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Journal of Vascular Surgery Aug 2022Clostridium septicum bacteremia is often associated with occult malignancies (approximately 80%), especially of the right colon. Furthermore, inflammation of the aortic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Clostridium septicum bacteremia is often associated with occult malignancies (approximately 80%), especially of the right colon. Furthermore, inflammation of the aortic wall can rapidly lead to aneurysm induction through bacterial seeding into atheromatous lesions with consecutive life-threatening rupture. We summarize all published data on this rare and lethal disease to evaluate therapeutic approaches and give valid treatment recommendations because there are no guidelines.
METHODS
A systematic review of the literature was conducted screening EMBASE and MEDLINE databases following the PRISMA guidelines with search period from first description to August 25, 2021.
RESULTS
There were 72 cases of C septicum aortitis reported in 64 publications. Endovascular aortic repair (EVAR) was performed in a minority of patients (n = 6) unfit for surgery but lacked long-term survivors. Antibiotic treatment was beneficial in a bridge to surgery concept, but up to now harbored a 6-month mortality rate of 100% (median overall survival, 0.5 months) when no additional aortic repair was performed. Open aortic repair was the only potential curative approach but was accompanied with a 90-day-mortality of 26.7% (4/15).
CONCLUSIONS
Open aortic repair combined with perioperative antibiotic treatment should be offered to all patients as the only potentially curative approach. If applicable, resection of a coexisting colonic tumor should be performed after successful aortic repair. Alternatively, long-term antibiotic treatment can be offered to patients unfit for surgery in a palliative setting. Endovascular aortic repair has been performed on a minority of patients with a high risk for stent graft infection and should remain a salvage strategy when therapeutic pressure demands acute intervention in patients unfit for surgery.
Topics: Anti-Bacterial Agents; Aorta; Aortic Aneurysm, Abdominal; Aortitis; Blood Vessel Prosthesis Implantation; Clostridium septicum; Endovascular Procedures; Humans; Stents; Treatment Outcome
PubMed: 35358668
DOI: 10.1016/j.jvs.2022.02.029 -
European Journal of Vascular and... Apr 2022Increased aortic stiffness (AoS) has been recognised as a risk factor in the development of cardiovascular disease. The aim of this systematic review and meta-analysis... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Increased aortic stiffness (AoS) has been recognised as a risk factor in the development of cardiovascular disease. The aim of this systematic review and meta-analysis was to assess the impact of aortic repair on AoS.
DATA SOURCES
PubMed, Scopus, and Web of Science were searched systematically for relevant studies evaluating the consequences of endovascular and open aortic repair on AoS.
REVIEW METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement was followed to perform the research process. Papers containing data on AoS before and after both thoracic (TEVAR) and abdominal (EVAR) endovascular repair, as well as open surgical repair (OSR), were included for detailed evaluation. A fixed effects model was used to perform analysis. The Newcastle-Ottawa Scale was calculated for each included study.
RESULTS
The first article cluster comprised 367 papers. After removal of duplicates and the adoption of inclusion/exclusion criteria, 14 articles remained, 13 of which were selected for meta-analysis. Ten studies analysed EVAR and three analysed TEVAR. Five of the selected papers were case control studies, with OSR adopted in four of these as the EVAR comparator. Several graft types were used in the endovascular group. AoS increased after TEVAR and EVAR, in terms of pulse wave velocity (PWV), even though several spatial levels and measurement modalities were adopted. No differences were described after OSR, although no pooled data could be analysed.
CONCLUSION
EVAR and TEVAR both demonstrated a significant increase in AoS measurement (PWV). Although the heterogeneity and the low number of available studies limit the strength of the results, this review highlights the potential deleterious endograft role in the cardiovascular system although further studies are needed to achieve robust evidence. Further studies are needed to improve the mutual interaction between aorta and endograft, minimising their impact on the native aortic wall properties.
