Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over

15 Pages·2013·3.04 MB·English

REVIEW ARTICLE
Richard P. Cambria, MD, Section Editor
Endovascular repair for ruptured abdominal aortic
fi
aneurysm confers an early survival bene t over open
repair
GeorgeA. Antoniou, MD,PhD,a,bGeorgeS.Georgiadis, MD,PhD,bStavros A. Antoniou, MD,c
PolyviosPavlidis, MD,aDimitrios Maras, MD,aGeorge S.Sfyroeras, MD,PhD, FEBVS,d
EfstratiosI.Georgakarakos,MD,PhD,bandMiltosK.Lazarides,MD,FEBVS,bAthens,Alexandroupolis,and
Crete,Greece
Background: Despite the intuitive advantages of endovascular repair (EVAR) of ruptured abdominal aortic aneurysms
(AAAs), uncertainty remains about the optimal management in the absence of convincing high-quality evidence. Our
objectivewastoundertakeacomprehensiveliteraturereviewandperformameta-analysisofoutcomedataoftreatment
modalitiesforrupturedAAAs.
Methods:Systematicsearcheswereconductedofelectronicinformationsourcestoidentifystudiescomparingperioperative
outcomesofEVARandopenrepairforAAArupture.Summaryestimatesofoddsratios(ORs)orstandardizedmean
differenceand95%confidenceintervals(CIs)wereobtainedwitharandom-effectsmodel.Meta-regressionmodelswere
formedtoexplorepotentialheterogeneityasaresultofchangesinpracticeovertime.
Results:Weselected41studiesforanalysis.Theentiremeta-analysispopulationcomprised59,941patients(8201EVAR
patients and 51,740 open repair patients). EVAR was associated with a significantly lower incidence of in-hospital
mortality(OR,0.56;95%CI,0.50-0.64;P<.01;meta-analysisofrisk-adjustedobservationalstudiesandrandomized
controlledtrials:OR,0.58;95%CI,0.46-0.73;P<.01).EVARpatientshadasignificantlydecreasedriskofdeveloping
respiratorycomplications(OR,0.59;95%CI,0.49-0.69;P<.01)andacuterenalfailure(OR,0.65;95%CI,0.55-0.78;
P<.01)andatrendtowardareducedincidenceofcardiaccomplications(OR,L0.02;95%CI,L0.03to0.00;P[.05)
and mesenteric ischemia (OR, 0.66; 95% CI, 0.44-1.00; P [ .05). Patients treated with EVAR had significantly
lessrequirementsofintraoperativebloodtransfusion(standardizedmeandifference,L0.88;95%CI,L1.06toL0.70;
P < .01). Random-effects meta-regression revealed no statistical evidence for an association between death and year
ofpublication(P[.19).
Conclusions:OuranalysisprovidesevidencetomotivatetheadoptionofanEVAR-firstpolicyinanonelectivesettingand
theestablishmentofstandardizedprotocolsforthemanagementrupturedAAAs.(JVascSurg2013;58:1091-105.)
A plethora of cohort studies, randomized trials, and data,modelsofservicedeliveryhaveundergonereconfigu-
meta-analyses have provided sufficient evidence demon- ration in several countries to accommodate optimum
stratinganearlysurvivaladvantageofelectiveendovascular electiveAAAservices.3Inrecentyears,considerablespecu-
treatment for abdominal aortic aneurysms (AAAs) over lation about the relative merits of applying endovascular
conventional surgical repair.1,2 On the basis of outcome techniquesforthetreatmentofrupturedAAAhasbeenre-
flected in the establishment of standardized protocols for
themanagementofthiscriticalconditionintheemergency
FromtheDepartmentofVascularSurgery,HellenicRedCrossHospital, settingby severalinstitutions.
Athensa;theDepartmentofVascularandEndovascularSurgery,Univer- Despitetheintuitiveadvantagesofendovascularaneu-
sity Hospital of Alexandroupolis, Democritus University of Thrace,
Alexandroupolisb; the Department of Surgery, University Hospital of rysm repair (EVAR) related to less physiologic insult to
Heraklion,UniversityofCrete,Cretec;andtheDepartmentofVascular acriticallyillpatientpresentingwithrupturedAAA,insuf-
Surgery,AttikonUniversityHospital,AthensUniversityMedicalSchool, ficient quantification of the role of EVAR in the care
Athens.d pathway for these patients exists. Single-center cohort,
Authorconflictofinterest:none.
multicenter cohort, and population-based studies have
Reprintrequests:GeorgeA.Antoniou,MD,PhD,Souniou11,19001Ker-
revealed a trend toward a survival benefit of emergency
atea,Greece(e-mail:[email protected]).
