Time-to-event data meta-analysis of late outcomes of endovascular versus open repair for ruptured abdominal aortic aneurysms

Objective: We investigated whether the well-documented perioperative survival advantage of emergency endovascular aneurysm repair (EVAR) compared with open repair would be sustained during follow-up. Methods: A systematic review conforming to the PRISMA (preferred reporting items for systematic reviews and metaanalyses) statement standards was conducted to identify studies that had reported the follow-up outcomes of endovascular vs open repair for ruptured abdominal aortic aneurysms. Electronic bibliographic sources (MEDLINE [medical literature analysis and retrieval system online], Embase [Excerpta Medica database], CINAHL [cumulative index to nursing and allied health literature], and CENTRAL [Cochrane central register of controlled trials]) were interrogated using the Healthcare Databases Advanced Search interface (National Institute for Health and Care Excellence, London, United Kingdom). A time-to-event data meta-analysis was performed using the inverse variance method, and the results were reported as summary hazard ratios (HRs) and associated 95% confidence intervals (CIs). Mixed effects regression was applied to investigate the outcome changes over time. The quality of the body of evidence was appraised using the GRADE (grades of recommendation, assessment, development, and evaluation) system. Results: Three randomized controlled trials and 22 observational studies reporting a total of 31,383 patients were included in the quantitative synthesis. The mean follow-up duration across the studies ranged from 232 days to 4.9 years. The overall all-cause mortality was significantly lower after EVAR than after open repair (HR, 0.79; 95% CI, 0.73-0.86). However, the postdischarge all-cause mortality was not significantly different (HR, 1.10; 95% CI, 0.85-1.43). The aneurysm-related mortality, which was reported by one randomized controlled trial, was not significantly different between EVAR and open repair (HR, 0.89; 95% CI, 0.69-1.15). Meta-regression showed the mortality difference in favor of EVAR was more pronounced in more recent studies (P =.069) and recently treated patients ( P = .062). The certainty for the body of evidence for overall and postdischarge all-cause mortality was judged to be low and that for aneurysm-related mortality to be high. Conclusions: EVAR showed a sustained mortality benefit during follow-up compared with open repair. A wider adoption of an endovascular-first strategy is justified.

Automated summary

The study found that there were significant differences in all-cause mortality during the perioperative and postoperative period between EVAR and open repair. However, no significant difference was observed in aneurysm-related mortality. Recent studies and treated patients showed a more pronounced advantage for EVAR. The certainty for the body of evidence for overall and postdischarge all-cause mortality was judged to be low, while that for aneurysm-related mortality was high.