Topics: Aorta; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Pulse Wave Analysis; Risk Factors; Treatment Outcome; Vascular Stiffness
PubMed: 35283000
DOI: 10.1016/j.ejvs.2022.01.008 -
Biomedicines Oct 2021The aim of this systematic review was to pool evidence from studies testing if pentagalloyl glucose (PGG) limited aortic expansion in animal models of abdominal aortic...
BACKGROUND
The aim of this systematic review was to pool evidence from studies testing if pentagalloyl glucose (PGG) limited aortic expansion in animal models of abdominal aortic aneurysm (AAA).
METHODS
The review was conducted according to the PRISMA guidelines and registered with PROSPERO. The primary outcome was aortic expansion assessed by direct measurement. Secondary outcomes included aortic expansion measured by ultrasound and aortic diameter at study completion. Sub analyses examined the effect of PGG delivery in specific forms (nanoparticles, periadventitial or intraluminal), and at different times (from the start of AAA induction or when AAA was established), and tested in different animals (pigs, rats and mice) and AAA models (calcium chloride, periadventitial, intraluminal elastase or angiotensin II). Meta-analyses were performed using Mantel-Haenszel's methods with random effect models and reported as mean difference (MD) and 95% confidence intervals (CIs). Risk of bias was assessed with a customized tool.
RESULTS
Eleven studies reported in eight publications involving 214 animals were included. PGG significantly reduced aortic expansion measured by direct observation (MD: -66.35%; 95% CI: -108.44, -24.27; = 0.002) but not ultrasound (MD: -32.91%; 95% CI: -75.16, 9.33; = 0.127). PGG delivered intravenously within nanoparticles significantly reduced aortic expansion, measured by both direct observation (MD: -116.41%; 95% CI: -132.20, -100.62; < 0.001) and ultrasound (MD: -98.40%; 95% CI: -113.99, -82.81; < 0.001). In studies measuring aortic expansion by direct observation, PGG administered topically to the adventitia of the aorta (MD: -28.41%; 95% CI -46.57, -10.25; = 0.002), studied in rats (MD: -56.61%; 95% CI: -101.76, -11.46; = 0.014), within the calcium chloride model (MD: -56.61%; 95% CI: -101.76, -11.46; = 0.014) and tested in established AAAs (MD: -90.36; 95% CI: -135.82, -44.89; < 0.001), significantly reduced aortic expansion. The findings of other analyses were not significant. The risk of bias of all studies was high.
CONCLUSION
There is inconsistent low-quality evidence that PGG inhibits aortic expansion in animal models.
PubMed: 34680560
DOI: 10.3390/biomedicines9101442 -
International Journal of Surgery... Nov 2021To study the mid- and long-term outcomes of type II endoleak treatment after EVAR and the technical aspects of different techniques to exclude endoleaks which different... (Review)
Review
OBJECTIVE
To study the mid- and long-term outcomes of type II endoleak treatment after EVAR and the technical aspects of different techniques to exclude endoleaks which different embolic agents.
METHODS
A systematic review was performed using the approach recommended by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for meta-analyses of interventional studies. The comprehensive search was conducted using the following database: MEDLINE, EMBASE, and the Cochrane Library. Patient characteristic, intervention approaches, embolic agents, and results at mid and long term follow up were studied.
RESULTS
A total of 6 studies corresponding to a total of 141 patients fulfilled the inclusion criteria with a mean age of 73-78.6 years and a mean duration of follow up varying from 25 to 42 months. There were different techniques for embolization used (translumbar, transarterial, and transcaval approach) with various types of embolic agents. In all studies, the indication for embolization of the type II endoleaks was sac enlargement of more than 5 mm. A wide range of technical success rate was reported regardless of the intervention strategy being used (17,6%-100%). The overall technical success rate of all studies was 62%.
