Ten-year Comparison of All-Cause Mortality after Endovascular or Open Repair of Abdominal Aortic Aneurysms: A Propensity Score Analysis

Long-Term Outcomes of Open Versus Endovascular Treatment for Abdominal Aortic Aneurysm: Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data

BACKGROUND

The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair.

METHODS

PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model.

RESULTS

Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I2=62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001).

CONCLUSIONS

Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up.

CLINICAL IMPACT

Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures.

The contribution of matrix metalloproteinases and their inhibitors to the development, progression, and rupture of abdominal aortic aneurysms

Abdominal aortic aneurysms (AAAs) account for up to 8% of deaths in men aged 65 years and over and 2.2% of women. Patients with AAAs often have atherosclerosis, and intimal atherosclerosis is generally present in AAAs. Accordingly, AAAs are considered a form of atherosclerosis and are frequently referred to as atherosclerotic aneurysms. Pathological observations advocate inflammatory cell infiltration alongside adverse extracellular matrix degradation as key contributing factors to the formation of human atherosclerotic AAAs. Therefore, macrophage production of proteolytic enzymes is deemed responsible for the damaging loss of ECM proteins, especially elastin and fibrillar collagens, which characterise AAA progression and rupture. Matrix metalloproteinases (MMPs) and their regulation by tissue inhibitors metalloproteinases (TIMPs) can orchestrate not only ECM remodelling, but also moderate the proliferation, migration, and apoptosis of resident aortic cells, alongside the recruitment and subsequent behaviour of inflammatory cells. Accordingly, MMPs are thought to play a central regulatory role in the development, progression, and eventual rupture of abdominal aortic aneurysms (AAAs). Together, clinical and animal studies have shed light on the complex and often diverse effects MMPs and TIMPs impart during the development of AAAs. This dichotomy is underlined from evidence utilising broad-spectrum MMP inhibition in animal models and clinical trials which have failed to provide consistent protection from AAA progression, although more encouraging results have been observed through deployment of selective inhibitors. This review provides a summary of the supporting evidence connecting the contribution of individual MMPs to AAA development, progression, and eventual rupture. Topics discussed include structural, functional, and cell-specific diversity of MMP members; evidence from animal models of AAA and comparisons with findings in humans; the dual role of MMPs and the requirement to selectively target individual MMPs; and the advances in identifying aberrant MMP activity. As evidenced, our developing understanding of the multifaceted roles individual MMPs perform during the progression and rupture of AAAs, should motivate clinical trials assessing the therapeutic potential of selective MMP inhibitors, which could restrict AAA-related morbidity and mortality worldwide.

Antithrombotic Therapy for Aortic Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVES

The role of antithrombotic therapy in the management of aortic and peripheral aneurysms is unclear. This systematic review and meta-analysis aimed to assess the impact of antithrombotics on clinical outcomes for aortic and peripheral aneurysms.

METHODS

Medline, Embase, and CENTRAL databases were searched. Randomised controlled trials and observational studies investigating the effect of antithrombotic therapy on clinical outcomes for patients with any aortic or peripheral artery aneurysm were included.

RESULTS

Fifty-nine studies (28 with antiplatelet agents, 12 anticoagulants, two intra-operative heparin, and 16 any antithrombotic agent) involving 122 102 patients were included. Abdominal aortic aneurysm (AAA) growth rate was not significantly associated with the use of antiplatelet therapy (SMD -0.36 mm/year; 95% CI -0.75 - 0.02; p = .060; GRADE certainty: very low). Antithrombotics were associated with increased 30 day mortality for patients with AAAs undergoing intervention (OR 2.30; 95% CI 1.51 - 3.51; p < .001; GRADE certainty: low). Following intervention, antiplatelet therapy was associated with reduced long term all cause mortality (HR 0.84; 95% CI 0.76 - 0.92; p < .001; GRADE certainty: moderate), whilst anticoagulants were associated with increased all cause mortality (HR 1.64; 95% CI 1.14 - 2.37; p = .008; GRADE certainty: very low), endoleak within three years (OR 1.99; 95% CI 1.10 - 3.60; p = .020; I² = 60%; GRADE certainty: very low), and an increased re-intervention rate at one year (OR 3.25; 95% CI 1.82 - 5.82; p < .001; I² = 35%; GRADE certainty: moderate). Five studies examined antithrombotic therapy for popliteal aneurysms. Meta-analysis was not possible due to heterogeneity.

