Editor's Choice - Systematic Review and Meta-Analysis of Sex Specific Differences in Adverse Events After Open and Endovascular Intact Abdominal Aortic Aneurysm Repair: Consistently Worse Outcomes for Women.

Previously, reports have shown that women experience a higher mortality rate than men after elective open (OAR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With recent improvements in overall AAA repair outcomes, this study aimed to identify whether sex specific disparity has been ameliorated by modern practice, and to define sex specific differences in peri- and post-operative complications and pre-operative status; factors which may contribute to poor outcome. This was a systematic review, meta-analysis, and meta-regression of sex specific differences in 30 day mortality and complications conducted according to PRISMA guidance (Prospero registration CRD42020176398). Papers with ≥ 50 women, reporting sex specific outcomes, following intact primary AAA repair, from 2000 to 2020 worldwide were included; with separate analyses for EVAR and OAR. Data sources were Medline, Embase, and CENTRAL databases 2005 - 2020 searched using ProQuest Dialog. Twenty-six studies (371 215 men, 65 465 women) were included. Meta-analysis and meta-regression indicated that sex specific odds ratios (ORs) for 30 day mortality were unchanged from 2000 to 2020. Mortality risk was higher in women for OAR and more so for EVAR (OR [95% CI] 1.49 [1.37 - 1.61]; 1.86 [1.59 - 2.17], respectively) and this remained following multivariable risk adjustment. Transfusion, pulmonary complications, and bowel ischaemia were more common in women after OAR and EVAR (OAR: ORs 1.81 [1.60 - 2.04], 1.40 [1.28 - 1.53], 1.54 [1.36 - 1.75]; EVAR: ORs 2.18 [2.08 - 2.29] 1.44 [1.17 - 1.77], 1.99 [1.51 - 2.62], respectively). Arterial injury, limb ischaemia, renal and cardiac complications were more common in women after EVAR (ORs 3.02 [1.62 - 5.65], 2.13 [1.48 - 3.06], 1.46 [1.22 - 1.72] and 1.19 [1.03 - 1.37], respectively); the latter was associated with greater mortality risk on meta-regression. Increased mortality risk for women following AAA repair remains. Women had a higher incidence of transfusion, pulmonary and bowel complications after EVAR and OAR. Higher mortality risk ratios for EVAR may result from cardiac complications, additional arterial injury, and embolisation, leading to renal and limb ischaemia. These findings indicate possible causes for observed outcome disparities and targets for quality improvement.

Pouncey AL ，David M ，Morris RI ，Ulug P ，Martin G ，Bicknell C ，Powell JT ... -  《-》

Meta-Analysis and Meta-Regression Analysis of Outcomes of Endovascular and Open Repair for Ruptured Abdominal Aortic Aneurysm.

The aim was to assess peri-operative mortality of endovascular aneurysm repair (EVAR) vs. open repair for ruptured abdominal aortic aneurysm (AAA) and to investigate whether outcomes have improved over the years and whether there is an association between institutional caseload and peri-operative mortality. Electronic information sources (MEDLINE, EMBASE, CINAHL and CENTRAL) were searched up to August 2019. A systematic review was carried out according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a registered protocol (CRD42018106084). Studies were selected that reported peri-operative mortality of EVAR for ruptured AAA. A proportion meta-analysis was conducted, and summary estimates of odds ratios (ORs) and 95% confidence intervals (CIs) for EVAR vs. open surgical repair were obtained using random effects models. Mixed effects regression models were developed to investigate outcome changes over time and with institutional caseload. One hundred and thirty-six studies were included in quantitative synthesis reporting a total of 267 259 patients (EVAR 58 273; open surgery 208 986). The pooled peri-operative mortality of EVAR and open surgical repair was 0.245 (95% CI 0.234-0.257) and 0.378 (95% CI 0.364-0.392), respectively. EVAR was associated with reduced peri-operative mortality (OR 0.54, 95% CI 0.51-0.57, p < .001). Meta-regression analysis found decreasing peri-operative mortality over the years following EVAR (p < .001) and open repair (p < .001), and a decreasing OR of peri-operative mortality in favour of EVAR (p = .053). Meta-regression found a significant positive association between peri-operative mortality and institutional case load for open repair (p = .004). If EVAR can be done, it is a better treatment for ruptured AAA in view of the reduced peri-operative mortality compared with open surgery. The outcomes of both EVAR and open surgical repair have improved over the years, and the difference in peri-operative mortality in favour of EVAR has become more pronounced. There is a significant association between peri-operative mortality and institutional case load for open repair of ruptured AAA.