CONCLUSION
This systematic review shows that there is a wide variety of techniques to exclude a persistent type II endoleak. Different kinds of embolic agents have be used. Due to a lack of peer reviewed data on longterm follow-up, it was not possible to come to recommendations what treatment would be the best for a durable exclusion of a persistent type II endoleak after an initially successful EVAR. There remains an urgent need for proper executed studies, either randomized or with close observation in relation to longer follow-up.
Topics: Aged; Aortic Aneurysm, Abdominal; Embolization, Therapeutic; Endoleak; Endovascular Procedures; Humans
PubMed: 34637951
DOI: 10.1016/j.ijsu.2021.106138 -
Diagnostics (Basel, Switzerland) Aug 2021(1) Background: Perivascular adipose tissue attenuation, measured with computed tomography imaging, is a marker of mean local vascular inflammation since it reflects the... (Review)
Review
(1) Background: Perivascular adipose tissue attenuation, measured with computed tomography imaging, is a marker of mean local vascular inflammation since it reflects the morphological changes of the fat tissue in direct contact with the vessel. This method is thoroughly validated in coronary arteries, but few studies have been performed in other vascular beds. The aim of the present study is to provide insight into the potential application of perivascular adipose tissue attenuation through computed tomography imaging in extra-coronary arteries. (2) Methods: A comprehensive search of the scientific literature published in the last 30 years (1990-2020) has been performed on Medline. (3) Results: A Medline databases search for titles, abstracts, and keywords returned 3251 records. After the exclusion of repetitions and the application of inclusion and exclusion criteria and abstract screening, 37 studies were selected for full-text evaluation. Three papers were finally included in the systematic review. Perivascular adipose tissue attenuation assessment was studied in the internal carotid artery, ascending thoracic aorta, and abdominal aorta. (4) Conclusions: Perivascular adipose tissue attenuation seems to be an applicable parameter in all investigated vascular beds, generally with good inter-observer reproducibility.
PubMed: 34441429
DOI: 10.3390/diagnostics11081495 -
The Cochrane Database of Systematic... Jul 2021A dissection of the aorta is a separation or tear of the intima from the media. This tear allows blood to flow not only through the original aortic flow channel (known...
BACKGROUND
A dissection of the aorta is a separation or tear of the intima from the media. This tear allows blood to flow not only through the original aortic flow channel (known as the true lumen), but also through a second channel between the intima and media (known as the false lumen). Aortic dissection is a life-threatening condition which can be rapidly fatal. There is debate on the optimal surgical approach for aortic arch dissection. People with ascending aortic dissection have poor rates of survival. Currently open surgical repair is regarded as the standard treatment for aortic arch dissection. We intend to review the role of hybrid and open repair in aortic arch dissection.
OBJECTIVES
To assess the effectiveness and safety of a hybrid technique of treatment over conventional open repair in the management of aortic arch dissection.
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 8 February 2021. We also undertook reference checking for additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and clinical controlled trials (CCTs), which compared the effects of hybrid repair techniques versus open surgical repair of aortic arch dissection. Outcomes of interest were dissection-related mortality and all-cause mortality, neurological deficit, cardiac injury, respiratory compromise, renal ischaemia, false lumen thrombosis (defined by partial or complete thrombosis) and mesenteric ischaemia.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened all records identified by the literature searches to identify those that met our inclusion criteria. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of the evidence using GRADE.
MAIN RESULTS
We identified one ongoing study and two unpublished studies that met the inclusion criteria for the review. Due to a lack of study data, we could not compare the outcomes of hybrid repair to conventional open repair for aortic arch dissection.
AUTHORS' CONCLUSIONS
This review revealed one ongoing RCT and two unpublished RCTs evaluating hybrid versus conventional open repair for aortic arch surgery. Observational data suggest that hybrid repair for aortic arch dissection could potentially be favourable, but conclusions can not be drawn from these studies, which are highly selective, and are based on the clinical status of the patient, the presence of comorbidities and the skills of the operators. However, a conclusion about its definitive benefit over conventional open surgical repair cannot be made from this review without published RCTs or CCTs. Future RCTs or CCTs need to have adequate sample sizes and follow-up, and assess clinically-relevant outcomes, in order to determine the optimal treatment for people with aortic arch dissection. It must be noted that this may not be feasible, due to the reasons mentioned.
