A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair

Objective: The objectives of the present study were to summarize and pool the available data from studies that had directly compared endovascular and open repair of juxtarenal aortic aneurysms.

Methods: OVID Medline and Embase were searched for studies from January 2000 to December 2018 that had compared endovascular vs open repair of juxtarenal aortic aneurysms. Studies that had included patients with pararenal and suprarenal aneurysms were also included. The endovascular interventions included short-neck standard endovascular aneurysm repair (EVAR), parallel grafts, and fenestrated/branched EVAR. The primary outcomes were 30-day mortality, perioperative reinterventions, acute renal failure, permanent dialysis, stroke, and spinal cord ischemia. The secondary outcomes were myocardial infarction, bowel and limb ischemia, length of stay, and long-term survival. The data were pooled, and a meta-analysis using a random effects model was performed.

Results: A total of 20 studies met the inclusion criteria. Of the 20 studies, five had contained duplicated data and one had included only 2-year follow-up data. Therefore, 14 studies with 5121 patients (1506 endovascular, 3615 open) were included for analysis. The patients undergoing endovascular repair were older (mean difference, 3.42; 95% confidence interval [CI], 2.54-4.3; P < .001; I² = 56%), more likely to be men (odds ratio [OR], 1.33; 95% CI, 1.02-1.73; P = .04; I² = 33%), and more likely to have diabetes (OR, 1.24; 95% CI, 1.04-1.50; P = .02; I² = 0%), coronary artery disease (OR, 1.64; 95% CI, 1.03-2.62; P = .04; I² = 75%), and chronic kidney disease (OR, 1.52; 95% CI, 1.07-2.15; P = .02; I² = 50%). Endovascular repair was associated with significantly decreased 30-day mortality (OR, 0.50; 95% CI, 0.34-0.74; P < .001; I² = 0%). This remained significant when including only fenestrated EVAR (OR, 0.55; 95% CI, 0.36-0.85; P = .007; I² = 0%). Endovascular repair also resulted in a significantly decreased incidence of acute renal failure (OR, 0.50; 95% CI, 0.28-0.89; P = .02; I² = 67%), an increased incidence of spinal cord ischemia (OR, 3.14; 95% CI, 1.08-9.09; P = .03; I² = 0%), a decreased incidence of bowel ischemia (OR, 0.50; 95% CI, 0.24-1.05; P = .07; I² = 7%), and decreased length of stay (mean difference, -5.99 days; 95% CI, -7.42 to -4.57 days; P < .00001; I² = 78%). No significant differences were found for the other outcomes. Of the nine studies that had reported long-term survival (1-7 years of follow-up), eight had found no significant differences between groups (data not pooled) and one study had found improved long-term survival in the open repair group. Reinterventions during follow-up were increased in the endovascular group.

Conclusions: Pooling data from 14 studies, we found endovascular repair was associated with lower 30-day mortality, acute renal failure, bowel ischemia, and length of stay but with increased spinal cord ischemia. These data were limited by the risk of bias of the included studies. Further long-term studies are needed to determine whether these differences persist during long-term follow-up.