Long-Term Comparison of Endovascular and Open Repair of Abdominal Aortic Aneurysm

Abstract

Endovascular repair and open repair resulted in similar long-term survival. The perioperative survival advantage with endovascular repair was sustained for several years, but rupture after repair remained a concern. Endovascular repair led to increased long-term survival among younger patients but not among older patients, for whom a greater benefit from the endovascular approach had been expected. (Funded by the Department of Veterans Affairs Office of Research and Development; OVER ClinicalTrials.gov number, NCT00094575.).

Meta-Analysis of Individual-Patient Data From EVAR-1, DREAM, OVER and ACE Trials Comparing Outcomes of Endovascular or Open Repair for Abdominal Aortic Aneurysm Over 5 Years

“…5 Unadjusted hazard ratios, with 95 per cent confidence intervals, for total mortality by subgroups of history of angina or myocardial infarction (MI), ankle : brachial pressure index (ABPI) and cardiovascular risk score, overall and at 0-6 months, 6 months to 4 years and more than 4 years since randomization. Interaction P values for ABPI and cardiovascular risk score were calculated using continuous measures.…”

“…The EVAR-1, DREAM and OVER trials all showed an early survival benefit for EVAR, whereas ACE did not. This early survival benefit for EVAR was lost within 1-3 years in the EVAR-1 and DREAM trials, but not until later in the OVER trial 3,5,6 . This 'catch-up' in mortality has been noted in many other studies, including a Cochrane review 7 and analyses of the Medicare database 8 , but no satisfactory explanation for this phenomenon has emerged.…”

“…In the 1990s, the less invasive endovascular aneurysm repair (EVAR) was introduced; EVAR-1 2 , the first multicentre randomized trial of EVAR versus open repair, was started in 1999 in the UK. This was soon followed by the DREAM 3 and ACE 4 multicentre trials in Europe, and the OVER trial 5 in the USA. Each of the randomized trials of EVAR versus open repair recruited patients (suitable for either open or endovascular repair) with slightly different entry characteristics with respect to age, sex, aneurysm morphology and other demographics.…”

An evaluation of the effect of an angiotensin-converting enzyme inhibitor on the growth rate of small abdominal aortic aneurysms: a randomised placebo-controlled trial (AARDVARK)

“…27 The less-invasive EVAR technique has significantly lowered perioperative morbidity and mortality rates 27 but not all patients are anatomically suitable for EVAR and there is still debate regarding the long-term benefits of EVAR. Several trials, including the EVAR, 30 DREAM (Dutch Randomized Endovascular Aneurysm Repair) 31 and OVER (Open Versus Endovascular Repair) 32 trials, have found that the advantage of EVAR over open repair is lost during mid-term follow-up, with survival rates beyond 2 years being similar in both groups.…”

Percutaneous Interventions in Aortic Disease

“…19,24 Percutaneous Abdominal and Thoracic Aneurysm Repair aneurysm as a less invasive approach with decreased perioperative morbidity and mortality. 25,26 In an effort to produce an even more minimally invasive option, percutaneous EVAR (PEVAR) was pioneered by Haas et al 27 in 1999 using the Prostar XL and was shown at that time to be a safe and effective option for management of the femoral access site. Since that time, both the development of smaller-profile devices and the creation of another option for suture-mediated closure have allowed some centers to adopt a "percutaneous first" approach to EVAR.…”