Topics: Aortic Dissection; Aortic Aneurysm, Thoracic; Combined Modality Therapy; Humans; Randomized Controlled Trials as Topic; Vascular Grafting
PubMed: 34304394
DOI: 10.1002/14651858.CD012920.pub2 -
European Journal of Vascular and... Sep 2021To investigate whether patients with severe infrarenal aortic neck angulation have worse outcomes than those without severe angulation after endovascular aneurysm repair... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To investigate whether patients with severe infrarenal aortic neck angulation have worse outcomes than those without severe angulation after endovascular aneurysm repair (EVAR).
DATA SOURCES
The HDAS (Healthcare Database Advanced Search) interface developed by NICE (National Institute for Health and Care Excellence) was used to search electronic bibliographic databases.
REVIEW METHODS
Studies comparing outcomes of standard EVAR in patients with and without severe neck angulation were considered. Pooled outcome estimates were calculated using the odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI), using the Mantel-Haenszel or inverse variance method, as appropriate. Random effects models of meta-analysis were applied. The GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) methodology was used to assess the certainty of evidence.
RESULTS
Ten studies reporting a total of 7 371 patients (1 576 with severe neck angulation and 5 795 without) were included. The studies reported medium term follow up. No statistically significant difference was found for the primary outcomes (overall mortality: HR 1.27, 95% CI 0.88 - 1.85, low certainty; aneurysm related mortality: HR 1.07, 95% CI 0.80 - 1.44, moderate certainty; aneurysm rupture: HR 1.41, 95% CI 0.66 - 2.99, low certainty). The hazard of type Ia endoleak (HR 1.86, 95% CI 1.32 - 2.61) and re-intervention was higher in patient with severe angulation (HR 1.24, 95% CI 1.01 - 1.54), but there was no significant difference in the odds of adjunctive procedures (OR 1.23, 95% CI 0.48 - 3.11), or the hazard of sac expansion (HR 0.83, 95% CI 0.44 - 1.55) or stent migration (HR 1.22, 95% CI 0.78 - 1.92). Meta-analysis of studies that conducted multiple Cox regression analysis showed no significant difference for any of the primary outcomes.
CONCLUSION
Severe neck angulation may not be a poor prognostic indicator for overall/aneurysm related mortality and rupture in the medium term after EVAR but may increase the risk of late type 1 endoleaks and re-intervention; therefore, patients require close surveillance.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Humans; Models, Statistical; Odds Ratio; Postoperative Complications; Prognosis; Reoperation; Risk Factors; Treatment Outcome
PubMed: 34301460
DOI: 10.1016/j.ejvs.2021.05.014 -
The Cochrane Database of Systematic... Jul 2021An abdominal aortic aneurysm (AAA) is an abnormal dilation in the diameter of the abdominal aorta of 50% or more of the normal diameter or greater than 3 cm in total.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
An abdominal aortic aneurysm (AAA) is an abnormal dilation in the diameter of the abdominal aorta of 50% or more of the normal diameter or greater than 3 cm in total. The risk of rupture increases with the diameter of the aneurysm, particularly above a diameter of approximately 5.5 cm. Perioperative and postoperative morbidity is common following elective repair in people with AAA. Prehabilitation or preoperative exercise is the process of enhancing an individual's functional capacity before surgery to improve postoperative outcomes. Studies have evaluated exercise interventions for people waiting for AAA repair, but the results of these studies are conflicting.
OBJECTIVES
To assess the effects of exercise programmes on perioperative and postoperative morbidity and mortality associated with elective abdominal aortic aneurysm repair.