Theeditorsandreviewersofthisarticlehavenorelevantfinancialrelationships EVAR for ruptured AAA.4,5 Our objective was to under-
todisclosepertheJVSpolicythatrequiresreviewerstodeclinereviewofany takeacomprehensiveliteraturereviewanddefinetheeffect
manuscriptforwhichtheymayhaveaconflictofinterest. ofEVARonthemanagementofAAArupturebyconduct-
0741-5214/$36.00
Copyright(cid:1)2013bytheSocietyforVascularSurgery. ingananalysisoftheperioperativeoutcomesofsuchtreat-
http://dx.doi.org/10.1016/j.jvs.2013.07.109 mentcomparedwith conventional surgicalrepair.
1091
JOURNALOFVASCULARSURGERY
1092 Antoniou et al October2013
METHODS other reviewers. A data extraction sheet (based on the
Cochrane Consumers and Communication Review
Eligibilitycriteria. Themethodsofanalysisandinclu-
sion criteria were prespecified in a protocol. Studies Group’s data extraction template) was pilot-tested on the
three most recent studies and refined accordingly. Infor-
comparing perioperative outcomes of endovascular and
mationextractedfromeachstudycanbegroupedinto(1)
open repair ofruptured infrarenalor juxtarenal AAA were
that related to the study design and characteristics (first
considered for analysis. All types of comparative studies,
author, year of publication, patient recruitment period,
includingprospectiveorretrospective,observationalstudies,
type of study, and inclusion/exclusion criteria for patient
or randomized controlled trials (RCTs) were included.
Studies not specifically defining ruptured AAA were arbi- enrollment); (2) data related to clinical and demographic
trarily presumed to have confirmed the presence of AAA characteristicsofthestudypopulations,includingage,sex,
presenceofhypertension,coronaryarterydisease,diabetes
rupture on preoperative computed tomography imaging,
mellitus, chronic obstructive pulmonary disease (COPD),
byvisualizationofbloodoutsidetheaorticlumenintothe
chronic renal insufficiency, and hemodynamic instability;
retroperitonealspaceortheperitonealcavity(containedor
and(3) outcomeparameters, asoutlinedabove.
free rupture), or intraoperatively during on-table angiog-
The methodologic quality of the included observa-
raphyorlaparotomy.Studiesreportingpatientswithacute
tional studies was ascertained with the Newcastle-Ottawa
orsymptomaticaneurysmwithoutclearlystatingthepres-
scale (NOS),7 and the Jadad scale was applied for the
enceofrupturewereexcluded.
assessment of RCTs. This assessment tool evaluates three
Types of interventions included conventional endo-
mainmethodologicelementsofcase-controlstudies:selec-
aneurysmorrhaphy with tube or bifurcated grafts through
tion methods (adequate case definition, representativeness
atransperitonealorretroperitonealapproachandstandard
of the cases, appropriate selection, and definition of
EVAR with bifurcated grafts or an aortouniiliac device,
controls), comparability of cases and controls on the basis
followed by femorofemoral crossover bypass. Studies
ofthedesignoranalysis,andassessmentofexposure(ascer-
describing endovascular treatments of complex aneurysms
tainment of exposure, nonresponse rate). The scale uses
with the chimney technique or with fenestrated or
a star system, with a maximum of nine stars; studies
branched grafts werenotconsidered.
The primary outcome measure was defined as the in- achieving$6starswereconsideredtobeofhigherquality.