CONCLUSIONS

There was a lack of high quality data examining antithrombotic therapy for patients with aneurysms. Antiplatelet therapy was associated with a reduction in post-intervention all cause mortality for AAA, whilst anticoagulants were associated with an increased risk of all cause mortality, endoleak, and re-intervention. Large, well designed trials are still required to determine the therapeutic benefits of antithrombotic agents in this setting.

What factors counteract mid-term survival following endovascular repair of abdominal aortic aneurysms?

Introduction

Endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used, and has become the standard treatment option for AAA.

Aim

To evaluate the outcomes and predictors of survival of endovascular treatment of AAA in the short- and medium-term.

Material and methods

A total of 222 patients having endovascular AAA repair between January 2013 and December 2019 by the same surgical team were included in the study. Patient demographics, perioperative and follow-up data including mortality, complications, and need for secondary intervention were collected. The primary endpoint was all-cause mortality. Kaplan-Meier analysis was conducted for survival and Cox regression models were assessed for predictors of survival.

Results

The median age was 70 years, with male predominance (202 patients, 91%). Thirty-day mortality was 1.8%. Median follow-up to the primary endpoint was 20 months (range: 1–80 months). Survival rates at 1, 3, and 5 years were 93.5%, 81.4%, and 62.2%, respectively. Freedom from secondary intervention rates were 95.5% at 1 year, 88.7% at 3 years, and 82.1% at 5 years. Cox proportional hazard models showed that preoperative creatinine levels ≥ 1.8 mg/dl (hazard ratio (HR) = 2.68, 95% CI: 1.21–6.42, p = 0.027), haemoglobin levels < 10 gr/dl (HR = 3.38, 95% CI: 1.16–9.90, p = 0.026), ejection fraction < 30% (HR = 5.67, 95% CI: 1.29–24.86, p = 0.021), and AAA diameter ≥ 6.0 cm (HR = 2.20, 95% CI: 1.01–4.81, p = 0.049) were independently associated with mid-term survival.

Conclusions

EVAR is a safe procedure with low postoperative morbidity and mortality. This study confirms that the mid-term survival and results are favourable. However, the analysed factors in this study that predict reduced survival (high preoperative creatinine, low haemoglobin, low ejection fraction and larger aneurysms) should be judged when planning endovascular repair of AAA.

Development and internal validation of a prognostic model for mortality of patients with abdominal aortic aneurysms treated with endovascular aneurysm repair

Background: Morbidity and mortality associated with elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA) must be balanced against the impending risk of aneurysm rupture and the estimated remaining lifetime. The aim of this study is to develop and validate a prognostic model for mortality of patients with AAA treated with EVAR. Methods: This retrospective observational study included 251 consecutive patients treated with EVAR for asymptomatic AAA between January 2001 and December 2012 at the University Hospital in Bern, Switzerland. Pre-selection of variables was based on a literature review; least absolute shrinkage and selection operator technique was used for the final variable selection. A Firth's bias reduced Cox proportional hazard model was developed and validated using 10,000 bootstrap samples to predict survival after EVAR. Results: The median follow-up time was 5.3 years (range 0.1 to 15.9). At the study closing date 95% of follow-up information was available. The mortality rates were 31.9% at 5 years and 50.5% at the study closing date, respectively. Identified predictors for overall mortality after EVAR were age, hazard ratio (HR) = 2.24 per 10-year increase (95% CI 1.64 to 3.09), the presence of chronic obstructive pulmonary disease (COPD), HR = 2.22 (95% CI 1.48 to 3.31), and lower estimated glomerular filtration rate, HR = 1.24 per 10 ml/min/1.73 m² decrease (95% CI 1.12 to 1.39). The model showed good discrimination ability, Harrell's C = 0.722 (95% CI 0.667 to 0.778) and was very robust in the bootstrap in-sample validation Harrell's C = 0.726 (95% CI 0.662 to 0.788). Conclusion: Higher age, the presence of COPD and impaired kidney function are independent predictors for impaired survival after EVAR. The expected remaining lifetime should be considered in patients with AAA. This prognostic model can help improving patient care; however, external validation is needed prior to clinical implementation.