Kontopodis N ，Galanakis N ，Antoniou SA ，Tsetis D ，Ioannou CV ，Veith FJ ，Powell JT ，Antoniou GA ... -  《-》

Systematic review and meta-analysis of sex differences in outcomes after endovascular aneurysm repair for infrarenal abdominal aortic aneurysm.

Women face distinctive challenges when they receive endovascular aneurysm repair (EVAR) treatment, and according to the previous studies, sex differences in outcomes after EVAR for infrarenal abdominal aortic aneurysm (AAA) remains controversial. This study aimed to compare the short-term and long-term outcomes between women and men after EVAR for infrarenal AAA. We conducted a comprehensive systematic review and meta-analysis of all available studies reporting sex differences after EVAR for infrarenal AAA, which were retrieved from the MEDICINE, Embase, and Cochrane Database. The pooled results were presented as odds ratios (ORs) for dichotomous data and hazard ratios for time-to-event data using a random effect model. Thirty-six cohorts were included in this meta-analysis. The pooled results showed that women were associated with a significantly increased risk of 30-day mortality (crude OR, 1.67; 95% confidence interval [CI], 1.50-1.87; P < .001; adjusted OR, 1.73; 95% CI, 1.32-2.26; P < .001), in-hospital mortality (OR, 1.90; 95% CI, 1.43-2.53; P < .001), limb ischemia (OR, 2.44; 95% CI, 1.73-2.43; P < .001), renal complications (OR, 1.73; 95% CI, 1.12-2.67; P = .028), cardiac complications (OR, 1.68; 95% CI, 1.01-2.80; P = .046), and long-term all-cause mortality (hazard ratio, 1.23; 95% CI, 1.09-1.38; P = .001) compared with men; however, no significant sex difference was observed for visceral/mesenteric ischemia (OR, 1.62; 95% CI, 0.91-2.88; P = .098), 30-day reinterventions (OR, 1.37; 95% CI, 0.95-1.98; P = .095), late endoleaks (OR, 1.18; 95% CI, 0.88-1.56; P = .264), and late reinterventions (OR, 1.05; 95% CI, 0.78-1.41; P = .741). In the intact AAA subgroup, women had a significantly increased risk of visceral/mesenteric ischemia (OR, 1.85; 95% CI, 1.01-3.39; P = .046) and an equivalent risk of cardiac complications (OR, 1.64; 95% CI, 0.85-3.17; P = .138) compared with men. Compared with male sex, female sex is associated with an increased risk of 30-day mortality, in-hospital mortality, limb ischemia, renal complications, cardiac complications, and long-term all-cause mortality after EVAR for infrarenal AAA. Women should be enrolled in a strict and regular long-term surveillance after EVAR.

Liu Y ，Yang Y ，Zhao J ，Chen X ，Wang J ，Ma Y ，Huang B ，Yuan D ，Du X ... -  《-》

Risk factors and outcomes for bowel ischemia after open and endovascular abdominal aortic aneurysm repair.