Individualstudyoddsratios(ORs)and95%confidence
hospital or 30-day mortality of any cause. Secondary
intervals (CIs) were calculated from event numbers
outcomeendpointswerecommonperioperativecomplica-
extractedfromeachstudybeforedatapooling.Incalcula-
tions (cardiac and respiratory complications, acute renal
tion of the OR, the total number of patients assigned in
impairment, mesenteric and lower limb ischemia, and
each group was used as the denominator. Summary esti-
development of abdominal compartment syndrome),
matesofORswereobtainedwitharandomeffectsmodel.
requirementsforintraoperative blood transfusion,and the
Forcontinuousvariables,thestandardizedmeandifference
hospitallengthof stay.
or difference in means and corresponding 95% CI were
Information sources and search strategy. Studies
were identified by searching electronic bibliographic data- computedusingtherandom-effectsmodel.Thepercentage
of variability across studies attributable to heterogeneity
bases and scanning reference lists of articles. The search
wasappliedtoMEDLINEfromthetimeofthefirstreport beyondchancewasestimatedwiththeI2statistic.Potential
ofendovasculartreatmentofrupturedAAAbyYusufetal6 publicationbiaswasassessedwiththeEggertestandrepre-
sentedgraphicallywithBeggfunnelplotsofthenaturallog
in 1994 to the present date. Unfortunately, language
oftheOR vsitsstandard error.8
constraints were applied because of lack of funding for
Sensitivityanalyseswereperformedtoassessthecontri-
translation; thus, only English and German language arti-
bution of each study to the pooled estimate by excluding
cles wereconsidered.
individual studies one at a time and recalculating the
The following Expanded Medical Subject Headings
pooled OR estimates for the remaining studies. Separate
(MeSH)andkeywordswerecombinedwithBooleanoper-
ators: “aortic rupture” or “aortic aneurysm rupture” or meta-analyses of risk-adjusted observational studies for in-
“rupturedaorticaneurysm”and“EVAR”or“endovascular hospital(or30-day)mortalityandRCTswereundertaken.
repair” or “open repair.” Relevant articles were retrieved, Acceptable risk-adjustment methods included propensity
score analyses and multivariate logistic regression models.
and the reference lists were manually interrogated as part
We explored potential heterogeneity in estimates with
ofasecond-levelsearch.Asupplementarysearchofrelated
univariate meta-regression to identify trends in the treat-
articles suggested by the PubMed search engine was con-
menteffects overtimeandby comparing summaryresults
ducted. The literature search protocol and retrieval of the
obtained from subsets of studies grouped by study design
full text of related articles was conducted in cooperation
and quality. A two-sided P value of < .05 was regarded
withalibrarianattheUniversityofAthens.Thelastsearch
as significant for all analyses. Analyses were performed
was onMay 6, 2013.
using the Review Manager 5.2 software (The Nordic
Methods of data synthesis and analysis. Eligibility
CochraneCentre,TheCochraneCollaboration,Copenha-
assessment and data collection was performed by a single
gen,Denmark)andtheComprehensiveMeta-Analysis2.0
reviewer in consultation with and cross-checked by two
JOURNALOFVASCULARSURGERY
Volume58,Number4 Antoniou et al 1093
Fig1. Flowchartshowsthestrategyusedfortheliteraturesearch.AAA,Abdominalaorticaneurysm.
software(Biostat,Englewood,NJ).Thismeta-analysiswas achievedaNOSscore>6(nineof39studies).Maindemo-
done in accordance with the Preferred Reporting Items graphic and clinical features of the study populations are
for Systematic Reviews and Meta-Analyses (PRISMA) outlined in Table II. The perioperative complications
guidelines.9 were ill-defined and inconsistently reported among the
studies(TableIII).
RESULTS
Synthesis ofresults andoutcome
Literaturesearchresultsandstudycharacteristics.
Thesearchoftheelectronicbibliographicdatabasesidenti- In-hospitalmortality. All41studiesreporteddataof
fied 5089 records, of which 44 were reviewed in full text. the primary outcome parameter set for the meta-analysis.
