A Systematic Review and Meta-Analysis of Endovascular Juxtarenal Aortic Aneurysm Repair Demonstrates Lower Perioperative Mortality Compared With Open Repair

Abstract

The objective of this study was to compare outcomes of endovascular versus open repair for the treatment of juxtarenal aortic aneurysms. OVID, MedLine, and Embase were searched for studies from January 2000 to December 2018 that compared endovascular versus open repair of juxtarenal aortic aneurysms. Studies that included patients with pararenal and suprarenal aneurysms were also included. Endovascular interventions included were off instructions for use standard endovascular aneurysm repair (EVAR), parallel grafts, and fenestrated/branched EVAR. Primary outcomes were 30-day mortality, perioperative reinterventions, acute renal failure, permanent dialysis, stroke, and spinal cord ischemia. Secondary outcomes were myocardial infarction, bowel and limb ischemia, length of stay, and long-term survival. Data were pooled and we performed a meta-analysis using random-effects models. There were 20 studies meeting inclusion criteria. Five studies contained duplicated data and therefore only 15 were included for analysis with 5121 patients (1506 endovascular, 3615 open). There were no randomized controlled trials. Endovascular repair patients were older (mean difference, 3.42; 95% confidence interval [CI], 2.54-4.3; P < .00001; I2 = 56%) more likely to be male (odds ratio [OR], 1.33; 95% CI, 1.02-1.73; P = .04; I2 = 33%), 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%). Pooled analysis found endovascular repair to be associated with significantly decreased 30-day mortality (OR, 0.50; 95% CI, 0.34-0.74; P = .0006, 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 had significantly decreased acute renal failure (OR, 0.50; 95% CI, 0.28-0.89; P = .02; I2 = 67%), increased spinal cord ischemia (OR, 3.14; 95% CI, 1.08-9.09; P = .03; I2 = 0%), decreased bowel ischemia (OR, 0.50; 95% CI, 0.24-1.05; P = .07; I2 = 7%), and a length of stay mean difference (−5.99 days; 95% CI, −7.42 to −4.57; P < .00001; I2 = 78%). There were no significant differences in other outcomes, including permanent dialysis and stroke. Eight of nine studies that reported long-term survival (1-7 years of follow-up) found no significant difference between groups (data not pooled). Only 1 study was noted to have improved long-term survival in the open repair group. Pooling data from 15 studies, we found endovascular repair to be associated with lower 30-day mortality, acute renal failure, bowel ischemia, and length of stay, but increased spinal cord ischemia. These data are limited by risk of bias of the included studies. Further long-term studies are needed to determine if these differences persist during long-term follow-up.