Bowel ischemia (BI) is a serious complication after abdominal aortic aneurysm (AAA) repair. We sought to identify the incidence and risk factors associated with the development of postoperative BI and the post-BI outcomes for patients undergoing open aortic repair (OAR) and endovascular aortic repair (EVAR) of AAAs. A retrospective analysis was conducted for all patients who had undergone OAR or EVAR from 2003 to 2017 using the Vascular Quality Initiative database. Univariate (Student's t test, χ2, median) and multivariable (logistic regression) analyses were used to identify independent factors associated with postoperative BI and compare the post-BI in-hospital outcomes and mortality. We identified 45,474 patients who had undergone infrarenal AAA repair (OAR, 21.5%; EVAR, 78.5%). The overall incidence of postoperative BI was 1.9% (OAR, 6.2% vs EVAR, 0.8%; P < .001). OAR was associated with a threefold increased odds of BI compared with EVAR (adjusted odds ratio [aOR], 3.24; 95% confidence interval [CI], 2.49-4.22; P < .001). The independent factors associated with BI after OAR included older age (aOR per year of age, 1.02; 95% CI, 1.00-1.03), congestive heart failure (aOR, 1.44; 95% CI, 1.05-1.98), and ruptured aneurysm (aOR, 4.16; 95% CI, 2.98-5.81; P < .01 for all). We also found that transfusion ≥1 U (aOR, 1.69; 95% CI, 1.30-2.20), a transperitoneal approach (aOR, 2.13; 95% CI, 1.03-1.87), supraceliac clamping (aOR, 1.58; 95% CI, 1.08-2.33), and inferior mesenteric artery reimplantation (aOR, 1.41; 95% CI, 1.06-1.89) were associated with greater odds of BI after OAR (P < .01 for all). Similarly, we found that ruptured aneurysms, a longer operative time, and transfusion of ≥1 U of blood were associated with BI after EVAR (P < .001 for all). For both OAR and EVAR, the postoperative stay (median, 13 days [interquartile range (IQR), 7-26 days] vs 7 days [IQR, 5-10 days] and 11 days [IQR, 4-23 days] vs 1 day [IQR, 1-3 days], respectively) and 30-day mortality (35.0% vs 6.4% and 40.5% vs 1.9%, respectively) were significantly higher for patients with BI (P < .001 for all). The predictors of mortality for patients with BI were surgical management (aOR, 2.05; 95% CI, 1.28-3.30), older age (aOR, 1.05; 95% CI, 1.02-1.07), symptomatic aneurysm (aOR, 1.26; 95% CI, [0.60-2.62), ruptured aneurysm (aOR, 2.23; 95% CI, 1.43-3.48), longer operative time (aOR, 1.11; 95% CI, 1.01-1.22), and postoperative renal complications (aOR, 2.98; 95% CI, 1.80-4.96; P < .05 for all). Confirming the results from previous studies, we found that BI is more common after a ruptured aneurysm and OAR. Other associated intraoperative factors included a transperitoneal approach, supraceliac clamping, and a reimplanted inferior mesenteric artery. More than one third of patients who developed postoperative BI in our cohort had died within 30 days after AAA repair. The factors associated with mortality after BI included surgical management and postoperative renal failure. A high index of suspicion for the signs and symptoms of BI should be maintained postoperatively for patients presenting with the risk factors identified.

Gurakar M ，Locham S ，Alshaikh HN ，Malas MB ... -  《-》

A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective settings.

Females represent a group of patients with higher mortality after abdominal aortic aneurysm (AAA), endovascular (EVAR), or open surgical (OSR), repair. This systematic review aimed to evaluate the 30-day mortality after AAA repair in females, comparing both EVAR and OSR, in elective and urgent settings. The protocol of the review was registered to the PROSPERO database (CRD42021242686). A search of the English literature was conducted, using PubMed, EMBASE, and CENTRAL databases, from inception to March 5, 2021, using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA). Only studies reporting on 30-day mortality of AAA repair, in urgent and elective settings, comparing EVAR and OSR, in the female population were eligible. Patients were stratified according to the need for elective or urgent repair. Symptomatic and ruptured cases were included into the urgent group. Individual studies were assessed for risk of bias using the (Risk Of Bias In Non-randomised Studies - of Interventions) ROBINS-I tool. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to evaluate the quality of evidence. The primary outcome was 30-day mortality after AAA repair in the female population, comparing EVAR and OSR. The outcomes were summarized as odds ratio, along with their 95% confidence intervals (CIs), through a paired meta-analysis. Eight studies reported data on 30-day mortality following AAA repair. A total of 56,982 females (22,995 EVAR vs 33,987 OSR) were included. A significantly reduced total 30-day mortality rate was recorded among females that underwent EVAR compared with OSR (odds ratio [OR], 0.25; 95% CI, 0.23-0.27; P < .001; Ι2 = 86%). In addition, a reduced 30-day mortality was found in females that underwent elective EVAR compared with OSR (OR, 0.37; 95% CI, 0.33-0.41; P < .001; Ι2 = 48%). Despite the fact that OSR was more frequently offered in the urgent setting (OR, 0.21; 95% CI, 0.19-0.23; P < .001; Ι2 = 84%), EVAR was associated with a reduced 30-day mortality (OR, 0.48; 95% CI, 0.40-0.57; P < .001; Ι2 = 0%). In females, EVAR is associated with lower 30-day mortality in both elective and urgent AAA repair, although it appears as less likely to be offered in the setting of urgent AAA repair.

Nana P ，Dakis K ，Brodis A ，Spanos K ，Kouvelos G ，Eckstein HH ，Giannoukas A ... -  《-》