Studies reporting mixed outcome data of treatments in In-hospital mortality occurred in 30% of patients treated
symptomaticandrupturedAAA,thosecontainingoverlap- with EVAR and in 42% of the patients who underwent
ping populations, studies not in English or German, and open repair (OR, 0.56; 95% CI, 0.50-0.64; P < .01).
thosereportinginadequatedataforanalysiswereexcluded, Significantheterogeneity amongthestudieswasidentified
leaving32potentiallyeligiblestudies.Inonestudy,incon- (I2¼36%),andthelikelihoodofpublicationbiaswaslow
sistency between values in the abstract and main text was (P¼ .11; Fig 2).
noticed; therefore, we decided not to include it in our Cardiac complications. Twenty studies reported
analysis. An additional 10 studies were identified during cardiaccomplications.Theincidenceofsuchcomplications
scrutiny of the bibliographies of the included articles, was 14% in the EVAR group and 16% in the open repair
providing 41 studies for meta-analysis.10-50 Fig 1 shows group (OR, (cid:2)0.02; 95% CI, (cid:2)0.03 to 0.00; P ¼ .05).
theflow diagram ofstudyselection. Nosignificantheterogeneitywasfoundamongthestudies
Theentiremeta-analysispopulationcomprised59,941 (I2¼28%),andthepossibilityofpublicationbiaswaslow
patients, 8201 of whom underwent EVAR and the re- (P¼ .76; Fig 3).
maining 51,740 had an open repair of their ruptured Respiratorycomplications. Dataregardingperioper-
AAA. The studies selected for analysis were published ative respiratory complications were reported in 19
between 2002 and 2013, whereas the patient recruitment studies. Patients undergoing EVAR had a significantly
period extended from 1990 to 2011. Two RCTs were decreased risk of developing a respiratory complication
identified, with the remaining reports being single-center compared with patients treated with open repair (6% vs
or multicenter prospective or retrospective observational 11%; OR, 0.59; 95% CI, 0.49-0.69;P <.01). No signif-
studiesorpopulation-basedreports.Thestudycharacteris- icantheterogeneityamongthestudiesexisted(I2¼22%),
tics and inclusion and exclusion criteria for patient enroll- and the chance of publication bias was low (P ¼ .27;
ment are presented in Table I. The methodologic quality Fig 3).
oftheRCTs,representedintheJadadscore,waslow.Simi- Acuterenalfailure. Eightstudiesreportedincidences
larly, a small proportion of the observational studies ofacuterenalimpairmentduringtheperioperativeperiod.
JOURNALOFVASCULARSURGERY
1094 Antoniou et al October2013
Table I. Studycharacteristics
Firstauthor/year Studyperiod Typeofstudy Totalpatients(No.) EVAR Openrepair
Park/2013 2005-2009 Population-basedretrospectivestudy 16,557 3796 12,761
Reimerink/2013 2004-2011 RCT 116 57 59
Nedeau/2012 2000-2010 Hospital-basedretrospectivestudy 74 19 55
Noorani/2012 2006-2010 Hospital-basedretrospectivestudy 102 52 50
Saqib/2012 2001-2010 Hospital-basedretrospectivestudy 148 37 111
Mayer/2012 1998-2009 Hospital-basedretrospectivestudy 361 198 163
Mandawat/2012 2003-2007 Population-basedretrospectivestudy 271 64 207
Ioannidis/2012 2003-2008 Hospital-basedretrospectivestudy 43 20 23
Sarac/2011 1990-2008 Hospital-basedretrospectivestudy 160 32 128