Meta-analysis of phase-specific survival after elective endovascular versus surgical repair of abdominal aortic aneurysm from randomized controlled trials and propensity score-matched studies

OBJECTIVE

Although endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) significantly decreases perioperative mortality compared with open surgical repair (OSR), we have not concluded superiority between EVAR and OSR beyond the perioperative period. The aim of this study was to compare phase-specific survival after EVAR vs OSR.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Embase and MEDLINE were searched up to November 2019 to identify randomized controlled trials and propensity score-matched studies that investigated ≥2-year all-cause mortality (primary outcome) after EVAR vs OSR for intact infrarenal AAA. For each study, the hazard ratio (HR) with 95% confidence interval (CI) of mortality for EVAR vs OSR was calculated using survival curves for the following specific phases: early term (0-2 years after repair), midterm (2-6 years after repair), long term (6-10 years after repair), and very long term (≥10 years after repair). The risk ratio (RR) in the perioperative (in-hospital or 30-day) period was also extracted. Phase-specific HRs or RRs were separately pooled using the random effects model. Sensitivity analyses were performed by removing one study at a time to confirm that our findings were not derived from any single study. Funnel plot asymmetry was also examined using the linear regression test.

RESULTS

Our search identified four randomized controlled trials and seven propensity score-matched studies enrolling a total of 106,243 AAA patients assigned to EVAR (n = 53,123) or OSR (n = 53,120). The mortality after EVAR compared with OSR was significantly lower in the perioperative period (RR, 0.39; 95% CI, 0.29-0.51; P < .00001) and similar in the early-term period (HR, 0.93; 95% CI, 0.84-1.03; P = .16). Notably, significantly higher mortality was observed in the EVAR group compared with the OSR group in the midterm period (HR, 1.15; 95% CI, 1.03-1.29; P = .01). However, similar mortality was observed between the EVAR group and the OSR group in the long-term (HR, 1.06; 95% CI, 0.96-1.17; P = .27) and very-long-term (HR, 1.17; 95% CI, 0.93-1.47; P = .19) periods. In sensitivity analyses, the significant benefit of EVAR in the perioperative period and that of OSR in the midterm period were not changed. No funnel plot asymmetry was identified in all analyses.

CONCLUSIONS

Compared with OSR, EVAR was associated with lower perioperative mortality and higher mortality in the midterm period for intact infrarenal AAA. The superiority of EVAR was absent in the early-term period, and the inferiority of EVAR in the midterm period disappeared in the long-term and very-long-term periods.

The long-term outcomes of open and endovascular repair for abdominal aortic aneurysm: A meta-analysis

