Editor's Choice - Endovascular aneurysm repair versus open repair for patients with a ruptured abdominal aortic aneurysm: a systematic review and meta-analysis of short-term survival

S C van Beek, A P Conijn, M J Koelemay, R Balm
European Journal of Vascular and Endovascular Surgery 2014, 47 (6): 593-602

BACKGROUND: There is clinical equipoise between open (OR) and endovascular aneurysm repair (EVAR) for the best treatment of ruptured abdominal aortic aneurysm (RAAA).

OBJECTIVE: The aim of the study was to perform a systematic review and meta-analysis to estimate the short-term (combined 30-day or in-hospital) survival after EVAR and OR for patients with RAAA. Data sources included Medline, Embase, and the World Health Organization International Clinical Trials Registry until 13 January 2014. All randomised controlled trials (RCTs), observational cohort studies, and administrative registries comparing OR and EVAR of at least 50 patients were included. Articles were full-length and in English.

METHODS: Standard PRISMA guidelines were followed. The methodological quality of RCTs was assessed with the Cochrane Collaboration's tool for assessing risk of bias. The quality of observational studies was assessed with a modified Cochrane Collaboration's tool for assessing risk of bias, the Newcastle-Ottawa Scale, and the Methodological Index for Non-Randomized Studies. The results of the RCTs, of the obersvational studies, and of the administrative registries were pooled separately and analysed with the use of a random effects model.

RESULTS: From a total of 3,769 articles, three RCTs, 21 observational studies, and eight administrative registries met the inclusion criteria. In the RCTs, the risk of bias was lowest and the pooled odds ratio for death after EVAR versus OR was 0.90 (95% CI 0.65-1.24). The majority of the observational studies had a high risk of bias and the pooled odds ratio for death was 0.44 (95% CI 0.37-0.53). The majority of the administrative registries had a high risk of bias and the pooled odds ratio for death was 0.54 (95% CI 0.47-0.62).

CONCLUSION: Endovascular aneurysm repair is not inferior to open repair in patients with a ruptured abdominal aortic aneurysm. This supports the use of EVAR in suitable patients and OR as a reasonable alternative.

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