Holt/2010 2003-2008 Population-basedretrospectivestudy 4414 335 4079
Starnes/2010 2007-2009 Hospital-basedprospectiveobservationalstudy 51 27 24
Bosch/2010 2002-2008 Hospital-basedprospectiveobservationalstudy 58 25 33
Chagpar/2010 2003-2008 Hospital-basedretrospectivestudy 167 32 135
Lyons/2010 2006-2007 Hospital-basedretrospectivestudy 37 18 19
Davenport/2010 2005-2007 Population-basedretrospectivestudy 427 99 328
Giles/2009 2000-2005 Population-basedretrospectivestudy 28,429 2323 26,106
Vun/2009 2004-2008 Hospital-basedretrospectivestudy 45 7 38
Verhoeven/2009 2002-2009 Hospital-basedretrospectivestudy 159 45 114
Vogel/2009 2001-2005 Population-basedretrospectivestudy 700 82 618
Visser/2009 2004-2006 Multicenterprospectiveobservationalstudy 201 58 143
Giles/2009 2005-2007 Population-basedretrospectivestudy 567 121 446
Veith/2009 1994-2008 Hospital-basedretrospectivestudy 57 45 12
Wibmer/2008 2003-2006 Hospital-basedretrospectivestudy 47 16 31
Lee/2008 2002-2006 Hospital-basedretrospectivestudy 37 17 20
Sharif/2007 2001-2006 Hospital-basedobservationalstudy 126 52 74
Ockert/2007 2000-2005 Hospital-basedretrospectivestudy 58 29 29
Anain/2007 2001-2006 Hospital-basedobservationalstudy 40 30 10
Acosta/2007 2000-2004 Hospital-basedretrospectivestudy 162 56 106
Greco/2006 2000-2003 Population-basedretrospectivestudy 5798 290 5508
Coppi/2006 1999-2006 Hospital-basedobservationalstudy 124 33 91
Hinchliffe/2006 2002-2004 RCT 32 15 17
Peppelenbosch/2006 2003-2004 Multicenterprospectiveobservationalstudy 100 49 51
Dalainas/2006 1998-2005 Hospital-basedobservationalstudy 28 20 8
Larzon/2005 2001-2004 Hospital-basedretrospectivestudy 41 15 26
Alsac/2005 2001-2004 Hospital-basedobservationalstudy 37 17 20
Vaddineni/2005 1999-2004 Hospital-basedretrospectivestudy 24 9 15
Brandt/2005 2003-2004 Hospital-basedretrospectivestudy 24 11 13
Lee/2004 2002-2004 Hospital-basedretrospectivestudy 17 13 4
Reichart/2003 2000-2002 Hospital-basedretrospectivestudy 19 6 13
Resch/2003 2001-2002 Hospital-basedobservationalstudy 37 14 23
Yilmaz/2002 1999-2001 Hospital-basedobservationalstudy 46 17 29
AAA,Abdominalaorticaneurysm;CT,computedtomography;EVAR,endovascularaneurysmrepair;NOS,Newcastle-OttawaScale;NR,notreported;
RCT,randomizedcontrolledtrial;TAAA,thoracoabdominalaorticaneurysm;US,ultrasound.
JOURNALOFVASCULARSURGERY
Volume58,Number4 Antoniou et al 1095
Table I.Continued.
Inclusioncriteria Exclusioncriteria NOS/Jadadscore
NR Age<60years 6
CTconfirmedrupturedAAAsuitableforbothEVAR Juxta-/suprarenalAAA,kidneytransplant,horseshoe 3
andopenrepair kidney,allergytointravenouscontrast,connective
tissuedisease,severehemodynamicinstability
prohibitingCT
NR Aorticneck<5mm,diameterlargerthanthelargest 7
availablemainbodygraft,severeiliacarterialocclusive
disease
Confirmedrupture NR 7
CTorintraoperativelyconfirmedrupturedAAA AntecedentAAArepair,symptomaticAAAwithout 6
rupture,incompletemedicalreports
NR RupturedTAAA,rupturedisolatediliacaneurysms 5
PatientswithrupturedAAAtransferredfortreatment Thoracic/TAAAaorticdissection 5
fromotherhospitals
RupturedAAA(includingruptureafterEVARand RupturedthoracicandAAAs 5