To provide a meta-analysis of studies evaluating long-term all-cause mortality, aneurysm-related mortality and re-intervention after open or endovascular repair for abdominal aortic aneurysm. Electronic bibliographic sources were interrogated using a combination of free text and controlled vocabulary searches to identify studies comparing the long-term outcomes of open and endovascular repair for abdominal aortic aneurysm. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Fixed effect or random effects models were used. We retrieved 4 randomized controlled trials (RCTs; 2,783 patients), 7 nonrandomized trials (86,035 patients). The primary outcome was all-cause mortality. Heterogeneity was high and publication bias could not be excluded. Despite these limitations, the analysis showed that open and endovascular abdominal aortic aneurysm repair had similar all-cause mortality (OR 1.16, 95% CI, 0.89-1.51) over 5 years follow up, which was maintained after at least 10 years of follow-up (OR 0.87, 95% CI, 0.73-1.03). There was no significant difference in aneurysm-related mortality by 5 years or longer follow-up. A significantly lower proportion of patients undergoing open repair required reintervention (OR 0.38, 95% CI 0.24-0.64), which was maintained over 5 years of follow-up. There is no long-term survival difference between the patients who underwent open or endovascular aneurysm repair. There is significantly higher risk of reinterventions after endovascular aneurysm repair.

Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm

BACKGROUND

Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken.

METHODS

A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival.

RESULTS

Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1·16 (95 per cent c.i. 0·92 to 1·39) versus 3·27 (2·71 to 3·83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1·01, 1·00 and 0·98 for 3, 5 and 10 years respectively; P = 0·721, P = 0·912 and P = 0·777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3, 5 and 10 years for EVAR, and 0·96, 0·91 and 0·76 respectively for OSR.

CONCLUSION

Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.

Statin intensity and postoperative mortality following open repair of intact abdominal aortic aneurysm

Background

There is a lack of evidence for the association between intensive statin therapy and outcomes following vascular surgery. The aim of this study was to evaluate the association between perioperative statin intensity and in-hospital mortality following open abdominal aortic aneurysm (AAA) repair.

Methods

Patients undergoing open AAA repair between 2009 and 2015 were identified from the Premier Healthcare Database. Statin use was classified into low, moderate and high intensity, based on American College of Cardiology/American Heart Association guidelines. Supratherapeutic intensity was defined as doses higher than the recommended guidelines. Multivariable logistic regression analyses were undertaken to assess the association between statin intensity and postoperative major adverse events and in-hospital mortality.

Results

Of 6497 patients undergoing open AAA repair, 3217 (49·5 per cent) received perioperative statin. Statin users were more likely to present with three or more co-morbidities than non-users (26·5 versus 21·8 per cent; P < 0·001). Unadjusted postoperative mortality was significantly lower in statin users (2·6 versus 6·3 per cent; P < 0·001); however, there was no difference in the risk of developing major adverse events. Multivariable analysis showed that statin use was associated with lower odds of death (odds ratio 0·41, 95 per cent c.i. 0·31 to 0·54). Moderate, high and supratherapeutic statin intensities were not associated with lower odds of death or major adverse events compared with low-intensity statin therapy.

Conclusion

Statin use is associated with lower odds of death in hospital following open AAA repair. High-intensity statins were not associated with lower morbidity or mortality.

Association of Platelet to Lymphocyte Ratio and Risk of 30-Day Postoperative Complications in Patients Undergoing Abdominal Aortic Surgical Repair

Introduction:

The predictive value of the platelet to lymphocyte ratio (PLR) has been demonstrated in several cardiovascular diseases. The aim of this study was to investigate the interest of the preoperative PLR as a predictor of 30-day postoperative outcome in patients with abdominal aortic aneurysm (AAA) undergoing open or endovascular surgical repair.

Material and Methods:

Two hundred twenty-four consecutive patients with infrarenal AAA were retrospectively included and divided into 4 quartiles according to the value of the preoperative PLR: PLR < 91.5 (group I), 91.5 < PLR < 120.8 (group II), 120.8 < PLR < 163.3 (group III), and PLR > 163.3 (group IV).

Results:

The AAA diameter was similar among the groups (54.9 mm vs 58.6, 57.5, and 58.7 mm; P = .4655). The proportion of symptomatic AAA and the procedural characteristics did not differ. Patients from group I and IV had significantly higher rates of all-cause postoperative complications compared to group II and III (55.4% and 64.3% vs 39.3% and 46.4%, respectively; P = .0478). The all-cause mortality tended to be higher in group I and IV (7.1% and 8.9% vs 0% and 3.6%, respectively; P = .1305).