SEARCH METHODS
We searched the Cochrane Vascular Specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Physiotherapy Evidence Database (PEDro) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 6 July 2020. We also examined the included study reports' bibliographies to identify other relevant articles.
SELECTION CRITERIA
We considered randomised controlled trials (RCTs) examining exercise interventions compared with usual care (no exercise; participants maintained normal physical activity) for people waiting for AAA repair.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected studies for inclusion, assessed the included studies, extracted data and resolved disagreements by discussion. We assessed the methodological quality of studies using the Cochrane risk of bias tool and collected results related to the outcomes of interest: post-AAA repair mortality; perioperative and postoperative complications; length of intensive care unit (ICU) stay; length of hospital stay; number of days on a ventilator; change in aneurysm size pre- and post-exercise; and quality of life. We used GRADE to evaluate certainty of the evidence. For dichotomous outcomes, we calculated the risk ratio (RR) with the corresponding 95% confidence interval (CI).
MAIN RESULTS
This review identified four RCTs with a total of 232 participants with clinically diagnosed AAA deemed suitable for elective intervention, comparing prehabilitation exercise therapy with usual care (no exercise). The prehabilitation exercise therapy was supervised and hospital-based in three of the four included trials, and in the remaining trial the first session was supervised in hospital, but subsequent sessions were completed unsupervised in the participants' homes. The dose and schedule of the prehabilitation exercise therapy varied across the trials with three to six sessions per week and a duration of one hour per session for a period of one to six weeks. The types of exercise therapy included circuit training, moderate-intensity continuous exercise and high-intensity interval training. All trials were at a high risk of bias. The certainty of the evidence for each of our outcomes was low to very low. We downgraded the certainty of the evidence because of risk of bias and imprecision (small sample sizes). Overall, we are uncertain whether prehabilitation exercise compared to usual care (no exercise) reduces the occurrence of 30-day (or longer if reported) mortality post-AAA repair (RR 1.33, 95% CI 0.31 to 5.77; 3 trials, 192 participants; very low-certainty evidence). Compared to usual care (no exercise), prehabilitation exercise may decrease the occurrence of cardiac complications (RR 0.36, 95% CI 0.14 to 0.92; 1 trial, 124 participants; low-certainty evidence) and the occurrence of renal complications (RR 0.31, 95% CI 0.11 to 0.88; 1 trial, 124 participants; low-certainty evidence). We are uncertain whether prehabilitation exercise, compared to usual care (no exercise), decreases the occurrence of pulmonary complications (RR 0.49, 95% 0.26 to 0.92; 2 trials, 144 participants; very low-certainty evidence), decreases the need for re-intervention (RR 1.29, 95% 0.33 to 4.96; 2 trials, 144 participants; very low-certainty evidence) or decreases postoperative bleeding (RR 0.57, 95% CI 0.18 to 1.80; 1 trial, 124 participants; very low-certainty evidence). There was little or no difference between the exercise and usual care (no exercise) groups in length of ICU stay, length of hospital stay and quality of life. None of the studies reported data for the number of days on a ventilator and change in aneurysm size pre- and post-exercise outcomes.
AUTHORS' CONCLUSIONS
Due to very low-certainty evidence, we are uncertain whether prehabilitation exercise therapy reduces 30-day mortality, pulmonary complications, need for re-intervention or postoperative bleeding. Prehabilitation exercise therapy might slightly reduce cardiac and renal complications compared with usual care (no exercise). More RCTs of high methodological quality, with large sample sizes and long-term follow-up, are needed. Important questions should include the type and cost-effectiveness of exercise programmes, the minimum number of sessions and programme duration needed to effect clinically important benefits, and which groups of participants and types of repair benefit most.
