Endovascular Repair Versus Open Surgical Repair for Complex Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis

Background: The purpose of this systematic review and meta-analysis was to compare the short and long-term outcomes of endovascular repair (ER) versus open surgical repair (OSR) for complex abdominal aortic aneurysms (CAAAs), using propensity-matched and nonpropensity-matched methods.Methods: PubMed, OVID, Embase, ELSEVIER and Cochrane library were searched for the studies that compared ER versus OSR for CAAAs from January 1999 to December 2020. CAAAs were defined as short neck, juxtarenal, pararenal and suprarenal abdominal aortic aneurysms. The primary outcomes were 30-day mortality, 30-day reintervention, medi um and long-term survival. We pooled outcomes of original studies and also performed subgroup analyses using RevMan. The analysis of statistical heterogeneity was performed with STATA 16.0.Results: A total of 21 studies with 12,049 patients (3847 ERs, 8202 OSRs) were included in this meta-analysis. In general, the patients undergoing ER were significantly older and likely to be man; more common with diabetes mellitus, congestive heart failure, renal failure, but smaller aortic aneurysms. In the nonpropensity-matched subgroup analysis of ER versus OSR, ER was associated with significantly decreased 30-day mortality (odds ratio [OR]: 0.60; 95% confidence interval [CI]: 0.49-0.74; P<0.001; I2 = 4%) and 30-day reintervention (OR: 0.59; 95% CI: 0.40-0.87; P = 0.007; I2 = 56%); lower rate of long-term survival (hazard ratio [HR]: 1.73; 95% CI: 1.21-2.47; P = 0.002; I2 = 0%); less perioperative comorbidities including myocardial infarcand shorter hospital length of stay. In the propensity-matched subgroup, ER was associated with poorer long-term survival (HR: 1.80; 95% CI: 1.06-3.06; P = 0.03; I2 = 0%), higher incidences of lower extremity ischemia (OR: 12.25; 95% CI: 1.54-97.48; P = 0.02; I2 = 16%) and renal artery restenosis (OR: 7.63; 95% CI: 1.35-43.24; P = 0.02). However, there was no significant difference in 30-day mortality (OR: 1.31; 95% CI: 0.65-2.66; P = 0.45; I2 = 0%), 30-day reintervention (OR: 1.58; 95% CI: 0.62-4.03; P = 0.34; I2 = 26%), mid-term survival (HR: 1.03; 95% CI: 0.30-3.56; P = 0.96; I2 = 0%) between ER and OSR groups.Conclusions: Our analyses suggest that OSR of CAAAs, compared with ER, is associated with improved long-term survival without increasing of perioperative deaths. ER may be consid-ered in the patients who are high-risk for open repair.