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Comparing Open and Endovascular Abdominal Aortic Aneurysm Repair

Comparing Open and Endovascular Abdominal Aortic Aneurysm Repair. Michael Turner (Exeter College) and Charlotte Young (Harris Manchester). The Question.

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Comparing Open and Endovascular Abdominal Aortic Aneurysm Repair

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  1. Comparing Open and Endovascular Abdominal Aortic Aneurysm Repair Michael Turner (Exeter College) and Charlotte Young (Harris Manchester)

  2. The Question Mr. E. Is a 70 year old male who presented to clinic with a recently discovered abdominal aortic aneurysm (AAA) measuring 6cm in diameter. The recommended course of action is surgery; it must be decided whether an open abdominal or endovascular repair is appropriate for Mr.E with regards to mortality and reintervention rates. Mr.E has 3 grandchildren and is keen to get back on his feet and spend as little time in hospital as possible.

  3. The Search • We searched: (abdominal aortic aneurysm AND EVAR OR endovascular repair AND open AND mortality AND reintervention) AND (Therapy/Broad[filter])” This yielded 52 results. • We selected a study entitled “Long-Term Outcome of Open or Endovascular Repair of Abdominal Aortic Aneurysm” De Bruin et al., N Engl J Med, 2010. This compared the two possible methods of repair in 371 patients with AAAs measuring > 5cm, and of average age 70 years. Mortality and reintervention rates were compared.

  4. The Study appraisal Study title: “Long-Term Outcome of Open or Endovascular Repair of Abdominal Aortic Aneurysm” De Bruin et al, N Engl J Med, 2010. • Critical appraisal • Recruitment: • 371 patients continued from DREAM trial beyond that trial’s 2 year end point. • Allocation: • Randomly allocated by central computer with stratification. • Maintenance: • Follow up was >99% and done on an intention to treat basis. • Measurement: • End points were classified by a panel of 5 vascular surgeons in a “blinded fashion”. • Patients who had EVARs were followed up more rigorously than patients who underwent open surgery over post-operative years 3-5, which may cause an ascertainment bias towards reintervention in this group. BUT the follow up of patients undergoing open surgery was more rigorous than in standard clinical care, possibly creating an opposite skew in the first 2 post-operative years.

  5. The Results (interpretation of findings) The Benefits and risks to patient: • 30-day post-operation mortality rate is reduced with EVAR vs. open abdominal surgery, but this gain is lost by two years post-operation. This finding is in agreement with the EVAR-1 trial. • Patients undergoing open abdominal aortic aneurysm surgery were significantly less likely to have a secondary intervention over the 5 years post-operation than those undergoing an EVAR. • Reintervention in the EVAR cohort was predominantly due to the need to correct some graft related problem (such as endoleak and endograft migration), whereas reintervention in the open cohort was predominantly to correct abdominal incisional hernia. • There was a bolus of reinterventions in the fifth year in the EVAR cohort, pointing towards a real problem with durability of endografts rather than an ascertainment bias. *p<0.05

  6. Freedom from Reintervention Taken from De Bruin et al. (2010)

  7. The Implications Mr. E is an active, compos mentis 70 year old, therefore it seems most appropriate, having read the evidence provided here, that he should undergo open abdominal aortic surgery. Despite the 30-day decrease in mortality rate with EVAR, the long term benefits of open abdominal surgery overcome this. Open abdominal surgery minimises the chances of readmission and reintervention, therefore addressing Mr.E’s wish to spend as little time in hospital as possible.

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