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.
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References
Wanhainen A, Verzini F, Van Herzeele I et al (2019) Editor’s choice—European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg 57:8–93
Oderich GS, Forbes TL, Chaer R et al (2021) Writing committee group. Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg 73:4–52
Pitoulias GA, Fazzini S, Donas KP et al (2022) Multicenter mid-term outcomes of the chimney technique in the elective treatment of degenerative pararenal aortic aneurysms. J Endovasc Ther 29:226–239
Oderich GS, Farber MA, Schneider D et al (2021) Zenith fenestrated study investigators. Final 5-year results of the United States Zenith Fenestrated prospective multicenter study for juxtarenal abdominal aortic aneurysms. J Vasc Surg 73:1128–1138
Katsargyris A, Oikonomou K, Klonaris C et al (2013) Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther 20:159–169
Koncar IB, Jovanovic AL, Ducic SM (2020) The role of fEVAR, chEVAR and open repair in treatment of juxtarenal aneurysms: a systematic review. J Cardiovasc Surg (Torino) 61:24–36
Doonan RJ, Girsowicz E, Dubois L et al (2019) A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair. J Vasc Surg 70:2054–2064
Antoniou GA, Juszczak MT, Antoniou SA et al (2021) Editor’s choice - 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 61:228–237
Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int J Surg 88:105906
Shea BJ, Reeves BC, Wells G et al (2017) AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 358:4008
Sterne JA, Hernán MA, Reeves BC et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 12:i4919
Guyatt GH, Oxman AD, Kunz R et al (2011) Framing the question and deciding on important outcomes. J Clin Epidemiol 64:395–400
McGuinness LA, Higgins JPT (2021) Risk-of-bias VISualization (robvis): an R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Method 12:55–61
Dias S, Ades T, Welton NJ et al (2018) Network meta-analysis for decision-making. Wiley. https://doi.org/10.1002/9781118951651
Donas KP, Eisenack M, Panuccio G et al (2012) The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms. J Vasc Surg 56:285–290
Wei G (2013) Endovascular chimney technique versus fenestrated endovascular aneurysm repair of juxtarenal abdominal aortic aneurysms. Heart 99:1–302
Lee JT, Lee GK, Chandra V et al (2014) Comparison of fenestrated endografts and the snorkel/chimney technique. J Vasc Surg 60:849–856
Barillà D, Sobocinski J, Stilo F et al (2014) Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR. Int Angiol 33:466–473
Shahverdyan R, Majd MP, Thul R et al (2015) F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results. Eur J Vasc Endovasc Surg 50:432–441
Saratzis AN, Bath MF, Harrison SC et al (2015) Impact of fenestrated endovascular abdominal aortic aneurysm repair on renal function. J Endovasc Ther 22:889–896
Maeda K, Ohki T, Kanaoka Y et al (2017) Comparison between open and endovascular repair for the treatment of juxtarenal abdominal aortic aneurysms: a single-center experience with midterm results. Ann Vasc Surg 41:96–104
Wooster M, Tanious A, Patel S et al (2017) Concomitant parallel endografting and fenestrated experience in a regional aortic center. Ann Vasc Surg 38:54–58
Caradu C, Morin J, Poirier M et al (2017) Monocentric evaluation of chimney versus fenestrated endovascular aortic repair for juxtarenal abdominal aortic aneurysm. Ann Vasc Surg 40:28–38
Chinsakchai K, Prapassaro T, Salisatkorn W et al (2019) Outcomes of open repair, fenestrated stent grafting, and chimney grafting in juxtarenal abdominal aortic aneurysm: is it time for a randomized trial? Ann Vasc Surg 56:114–123
Soler R, Bartoli MA, Faries C et al (2019) Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms. J Vasc Surg 70:683–690
Steffen M, Schmitz-Rixen T, Böckler D, DIGG gGmbH, et al (2020) Comparison of open and endovascular repair of juxtarenal abdominal aortic aneurysms. Langenbecks Arch Surg 405:207–213
Rosenfeld ES, Macsata RA, Lala S et al (2021) Open surgical repair of juxtarenal abdominal aortic aneurysms in the elderly is not associated with increased thirty-day mortality compared with fenestrated endovascular grafting. J Vasc Surg 73:1139–1147
O’Donnell TFX, Boitano LT, Deery SE et al (2020) Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms. Ann Surg 271:969–977
von Meijenfeldt GCI, Alberga AJ, Balm R et al (2022) Results from a nationwide prospective registry on open surgical or endovascular repair of juxtarenal abdominal aortic aneurysms. J Vasc Surg 75:81–89
Taneva GT, Donas KP, Pitoulias GA et al (2020) Cost- effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies. J Cardiovasc Surg (Torino) 61:18–23
Menegolo M, Xodo A, Penzo M et al (2021) Open repair versus EVAR with parallel grafts in patients with juxtarenal abdominal aortic aneurysm excluded from fenestrated endografting. J Cardiovasc Surg (Torino) 62:483–495
Canavati R, Millen A, Brennan J et al (2013) Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair. J Vasc Surg 57:362–367
Banno H, Cochennec F, Marzelle J et al (2014) Comparison of fenestrated endovascular aneurysm repair and chimney graft techniques for pararenal aortic aneurysm. J Vasc Surg 60:31–39
Michel M, Becquemin JP, Clément MC, Trial Participants WINDOW et al (2015) Editor’s choice—thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms. Eur J Vasc Endovasc Surg 50:189–196
Fiorucci B, Speziale F, Kölbel T et al (2019) Short- and midterm outcomes of open repair and fenestrated endografting of pararenal aortic aneurysms in a concurrent propensity-adjusted comparison. J Endovasc Ther 26:105–112
Davis FM, Albright J, Battaglia M et al (2021) Fenestrated repair improves perioperative outcomes but lacks a hospital volume association for complex abdominal aortic aneurysms. J Vasc Surg 73:417–425
O’Donnell TFX, Boitano LT, Deery SE et al (2020) Hospital volume matters: the volume-outcome relationship in open juxtarenal AAA repair. Ann Surg 271:184–219
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Appendices
Appendix 1
See Table
6.
Appendix 2. Extracted data from each study with a pre-specified proforma
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Study characteristics first author; year of publication; study design (prospective or retrospective observational); type of AAA (JAAA, PAAA, or both) and intervention (ChEVAR, FEVAR, OS), study duration.
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Study demographics number of participants per each treatment arm; mean age; female sex; smoking; comorbidities including hypertension, hyperlipidemia, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease (CAD), cerebrovascular disease, chronic kidney disease (CKD); AAA diameter.
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Periprocedural data for endovascular group: the number of chimney/fenestrations, stent-graft manufacturer, for open surgery group: proximal clamp position and mean proximal clamping time, operation duration, total blood loss, hospital, and intensive care unit stay
Appendix 3
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Appendix 4
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Appendix 5
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Appendix 6
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Zlatanovic, P., Jovanovic, A., Tripodi, P. et al. Chimney Versus Fenestrated Endovascular Versus Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta-analysis of the Short-term Results. World J Surg 47, 803–823 (2023). https://doi.org/10.1007/s00268-022-06829-x
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DOI: https://doi.org/10.1007/s00268-022-06829-x