Conclusion:

Extreme values of PLR are associated with a higher risk of complications following AAA surgical repair, suggesting its interest as a biomarker to evaluate the surgical risk.

Endovascular Treatment of Asymptomatic Abdominal Aortic Aneurysms in Octogenarians: Factors Influencing Long-term Survival

BACKGROUND

Beyond the age of 80 years, the preventive treatment of an asymptomatic abdominal aortic aneurysm (AAA) has to be decided in light of the life expectancy which it is difficult to evaluate, but it is important to determine who in this population will benefit from it. The objective of our study was to determine the factors influencing short-term mortality and long-term survival in patients aged 80 years and older after the endovascular treatment of AAAs (EVAR).

MATERIAL AND METHODS

We present a retrospective analysis of the prospective databases of 4 French academic departments of vascular surgery, bringing together the data of all the patients presenting an AAA who were treated by EVAR between 1998 and 2011. Logistic regression and multivariate analysis with a Cox survival model were used to determine the factors influencing perioperative and long-term mortality. The cumulative rate of events for the measurement of survival was calculated with the technique of Kaplan-Meier.

RESULTS

We treated 345 octogenarians and 339 younger patients. The average follow-up was 40 months. Average survival was 75% at 36 months and 49% at 60 months. There was no evidence of any risk factor influencing mortality at 30 days in the octogenarians. However, chronic kidney disease (odds ratio [OR] = 3.95, P <0.001) and chronic respiratory failure (OR = 2.62, P <0.001) proved to be independent factors of a poor long-term prognosis.

CONCLUSIONS

The treatment by stent graft in octogenarians is effective in the long term. The presence of an impaired renal function or respiratory failure in this population could put into question the operative indication.

Treatment of Abdominal Aortic Pathology

Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.

Worse late-phase survival after elective endovascular than open surgical repair for intact abdominal aortic aneurysm

OBJECTIVES

To determine whether follow-up survival is better after elective endovascular aneurysm repair (EVAR) than open surgical repair (OSR) for intact abdominal aortic aneurysm (AAA), we combined 5-year survival curves themselves of EVAR and OSR in randomized controlled trials (RCTs) and propensity-score matched (PSM) studies.

METHODS

Eligible studies were RCTs or PSM studies of elective EVAR versus OSR enrolling patients with intact AAA and reporting 5-year (at least) survival curves. Data regarding detailed inclusion criteria, duration of follow-up, and survival curves were abstracted from each individual study. In case of crossing of the combined survival curves, a pooled late-phase (between the crossing time and 5years) hazard ratio (HR) for all-cause mortality was calculated.

RESULTS

Our search identified 7 eligible studies (including 2 RCTs and 5 PSM studies) enrolling a total of 92,333 patients with AAA assigned to EVAR or OSR. Pooled survival rates after EVAR and OSR were 98.1% and 96.1 at 1month, 94.2% and 93.1% at 1year, 85.1% and 86.8% at 3years, and 75.8% and 78.8% at 5years, respectively. The survival curves crossed at 1.8years with the survival rate of 90.5%. A pooled late-phase (between 1.8years and 5years) HR for calculated from data of the combined survival curves significantly favored OSR (1.29, 95% confidence interval, 1.24 to 1.35; p<0.00001).

CONCLUSIONS

For intact AAA, although survival was better immediately after elective EVAR than OSR, the survival curves crossed at 1.8years. Thereafter until 5years, survival was worse after EVAR than OSR.

Systematic Review and Meta-analysis of Factors Influencing Survival Following Abdominal Aortic Aneurysm Repair

BACKGROUND

Predicting long-term survival following repair is essential to clinical decision making when offering abdominal aortic aneurysm (AAA) treatment. A systematic review and a meta-analysis of pre-operative non-modifiable prognostic risk factors influencing patient survival following elective open AAA repair (OAR) and endovascular aneurysm repair (EVAR) was performed.

