Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm

Background: Any possible long-term benefit from endovascular (EVAR) versus open surgical repair for abdominal aortic aneurysm (AAA) remains unproven. Long-term data from the Open Versus Endovascular Repair (OVER) trial add to the debate regarding long-term all-cause and aneurysm-related mortality. The aim of this study was to investigate 30-day and long-term mortality, reintervention, rupture and morbidity after EVAR and open repair for AAA in a systematic review. Methods: Standard PRISMA guidelines were followed. Random-effects Mantel-Haenszelmeta-analysis was performed to evaluate mortality and morbidity outcomes. Results: The existing published randomized trials, together with information from Medicare and SwedVasc databases, were included in a meta-analysis. This included 25 078 patients undergoing EVAR and 27 142 undergoing open repair for AAA. Patients who had EVAR had a significantly lower 30-day or in-hospital mortality rate (1.3 per cent versus 4.7 per cent for open repair; odds ratio (OR) 0.36, 95 per cent confidence interval 0.21 to 0.61; P < 0.001). By 2-year follow-up there was no difference in all-cause mortality (14.3 versus 15.2 per cent; OR 0.87, 0.72 to 1.06; P = 0.17), which was maintained after at least 4 years of follow-up (347 versus 33.8 per cent; OR 1.11, 0.91 to 1.35; P = 0.30). There was no significant difference in aneurysm-related mortality by 2 years or longer follow-up. A significantly higher proportion of patients undergoing EVAR required reintervention (P = 0.003) and suffered aneurysm rupture (P < 0.001). Conclusion: There is no long-term survival benefit for patients who have EVAR compared with open repair for AAA. There are also significantly higher risks of reintervention and aneurysm rupture after EVAR.