Topics: Aortic Aneurysm, Abdominal; Bias; Circuit-Based Exercise; Elective Surgical Procedures; Heart Diseases; High-Intensity Interval Training; Humans; Kidney Diseases; Lung Diseases; Physical Conditioning, Human; Postoperative Complications; Postoperative Hemorrhage; Preoperative Exercise; Randomized Controlled Trials as Topic; Reoperation; Time Factors
PubMed: 34236703
DOI: 10.1002/14651858.CD013662.pub2 -
Journal of Vascular Surgery Dec 2021The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The aim of our systematic review and meta-analysis was to assess the effect of accessory renal artery (ARA) coverage on renal function in terms of acute kidney injury (AKI), renal infarction, chronic renal failure (CRF), and mortality in patients undergoing standard endovascular aortic aneurysm repair (EVAR) or endovascular repair of complex aneurysms.
METHODS
An electronic search of the English language medical literature from 2000 to September 2020 was conducted using the MEDLINE, EMBASE, and Cochrane databases with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) method for studies reporting on ARA management in patients undergoing endovascular repair of aneurysms in the abdominal and thoracoabdominal aorta. The patients were divided into two groups: group 1, patients with ARA coverage; and group 2, patients without an ARA or without coverage of the ARA. Each group included two arms, one of patients who had undergone standard EVAR and one of patients who had undergone endovascular treatment of a complex aortic aneurysm. The GRADE (grading of recommendations assessment, development, evaluation) approach was used to evaluate the quality of evidence and summary of the findings. The primary outcomes included the incidence of AKI, renal infarction, CRF, and mortality.
RESULTS
Ten retrospective, nonrandomized, control studies were included in the systematic review reporting on 1014 patients (302 with a covered ARA vs 712 without an ARA or without ARA coverage). In six studies, the mean diameter of the covered ARA was <4 mm (range, 2.7-3.4 mm). The mean follow-up was 22.74 months (range, 1-42 months). In the standard EVAR subgroup, the risk of AKI (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.21-2.51; I = 0%] in the early period, and CRF (OR, 4.44; 95% CI, 0.46-42.61; I = 87%) and death (OR, 0.91; 95% CI, 0.36-2.31; I = 0%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater in group 1 than in group 2 (OR, 93.3; 95% CI, 1.48-5869; I = 92%). In the complex aneurysm repair subgroup, the risk of AKI (OR, 1.85; 95% CI, 0.61-5.64; I = 42%) in early period and CRF (OR, 1.64; 95% CI, 0.88-3.07; I = not applicable) and death (OR, 3.63; 95% CI, 0.14-96.29; I = 56%) during follow-up were similar between groups 1 and 2. Only the risk of renal infarction was greater for group 1 compared with group 2 (OR, 8.58; 95% CI, 4.59-16.04; I = 0%).
CONCLUSIONS
ARA (<4 mm) coverage in patients undergoing standard EVAR or endovascular repair of complex aneurysms is associated with an increased risk of renal infarction. However, we found no clinical effects of ARA coverage on renal function or mortality in early postoperative and follow-up period. Preservation of an ARA >4 mm should be considered.
Topics: Acute Kidney Injury; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Kidney Failure, Chronic; Renal Artery; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 34197943
DOI: 10.1016/j.jvs.2021.06.032 -
The Cochrane Database of Systematic... Jun 2021There has been extensive debate in the surgical literature regarding the optimum surgical access approach to the infrarenal abdominal aorta during an operation to repair... (Meta-Analysis)
Meta-Analysis
BACKGROUND
There has been extensive debate in the surgical literature regarding the optimum surgical access approach to the infrarenal abdominal aorta during an operation to repair an abdominal aortic aneurysm. The published trials comparing retroperitoneal (RP) and transperitoneal (TP) aortic surgery show conflicting results. This is an update of the review first published in 2016.
OBJECTIVES
To assess the effectiveness and safety of the retroperitoneal versus transperitoneal approach for elective open abdominal aortic aneurysm repair on mortality, complications, hospital stay and blood loss.
