Collective Consciousness on Complex Aortic Repair: Time to Focus on Data Capture

Abstract

In this issue of EJVES, Antoniou et al. synthesise the current literature comparing open treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms (TAAs) with endovascular treatment using branched and fenestrated techniques.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Their meta-analysis of >7 000 patients should be commended, particularly given the fact that they only include comparative studies that utilise propensity or regression analyses, thereby limiting bias. They also capture follow up data. The take home messages are clear. Firstly, their analysis does not show a statistically significant difference in early or late survival between patients treated with either technique. Secondly, re-intervention is twice as likely in patients who have had endovascular vs. open repair, but there is a lack of granular data relating to the impact of these re-interventions, including any adverse effect on survival or quality of life. The third, and perhaps most important, message is that the quality of evidence found to inform both of the aforementioned conclusions is poor. The work by Antoniou et al. is a stark reminder of the need to improve the evidence base that guides treatment of complex aortic aneurysms. However, it is important that we do not obsess with the prospective randomised trial as the only acceptable standard of evidence and recognise the value of other study designs. The European Society for Vascular Surgery guidelines recommended fenestrated endografting as the preferred treatment for juxtarenal aneurysms (Class IIa, Level C), despite the lack of randomised trial data.2Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al.European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.Eur J Vasc Endovasc Surg. 2019; 57: 8-93Abstract Full Text Full Text PDF PubMed Scopus (757) Google Scholar Antoniou et al. consider a prospective trial randomising open and endovascular juxtarenal aneurysm repair as feasible but, rightly, suggest that TAA are a different proposition without equipoise for randomisation.1Antoniou G.A. Juszczak M. Antoniou S.A. Katsagyris A. Haulon S. Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time-to-event propensity score-matched data.Eur J Vasc Endovasc Surg. 2021; 61: 228-237Abstract Full Text Full Text PDF Scopus (4) Google Scholar Branched/fenestrated techniques allow treatment of significant numbers of patients with TAAs who would otherwise be turned down for open repair. However, detractors point to a risk of overenthusiasm for endovascular techniques and undue influence by manufacturers driving the operators' decisions to offer repair. To address this there is a need to instigate large scale, structured, prospective data collation from centres performing both endovascular and open repair to the same standard and to analyse these using the latest data science tools.3Dey D. Slomka P.J. Leeson P. Comaniciu D. Shrestha S. Sengupta P.P. et al.Artificial intelligence in cardiovascular imaging.J Am Coll Cardiol. 2019; 73: 1317-1335Crossref PubMed Scopus (151) Google Scholar In addition to post-operative survival and durability of repair, data on this scale may inform (1) objective assessment of anatomical characteristics that affect choice of repair modality; (2) the projected life expectancy of the patient, identifying those best served by conservative management; and (3) the relative effect on quality of life and likelihood of functional decline with each type of repair. For now, we must recognise that our life changing treatment decisions are best made in multidisciplinary teams consisting of a critical mass of experts. At a minimum, these teams should offer equal expertise in both open and endovascular repair so as not to limit the choice offered to the patient. They should also include medical colleagues able to give an objective opinion on the patient's physiology to aid decision making. The recent furore over the drafting of the National Institute for Health and Care Excellence aneurysm guidelines should be a wakeup call.4National Institute for Health and Care Excellence. Abdominal Aortic Aneurysm: Diagnosis and Management. NICE guideline NG156. Available at: https://www.nice.org.uk/guidance/ng156 [Accessed 25 November 2020].Google Scholar The time to gather better evidence that informs treatment of juxta/para/suprarenal and thoraco-abdominal aneurysms is now. Editor's Choice – Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched DataEuropean Journal of Vascular and Endovascular SurgeryVol. 61Issue 2PreviewThe aim of this review was to investigate comparative outcomes of fenestrated or branched endovascular aneurysm repair (F/BEVAR) with open repair for juxta/para/suprarenal or thoraco-abdominal aortic aneurysms. Full-Text PDF