Chimney Versus Fenestrated Endovascular Versus Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta‐analysis of the Short‐term Results

Abstract

Introduction The aim of this systematic review and network meta‐analysis was to compare the short‐term results of fenestrated endovascular repair (FEVAR), chimney endovascular repair (ChEVAR), and open surgery (OS) for patients with juxta/pararenal abdominal aortic aneurysms (JAAA/PAAA). Materials and methods MEDLINE, SCOPUS, and Web of Science were searched from inception to 1 July 2022. Any comparative studies investigating the results of two or three treatment strategies (ChEVAR, FEVAR, or OS) on clinical outcomes for patients with JAAA/PAAA were included. Analysed outcomes were 30‐day mortality, acute kidney injury (AKI), major adverse cardiovascular events (MACE), and bowel ischaemia (BI). Results A total of 22 studies with 8853 patients were included in the analysis. FEVAR (OR = 0.58, 95%CrI 0.36–0.82) and ChEVAR (OR = 0.56, 95%CrI 0.28–1.02) were associated with lower 30‐day mortality than OS. FEVAR (OR = 0.54, 95%CrI 0.33–0.85) was associated with lower risk of AKI than OS. FEVAR (OR = 0.43, 95%CrI 0.20–0.89) and ChEVAR (OR = 0.34, 95%CrI 0.10–0.93) compared to OS were associated with lower rates of BI. FEVAR (OR = 0.67, 95%CrI 0.49–0.90) and ChEVAR (OR = 0.61, 95%CrI 0.35–1.02) were associated with lower 30‐day MACE risk than OS. FEVAR was associated with a higher rate of SCI compared to OS (OR = 4.90, 95%CrI 1.55–19.17). Conclusion We found a clear benefit for FEVAR and ChEVAR versus OS in terms of reduced 30‐day mortality, BI, and MACE, as well as AKI for FEVAR. This suggests that higher‐risk patients might benefit from endovascular treatment of JAAA/PAAA; however, should be applied in clinical practice with caution, since long‐term outcomes were outside of the scope of this review.

Comparison of open surgery and endovascular treatment of asymptomatic juxta/pararenal abdominal aortic aneurysm

“…Nedavna metaanaliza je pokazala prednost endovaskularnih tehnika (FEVAR i ChEVAR) u odnosu na OSR u pogledu 30-dnevnog mortaliteta (12). Veća stopa 30-dnevnog mortaliteta u OSR grupi pacijenata može se delimično objasniti većom incidencijom neželjenih kardiovaskularnih događaja (engl.…”

“…Rezultati skorašnje multicentrične prospektivne opservacione studije, uključujući centre sa velikim iskustvom, pokazali su da je akutna povreda bubrega (engl. acute kidne injury -AKI) ređa u grupi koja je tretirana FEVAR-om u poređenju sa OSR i da je razlika bila prisutna i nakon pojedinačne analize JAAA pacijenata (12). Kod OSR kombinacija suprarenalnog klemovanja i produženog vremena trajanja suprarenalne kleme (više od 30 minuta) dovodi do postishemijske tubularne nekroze, za koju se zna da je primarni etiološki uzrok AKI u ovoj grupi pacijenata (13).…”

“…Ishemija kičmene moždine (engl. spinal cord ischaemia -SCI) češće se javljala kod pacijenata lečenih FEVARom u odnosu na one koji su lečeni OSR ili ChEVAR-om (12). Metoda FEVAR, sa komplikovanijim dizajnom i multiplim fenestracijama, zahteva dužu proksimalnu "landing" zonu i duže trajanje intervencije, produženu manipulaciju sa visceralnim krvnim sudovima, povećan gubitak krvi i veći broj pokrivenih visceralnih arterija, što su poznati prediktori za SCI (2)(3)(4).…”

Please, Look Beyond. Comment on ‘‘Chimney Versus Fenestrated Endovascular Versus Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta‐Analysis of the Short‐Term Results’’

“…Specifically considering those data, while fully recognizing the quality of the work carried out by Zlatanovic et al in their elegant systematic review and network metaanalysis [1], we strongly invoke the need to ''look beyond'' the immediate 30-day results. Therefore, we invite the authors to continue their work by collecting data for a new meta-analysis that also analyzes results of patients with at least 3 years of follow-up, particularly in terms of sac shrinkage (the only real market of healing), fate of bridging stent, and visceral vessel patency.…”

“…We read with great interest the work by Zlatanovic et al ''Chimney vs. fenestrated endovascular vs. open repair for juxta/pararenal abdominal aortic aneurysms: systematic review and network meta-analysis of the short-term results'' [1].…”