Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis

Nikolaos Kontopodis; Nikolaos Galanakis; Stavros Charalambous; Miltiadis Matsagkas; Athanasios D Giannoukas; Dimitrios Tsetis; Christos V Ioannou; George A Antoniou

doi:10.1016/j.ejvs.2022.07.009

Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis

Eur J Vasc Endovasc Surg. 2022 Nov;64(5):461-474. doi: 10.1016/j.ejvs.2022.07.009. Epub 2022 Jul 21.

Authors

Nikolaos Kontopodis¹, Nikolaos Galanakis², Stavros Charalambous³, Miltiadis Matsagkas⁴, Athanasios D Giannoukas⁴, Dimitrios Tsetis², Christos V Ioannou¹, George A Antoniou⁵

Affiliations

¹ Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece.
² Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece.
³ Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece; Department of Radiology, Division of Interventional Radiology, Nicosia General Hospital, Nicosia, Cyprus.
⁴ Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
⁵ Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom. Electronic address: georgios.antoniou@manchester.ac.uk.

PMID: 35872342
DOI: 10.1016/j.ejvs.2022.07.009

Abstract

Objective: To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients.

Methods: Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence.

Results: The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients.

Conclusion: The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.

Keywords: Abdominal aortic aneurysm; EVAR; Endovascular aneurysm repair; High risk.

Publication types

Review