Aktualisierte Metaanalyse EVAR versus offene Operation zur elektiven Ausschaltung von infrarenalen Bauchaortenaneurysmen

Zusammenfassung

Einleitung: Die elektive endovaskuläre abdominelle Aneurysmaausschaltung (EVAR) hat sich über die letzten 20 Jahre zu einer etablierten Therapieoption bei infrarenalen Bauchaortenaneurysmen (BAA) entwickelt. Dennoch wird der Benefit der EVAR im Vergleich zur offenen Aneurysmaauschaltung (OR) nach wie vor kontrovers diskutiert. Material und Methoden: Ein Random-Effects-Metaanalysemodell wurde verwendet, um das operative Outcome der elektiven EVAR mit der offenen Operation zu vergleichen. Die Endpunkte wurden unter Verwendung der Peto Odds Ratio (Peto OR) und Weighted Mean Differences (WMD) komparativ evaluiert. Vier prospektiv-randomisierte, kontrollierte Studien (EVAR-I, DREAM, OVER, ACE) mit insgesamt 2747 Patienten (EVAR: 1381; OR: 1366) wurden in die Metaanalyse inkludiert. Ergebnisse: Im Vergleich zur OR war die EVAR mit einer statistisch signifikant reduzierten 30-Tage-Mortalität assoziiert (Peto OR: 0,373; p < 0,001). Darüber hinaus bestand ein statistisch signifikanter Vorteil der EVAR gegenüber der OR hinsichtlich der aneurysmaassoziierten Mortalität (Peto OR: 0,589; p = 0,013) und der Dauer des Krankenhausaufenthalts (WMD − 0,494; p < 0,001). Demgegenüber wies die OR eine geringere Reinterventionsrate auf als die EVAR (Peto OR: 1,843; p < 0,001). Bei Betrachtung des Langzeitgesamtüberlebens (Peto OR: 0,977; p = 0,826) und der gesundheitsbezogenen Lebensqualität zeigte sich kein statistisch signifikanter Unterschied zwischen den beiden Therapieoptionen (WMD −0,032; p = 0,481). Schlussfolgerung: Trotz der klinischen Heterogenität der in die Metaanalyse eingeschlossenen Studien weist die Datenlage darauf hin, dass die EVAR einen deutlichen Benefit hinsichtlich der operativen Mortalität bietet. Im Langzeitverlauf geht dieser Überlebensvorteil verloren, was nicht durch die aneurysmaassoziierte Mortalität verursacht wird.

Abstract

Introduction: Elective endovascular abdominal aneurysm repair (EVAR) has become established in the past 20 years as a therapy option for infrarenal abdominal aortic aneurysms (AAA). Even so the benefits of EVAR over open aneurysm repair (OR) are still being discussed controversially. Materials and Methods: A random effects meta-analysis model was used to compare the surgical outcome of EVAR with that of open operations. The end points were evaluated comparatively by use of the Peto odds ratio (Peto OR) and weighted mean differences (WMD). Four prospective randomised studies (EVAR-1, DREAM, OVER, ACE) with a total of 2747 patients (EVAR 1381, OR 1366) were included in the metaanalysis. Results: In comparison to OR, EVAR was associated with a significantly reduced 30-day mortality rate (Peto OR: 0.373; p < 0.001). In addition, there was a statistically significant advantage of EVAR over OR with regard to aneurysm-associated mortality (Peto OR: 0.589, p = 0.013) and the length of hospital stay (SD in mean: − 0.494; p < 0.001). In contrast OR exhibited a lower re-intervention rate than EVAR (Peto OR: 1.843, p < 0.001). On consideration of long-term survival (Peto OR: 0,977; p = 0.826) and health-related quality of life there were no statistically significant differences between the two therapeutic options (SD in mean: − 0.032, p = 0.481). Conclusions: In spite of the clinical heterogeneity of the studies included in the metaanalysis, the data indicate that EVAR has a marked benefit with regard to surgical mortality. In the long-term course this advantage in survival is lost but this is not due to the aneurysm-associated mortality.

Schlüsselwörter

EVAR - Bauchaortenaneurysma - offene Operation - Metaanalyse

Key words

EVAR - abdominal aortic aneurysm - open repair - metaanalysis

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