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May 27, 2020

Increased Mortality Associated With EVAR for Ruptured AAA in Hostile Aortic Anatomy

May 27, 2020—Findings from an investigation of the effect of hostile aortic anatomy on the outcomes of endovascular aneurysm repair (EVAR) and open repair for ruptured abdominal aortic aneurysm (AAA) were published by Nikolaos Kontopodis, MD, et al in May issue of the European Journal of Vascular and Endovascular Surgery (EJVES; 2020;59:717–728).

The investigators concluded that hostile aortic anatomy is associated with increased mortality in patients with ruptured AAA treated by EVAR.

As summarized in EJVES, electronic bibliographic sources (Medline, Embase, CENTRAL) were searched using a combination of thesaurus and free-text terms to identify studies comparing treatment outcomes of ruptured AAA in patients with hostile versus friendly aortic anatomy.

A systematic review was conducted that conformed to the PRISMA guidelines using a registered protocol (CRD42019127307). The primary outcomes were perioperative mortality, freedom from aneurysm-related mortality, and overall survival.

The investigators did the following:

  • Calculated pooled estimates of dichotomous outcomes using odds ratio (OR) and 95% CI.
  • Conducted a time-to-event data meta-analysis using the inverse variance method and reported the results as summary hazard ratio (HR) and associated 95% CI.
  • Performed subgroup analysis for the type of treatment (EVAR or open repair).
  • Developed random-effects models of meta-analysis.

The analysis included 10 observational studies reporting a total of 1,284 patients (748 with hostile anatomy and 536 with friendly anatomy). The investigators found that patients with hostile anatomy had higher perioperative mortality than patients with friendly anatomy (OR, 1.73; 95% CI, 1.13-2.66; P = .01). Subgroup analysis showed a significant difference in perioperative mortality in favor of friendly anatomy in patients treated by EVAR (OR, 1.76; 95% CI, 1.01-3.08; P = .05), but not in those treated by open repair (OR, 1.37; 95% CI, 0.83-2.27; P = .22).

Patients with hostile anatomy treated by EVAR had a significantly higher hazard of death in the follow-up than patients with friendly aortic anatomy (HR, 2.01; 95% CI, 1.18-3.44; P = .01), whereas, for open surgical repair, the survival was similar in patients with hostile and those with friendly aortic anatomy (HR, 0.9; 95% CI, 0.61-1.32; P = .58), reported the investigators in EJVES.

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