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

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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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Funding

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Author information

Authors and Affiliations

  1. Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia

    Petar Zlatanovic & Lazar Davidovic

  2. Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia

    Aleksa Jovanovic

  3. Faculty of Medicine, University of Belgrade, Belgrade, Serbia

    Aleksa Jovanovic & Lazar Davidovic

  4. Vascular Surgery Division, Hospital Clinic, University of Barcelona, Barcelona, Spain

    Paolo Tripodi

Authors
  1. Petar Zlatanovic
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  2. Aleksa Jovanovic
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  3. Paolo Tripodi
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  4. Lazar Davidovic
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Correspondence to Petar Zlatanovic.

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Appendices

Appendix 1

See Table

Table 6 Search strategy
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6.

Appendix 2. Extracted data from each study with a pre-specified proforma

  • 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.

  • 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.

  • 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

See Table

Table 7 Summary of findings table showing comparison (A) FEVAR versus open surgery for JAAA/PAAA treatment, (B) Chimney EVAR versus open surgery for JAAA/PAAA treatment, (C) Chimney EVAR versus FEVAR for JAAA/PAAA treatment
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7.

Appendix 4

See Table

Table 8 Model comparison of fixed-effect versus random-effects models for the primary outcomes
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8.

Appendix 5

See Table

Table 9 Network meta-regression of (A) mortality in patients undergoing repair of juxta/pararenal abdominal aortic aneurysm, (B) acute kidney injury in patients undergoing repair of juxta/pararenal abdominal aortic aneurysm, (C) bowel ischaemia in patients undergoing repair of juxta/pararenal abdominal aortic aneurysm, (D) major adverse cardiovascular events (MACE) in patients undergoing repair of juxta/pararenal abdominal aortic aneurysm
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9.

Appendix 6

See Fig. 

Fig. 4
figure 4

The probability of each treatment being the best, second best, and worst for outcomes. Legend. AKI—acute kidney injury; BI—bowel ischaemia; LLI—lower limb ischaemia; SCI—spinal cord ischaemia; MACE—major adverse cardiac event; PC—pulmonary complications; VS/BO—visceral stent/bypass occlusion; WC—wound complication

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4.

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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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