term survival appears to converge between the two groups.”

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