METHODS

MEDLINE, Embase and Cochrane electronic databases were searched to identify all relevant articles reporting risk factors influencing long-term survival (≥1 year) following OAR and EVAR, published up to April 2015. Studies with <100 patients and those involving primarily ruptured AAA, complex repairs (supra celiac/renal clamp), and high risk patients were excluded. Primary risk factors were increasing age, sex, American Society of Anaesthesiologist (ASA) score, and comorbidities such as ischaemic heart disease (IHD), cardiac failure, hypertension, chronic obstructive pulmonary disease (COPD), renal impairment, cerebrovascular disease, peripheral vascular disease (PVD), and diabetes. Estimated risks were expressed as hazard ratio (HR).

RESULTS

A total of 5,749 study titles/abstracts were retrieved and 304 studies were thought to be relevant. The systematic review included 51 articles and the meta-analysis 45. End stage renal disease and COPD requiring supplementary oxygen had the worst long-term survival, HR 3.15 (95% CI 2.45-4.04) and HR 3.05 (95% CI 1.93-4.80) respectively. An increase in age was associated with HR of 1.05 (95% CI 1.04-1.06) for every one year increase and females had a worse survival than men HR 1.15 (95% CI 1.07-1.27). An increase in ASA score and the presence of IHD, cardiac failure, hypertension, COPD, renal impairment, cerebrovascular disease, PVD, and diabetes were also factors associated with poor long-term survival.

CONCLUSION

The result of this meta-analysis summarises and quantifies unmodifiable risk factors that influence late survival following AAA repair from the best available published evidence. The presence of these factors might assist in clinical decision making during discussion with patients regarding repair.

Effect of lipid-modifying therapy on long-term mortality after abdominal aortic aneurysm repair: a systemic review and meta-analysis

BACKGROUND

Several observational studies have demonstrated that lipid-modifying therapy may improve long-term survival in abdominal aortic aneurysm (AAA) patients after repair. We carried out a systematic review and meta-analysis of studies evaluating the effect of lipid-modifying therapy on long-term mortality.

PATIENTS AND METHODS

We conducted a systematic search of multiple databases up to April 2014. Studies that evaluated exposure to lipid-modifying therapy, reported mortality data and hazard ratio (HR) or provided survival curve for their estimation were included in the meta-analysis. Pooled HR estimates with 95% confidence intervals (CIs) were calculated using the random-effects model.

RESULTS

Eight studies (seven cohorts, one post hoc study of a randomization controlled trial) reporting 2,605 patients on lipid-modifying therapy were included. Meta-analysis showed a significant 39% reduction in long-term mortality with lipid-modifying therapy (HR 0.61; 95% CI 0.51-0.73). After exclusion of one study which was contributing to considerable heterogeneity, a significant 33% reduction in mortality risk was a more conservative, consistent estimate (HR 0.67; 95% CI 0.59-0.77).

CONCLUSION

Meta-analysis of studies supports a protective role of lipid-modifying therapy on mortality risk after AAA repair. Aggressive lipid intervention should be recommended to those who receiving AAA repair.

A unique technique for intentional occlusion of an abdominal aortic aneurysm

We report the case of a 78-year-old man with coronary artery disease, chronic obstructive pulmonary disease, and chronic renal insufficiency with an enlarging 6.7-cm infrarenal abdominal aortic aneurysm. He also had a 4-cm right common iliac artery aneurysm, and right external iliac artery occlusion. The patient had a history of an axillobifemoral bypass graft placed 10 years prior for aortoiliac occlusive disease. We describe the use of an infrarenal aorto-uni-iliac graft and subsequent intentional graft occlusion as an endovascular solution to treat aneurysmal disease in this sick patient. He remains asymptomatic after surgery, with demonstrated occlusion of his aneurysms.