rupturewithpenetratingulcers)
NR ReoperativeAAA,juxtarenalAAA,TAAA,isolatediliac 7
arteryaneurysms,symptomaticbutnotrupturedAAA
NR NR 6
NR NR 6
CTconfirmedrupturedAAAsuitableforEVAR NR 6
CTorintraoperativelyconfirmedrupturedAAA NR 6
NR SymptomaticbutnotrupturedAAA 6
NR NR 6
NR NR 6
CTorintraoperativelyconfirmedrupturedAAA NR 5
CTorintraoperativelyconfirmedrupturedAAA AcutenonrupturedAAA 6
NR NR 5
CTorintraoperativelyconfirmedrupturedAAA NR 6
NR NR 6
NR NR 6
NR Congenitalconnectivetissuedisease-relatedruptured 7
AAA,secondaryrupture(afterprecedingelective
repair)
CTorintraoperativelyconfirmedrupturedAAA Aneurysmsinvolvingtheoriginoftherenal/visceral 5
vessels
CTorintraoperativelyconfirmedrupturedAAA NR 6
USorCTorangiographicallyorintraoperatively SymptomaticbutnotrupturedAAA,rupturedTAAA, 7
confirmedrupturedAAA rupturedtraumaticaneurysms
CTorintraoperativelyconfirmedrupturedAAA SymptomaticbutnotrupturedAAA 6
CTorintraoperativelyorautopsyconfirmedruptured NonrupturedinflammatoryorsymptomaticAAA 5
AAA
NR NR 6
NR SymptomaticbutnotrupturedAAA 7
PatientswithrupturedAAAconsideredsuitablefor Endovascularteam/deviceunavailable,age<50years, 2
openrepair,patientsstableenoughtoundergoCT inabilitytogiveconsent,unconsciouspatient,allergyto
contrast,stainlesssteel,polyester;severecomorbidity,
previousEVAR,womenofchild-bearingpotential,
pregnant/lactatingwomen
CTorintraoperativelyconfirmedrupturedAAA Lifeexpectancy<1year,notconsentingtoparticipate 8
NR NR 6
NR NR 7
CTorintraoperativelyconfirmedrupturedAAA SymptomaticbutnotrupturedAAA,mycoticAAAor 8
(includingnoninfectedaorticpseudoaneurysmsand infectedaorticpseudo-aneurysms,post-traumatic
rupturedAAApreviouslytreatedwithEVAR) aneurysms,TAAA
CTorintraoperativelyconfirmedrupturedAAA NR 6
CTorintraoperativelyconfirmedrupturedinfrarenal NR 5
AAA
Rupturedinfra-renalAAA Isolatediliacarteryaneurysms 5
NR Nopre-operativeCT 6
NR NR 6
NR NR 6
JOURNALOFVASCULARSURGERY
1096 Antoniou et al October2013
Table II. Demographic and clinicalcharacteristics ofstudy populations
EVARvsopenrepair
Coronary Chronicrenal
Firstauthor/ Meanage Malegender Hypertension artery Diabetes insufficiency Hemodynamic
year (year) (%) (%) disease(%) mellitus(%) COPD(%) (%) instability(%)
Park/2013 NR 75vs75 55vs47 32vs25 16vs12 35vs34 18vs14 NR
Reimerink/2013 75vs75 86vs85 23vs17 28vs24b 4vs2 12vs5 2vs3 11vs14
Nedeau/2012 78vs76 74vs61 74vs66 53vs38 16vs13 26vs24 42vs9e 50vs57
Noorani/2012 78vs71a NR 45vs42 39vs32 6vs4 21vs10 4vs4 NR
Saqib/2012 75vs76 70vs62 82vs87 57vs64 41vs33 27vs31 8vs15 24vs44
Mayer/2012 74vs72 85vs87 NR NR NR NR NR 41vs34
Mandawat/2012 NR NR NR NR NR NR NR NR
Ioannidis/2012 70vs72 95vs100 50vs57 35vs48b 10vs13 20vs17 30vs30f NR
Sarac/2011 81vs72 66vs77 72vs80 66vs64 25vs16 41vs44 25vs23 NR
Holt/2010 NR NR NR NR NR NR NR NR
Starnes/2010 NR 85vs71 67vs86 54vs48 13vs10 29vs38 33vs14 67vs79
Bosch/2010 72vs74 88vs97 NR 64vs73d 12vs12 28vs18 42vs27g 56vs54
Chagpar/2010 76vs74a 75vs75 69vs72 22vs11 26vs19 44vs24 NR NR
Lyons/2010 76vs76a 100vs68 NR 50vs26 NR 33vs26 11vs26h NR
Davenport/2010 72vs74 80vs77 NR 9vs6 NR 19vs13 1vs2 NR
Giles/2009 75vs73 78vs78 52vs44 28vs22 10vs9 30vs32 2vs1 NR