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trials registers to 30 November 2020. The review authors searched the Chinese Biomedical Literature Database and handsearched reference lists of relevant articles to identify additional trials.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) that assessed the RP approach versus the TP approach for elective open abdominal aortic aneurysm (AAA) repair. There were no restrictions on language or publication status.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from the included trials. We resolved any disagreements through discussion with a third review author. Two review authors independently assessed the risk of bias in included trials with the Cochrane risk of bias tool. For dichotomous outcomes, we calculated the odds ratio (OR) with the corresponding 95% confidence interval (CI). For continuous data, we calculated a pooled estimate of treatment effect by calculating the mean difference (MD) and standard deviation (SD) with corresponding 95% CIs. We pooled data using a fixed-effect model, unless we identified heterogeneity, in which case we used a random-effects model. We used GRADE to assess the overall certainty of the evidence. We evaluated the outcomes of mortality, complications, intensive care unit (ICU) stay, hospital stay, blood loss, aortic cross-clamp time and operating time.
MAIN RESULTS
We identified no new studies from the updated searches. After reassessment, we included one study which had previously been excluded. Five RCTs with a combined total of 152 participants are included. The overall certainty of the evidence ranged from low to very low because of the low methodological quality of the included trials (unclear random sequence generation method and allocation concealment, and no blinding of outcome assessors), small sample sizes, small number of events, high heterogeneity and inconsistency between the included trials, no power calculations and relatively short follow-up. There was no evidence of a difference between the RP approach and the TP approach regarding mortality (odds ratio (OR) 0.32, 95% CI 0.01 to 8.25; 3 studies, 110 participants; very low-certainty evidence). Similarly, there was no evidence of a difference in complications such as hematoma (OR 0.90, 95% CI 0.13 to 6.48; 2 studies, 75 participants; very low-certainty evidence), abdominal wall hernia (OR 10.76, 95% CI 0.55 to 211.78; 1 study, 48 participants; very low-certainty evidence), or chronic wound pain (OR 2.20, 95% CI 0.36 to 13.34; 1 study, 48 participants; very low-certainty evidence) between the RP and TP approaches in participants undergoing elective open AAA repair. The RP approach may reduce ICU stay (mean difference (MD) -19.02 hours, 95% CI -30.83 to -7.21; 3 studies, 106 participants; low-certainty evidence); hospital stay (MD -3.30 days, 95% CI -4.85 to-1.75; 5 studies, 152 participants; low-certainty evidence); and blood loss (MD -504.87 mL, 95% CI -779.19 to -230.56; 4 studies, 129 participants; very low-certainty evidence). There was no evidence of a difference between the RP approach and the TP approach regarding aortic cross-clamp time (MD 0.69 min, 95% CI -7.23 to 8.60; 4 studies, 129 participants; very low-certainty evidence) or operating time (MD -15.94 min, 95% CI -34.76 to 2.88; 4 studies, 129 participants; very low-certainty evidence).
AUTHORS' CONCLUSIONS
Very low-certainty evidence from five small RCTs showed no clear evidence of a difference between the RP approach and the TP approach for elective open AAA repair in terms of mortality, or for rates of complications including hematoma (very low-certainty evidence), abdominal wall hernia (very low-certainty evidence), or chronic wound pain (very low-certainty evidence). However, a shorter intensive care unit (ICU) stay and shorter hospital stay was probably indicated following the RP approach compared to the TP approach (both low-certainty evidence). A possible reduction in blood loss was also shown after the RP approach (very low-certainty evidence). There is no clear difference between the RP approach and TP approach in aortic cross-clamp time or operating time. Further well-designed, large-scale RCTs assessing the RP approach versus TP approach for elective open AAA repair are required.
Topics: Aortic Aneurysm, Abdominal; Bias; Blood Loss, Surgical; Elective Surgical Procedures; Hematoma; Humans; Length of Stay; Operative Time; Pain, Postoperative; Peritoneum; Postoperative Complications; Randomized Controlled Trials as Topic; Retroperitoneal Space
PubMed: 34152003
DOI: 10.1002/14651858.CD010373.pub3