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) 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 9 th 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

Minimally invasive surgery Open repair Endovascular repair (Parodii, et al) 2006 EVAR > Open repair Parodi JC,. Ann Vasc Surg 1991;5: 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?

What evidence says day and in hospital mortality lower mortality in the EVAR group compared with open repair RCT: 1.7% EVAR vs 6% Open, p = 0.1 (EVAR 1 Trial) 1% EVAR vs 4% Open, p = 0.1 ( DREAM Trial) pooled data: 2.9% EVAR vs. 5.1% Open, p = 0.32 (Sicard, 2006) Midterm outcomes initial reduction in all-cause mortality was eliminated within one to two years with equivalent overall survival (EVAR 7.5 vs Open 7.7 per 100 person – years [1.03 (0.86 to 1.23); p = 0.721]) in both treatment groups AAA-related reinterventions (9.0% vs 1.7%) were more likely after EVAR than after open surgical repair.

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 mortality 2. Rate of reintervention

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

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 TrialStudy duration Date published Population EVAROpen Repair Becquemin (ACE) De Bruin (DREAM) UK EVAR team (EVAR) TOTAL STUDY CHARACTERISTICS

TrialEndpoint Risk Risk Difference [95% CI] p EVAR group (x/n) Open repair group (x/n) Becquemen, et al 2011 Death 11.3% 17/ % 12/ [-0.03; 0.10] de Bruin et al 2010 Death 33.5% 58/ % 60/ [-0.10; 0.10] UK EVAR Team, 2010 Death 41.5% 260/ % 264/ [-0.06; 0.05] 35.30% 335/ % 336/ [0.03; 0.05] 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 repair Favor EVAR

TrialEndpoint Risk Risk Difference [95% CI] p EVAR group (x/n) Open Repair group (x/n) Becquemen, et al 2011 reintervention 16.0% 24/ % 4/ [0.07; 0.20] de Bruin, et al 2010 reintervention 27.7% 48/ % 30/ [0.02; 0.20] UK EVAR team, et al 2010 reintervention 23.2% 145/ % 55/ [0.10; 0.18] 22.87% 217/ % 89/ [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