Vun/2009 NR 86vs74 NR NR NR NR NR NR
Verhoeven/2009 NR NR NR NR NR NR NR NR
Vogel/2009 NR NR NR NR NR NR NR NR
Visser/2009 73vs74 93vs83 50vs42 21vs25c 14vs9 26vs21 14vs11 7vs28
Giles/2009 73vs74 80vs76 64vs71 35vs27 15vs11 21vs15 2vs1i NR
Veith/2009 NR NR NR NR NR NR NR NR
Wibmer/2008 76vs69a 75vs84 81vs55 56vs52 25vs7 25vs34 50vs38j 13vs55
Lee/2008 NR 59vs65 NR NR NR NR NR 47vs75
Sharif/2007 NR NR NR NR NR NR NR 23vs50
Ockert/2007 71vs71a 72vs97 79vs79 28vs24 NR 17vs10 14vs21 48vs48
Anain/2007 NR NR NR NR NR NR NR 50vs60
Acosta/2007 76vs74a 80vs85 NR NR NR NR NR 34vs54
Greco/2006 NR NR 50vs49 33vs24 15vs10 25vs31 7vs7 NR
Coppi/2006 81vs77a 85vs81 87vs73 69vs55b 18vs11 69vs30 6vs15 45vs63
Hinchliffe/2006 74vs80 73vs76 33vs47 20vs29 NR 0vs18 7vs12 47vs35
Peppelenbosch/ 75vs74 86vs80 NR 18vs16b NR 29vs25 14vs22 43vs43
2006
Dalainas/2006 NR NR NR NR NR NR NR NR
Larzon/2005 NR NR NR NR NR NR NR NR
Alsac/2005 73vs73 94vs100 53vs60 18vs20 6vs10 41vs20 18vs5 NR
Vaddineni/2005 71vs72 71vs75 NR NR NR NR NR 0vs40
Brandt/2005 NR NR NR NR NR NR NR NR
Lee/2004 NR NR NR NR NR NR NR NR
Reichart/2003 NR NR NR NR NR NR NR NR
Resch/2003 79vs73 79vs87 71vs56 26vs35c NR 14vs26 14vs13 36vs74%
Yilmaz/2002 NR NR NR NR NR NR NR NR
COPD,chronicobstructivepulmonarydisease;EVAR,endovascularaneurysmrepair;NR,notreported.
aMedianvalue.
bCardiacdisease.
cPreviousmyocardialinfarction.
dCardiovascularcomorbidity.
eGlomerularfiltrationrate<60mL/min/1.73m2.
fSerumcreatinine>1.7mg/dL.
gSerumcreatinine>140mg/dL.
hSerumcreatinine>90mmol/L.
iOndialysis.
jSerumcreatinine>1.5mg/dL.
PatientstreatedwithEVARhadasignificantlylowerriskof wasidentified(I2¼43%),andthepossibilityofpublication
developing renal failure than patients undergoing open biaswas low(P ¼ .76;Fig 3).
AAA repair (16% vs 26%; OR, 0.65; 95% CI, 0.55-0.78; Acute lower limb ischemia. Eight studies reported
P < .01). Significant heterogeneity among the studies rates of acute limb ischemia, with an incidence of 3%
JOURNALOFVASCULARSURGERY
Volume58,Number4 Antoniou et al 1097
Table III. Definitions ofperioperative complications
Abdominal
Firstauthor/ Cardiac Respiratory Acuterenal Acutelimb Mesenteric compartment
year complications complications failure ischemia ischemia syndrome
Park/2013 MI ND ND ND ND NR
Reimerink/2013 ND NR Temporaryor NR ND NR
permanent
dialysisor
permanentrenal
insufficiency
Nedeau/2012 Cardiovascular Respiratory/ NR NR NR NR
complications infectious
complications
Noorani/2012 NR NR NR NR NR Requiring
laparotomy
Saqib/2012 MI Respiratoryfailure Requiringdialysis ND ND NR
requiring
>7daysof
ventilatory
support
Mayer/2012 MI ND ND ND ND NR
Mandawat/2012 NR NR NR NR NR NR
Ioannidis/2012 MI Pneumonia ND NR Requiringbowel ND
resection
Sarac/2011 MI Postoperative Serumcreatinine NR ND ND
intubation >1.8mg/dLor
period increaseof
>48hours, >50%of
needfor baseline
reintubation, creatininevalue
positivesputum
culture,
radiographically
confirmed
pneumonia
Holt/2010 NR NR NR NR NR NR
Starnes/2010 NR NR NR NR NR NR
Bosch/2010 Cardiacarrest ND NR NR NR NR
orMI
Chagpar/2010 NR NR NR NR NR ND
Lyons/2010 ND ND ND NR ND ND
Davenport/2010 MI Pneumonia ND NR ND ND
Giles/2009 MI NR ND NR NR NR
Vun/2009 ND ND ND ND ND NR
Verhoeven/2009 NR NR NR NR NR NR
Vogel/2009 NR NR NR Requiring Requiring Requiring
reintervention reintervention reintervention
Visser/2009 NR NR NR NR NR NR
Giles/2009 NR NR NR NR NR NR
Veith/2009 NR NR NR NR NR NR
Wibmer/2008 ND ND ND NR NR NR
Lee/2008 NR NR NR NR NR NR
Sharif/2007 MI ND ND NR NR NR
Ockert/2007 NR NR NR NR NR NR
Anain/2007 MI Pneumonia ND ND ND ND
Acosta/2007 NR NR NR NR NR Requiring
reintervention
Greco/2006 ND ND ND NR ND NR
Coppi/2006 ND ND Requiringdialysis NR ND NR
Hinchliffe/2006 NR ND ND NR ND ND
Peppelenbosch/ ND ND ND ND NR ND
2006
Dalainas/2006 NR NR NR NR NR NR
Larzon/2005 ND ND ND NR NR NR
Alsac/2005 MI ND ND ND ND ND
Vaddineni/2005 NR NR NR NR NR NR
Brandt/2005 NR NR NR NR NR NR
(Continuedonnextpage)
JOURNALOFVASCULARSURGERY
1098 Antoniou et al October2013
Table III.Continued.
Abdominal
Firstauthor/ Cardiac Respiratory Acuterenal Acutelimb Mesenteric compartment
year complications complications failure ischemia ischemia syndrome
Lee/2004 NR NR NR NR NR NR
Reichart/2003 NR NR NR NR NR NR
Resch/2003 NR NR NR NR NR NR
Yilmaz/2002 NR NR NR NR NR NR
MI,Myocardialinfarction;ND,notdefined;NR,notreported.
Fig2. Forestplotshowscomparisonofin-hospitalmortalityamongthestudiesinthemeta-analysis.CI,Confidence
interval;EVAR,endovascularaneurysmrepair;M-H,Mantel-Haenszel.
intheEVARgroupand4%intheopenrepairgroup(OR, Abdominalcompartmentsyndrome. Dataregarding
0.63; 95% CI, 0.37-1.07; P ¼ .09). Significant heteroge- abdominal compartment syndrome was reported in 12
neityamongthestudieswasfound(I2¼60%),andthelike- studies. The incidence of abdominal compartment
lihoodofpublicationbiaswaslow(P¼.76;Fig3). syndrome was 9% in the EVAR group and 8% in the
Mesenteric ischemia. Rates of mesenteric ischemia open repair group (OR, 1.06; 95% CI, 0.56-2.03; P ¼
were reported in 15 studies. A trend was found toward .85). Significant heterogeneity among the studies existed
a lower incidence of mesenteric ischemia developing (I2 ¼ 34%), and the chance of publication bias was low
among patients treated with EVAR than in those under- (P¼ .12; Fig 3).
going open repair (4% vs 6%; OR, 0.66; 95% CI, 0.44- Secondary interventions. Fourteen studies reported
1.00; P ¼ .05). Significant heterogeneity among the datarelatedtosecondaryinterventionswithintheperioper-
studieswasfound(I2¼69%),andthepossibilityofpubli- ativeperiod.The incidenceof such interventions was 16%
cation bias waslow(P¼ .91; Fig 3). in the EVAR group and 21% in the open repair group
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Volume58,Number4 Antoniou et al 1099
Fig3. Forestplotofcomparisonof(a)cardiaccomplications,(b)respiratorycomplications,(c)acuterenalfailure,(d)
lowerlimbischemia,(e)mesentericischemia,(f)abdominalcompartmentsyndrome,(g)secondaryinterventions,(h)
intraoperativebloodtransfusion,and(i)hospitallengthofstayamongthestudiesinthemeta-analysis.CI,Confidence
interval;EVAR,endovascularaneurysmrepair;M-H,Mantel-Haenszel;IV,inversevariance;SD,standarddeviation.
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1100 Antoniou et al October2013
Fig3. Continued