Umbrella review and meta-analysis of reconstructed individual patient data of mortality following conventional endovascular and open surgical repair of infrarenal abdominal aortic aneurysm

Figures & data

Table 1. Inclusion/Exclusion criteria for systematic screening of identified studies.

PICO(D)	Inclusion criteria	Exclusion criteria
Population	People undergoing surgery for a confirmed unruptured (planned) infrarenal abdominal aortic aneurysm.	Ruptured abdominal aortic aneurysm (urgent, emergent) Other aneurysm morphologies (juxtarenal, suprarenal, thoracoabdominal) or occlusive aortic disease
Intervention	Elective standard (on-IFU) EVAR	Elective complex EVAR including: ∘ Fenestrated EVAR ∘ EVAR with chimneys ∘ EVAR with snorkels ∘ Branched grafts ∘ ‘CHIMPS’ (CHIMneys, Periscopes, Snorkels) ∘ Infrarenal devices used for juxtarenal AAA – that is, off-IFU use of standard devices Emergent (non-elective) EVAR Endovascular Aneurysm Sealing (EVAS)
Comparator	Open surgical repair of AAAs	Other type of interventions (e.g. non-surgical interventions).
Outcome	All-cause mortality	Emergent and elective survival was not reported separately
Study design:	Meta-analyses of RCTs with minimal follow-up of 10 years	All other studies that are not meta-analyses
Status:	Published papers only Peer-review journal articles only	Non-published literature Conference proceedings (conference, congress, symposium, or other meetings) including: ∘ Posters ∘ Abstracts from oral presentations
Date	From 2019 – present*	Before 2019

PICO(D): Population, Intervention, Comparator, Design; IFU: instructions for use; EVAR: endovascular aneurysm repair; AAA: Abdominal aortic aneurysm, RCTs: randomized control trials.

*The long-term results from the OVER trial become available in 2019, and that is the rationale behind the date restriction.

Figure 1. PRISMA 2020 flow diagram.

Table 2. Studies included in the systematic review.

Meta-analyses	Analyzed RCTs	Method	Metrics
Antoniou et al. 2020 (30)	DREAM, OVER, EVAR-1	Random effects, inverse variance method	Hazard ratios (95% CI)
Giannopoulos et al. 2020 (31)	DREAM, OVER, EVAR-1	Random-effects model, not further specified	Hazard ratios (95% CI), Risk ratios (95% CI)
Bulder et al. 2019 (32)	DREAM, OVER, EVAR-1, ACE	Random-effects model of DerSimonian and Laird	Hazard ratios (95% CI)
Chen et al. 2019 (33)	DREAM, OVER, EVAR-1, ACE	Fixed or random-effects model, not further specified	Odds ratios (95% CI)

RCT: randomized control trials, CI: confidence intervals.

Table 3. Results of included meta-analyses of all-cause mortality from randomized control trials.

Period/ Meta analysis	Antoniou et al. 2020 [30]		Giannopoulos et al. 2020 [31]		Bulder et al. 2019 [32]		Chen et al, 2019 [33]
0–6 months	HR (95% CIs): 0.62 (0.42–0.91)	p = 0.01	-	-	-	-	-	-
0–3 years	-	-	-	-	HR (95% CIs): 1.01^§ (0.93–1.10)	p = 0.72
6 months – 4 years	HR (95% CIs): 1.02 (0.84–1.22)	p = 0.87	-	-	-	-	-	-
0–5 years	-	-	-	-	HR (95% CIs): 1.00 (0.91–1.10)	p = 0.91	-	-
4–8 years	HR (95% CIs): 1.09* (0.90–1.31)	p = 0.40	HR (95% CIs): 1.13 (0.94–1.35)	not significant (significance level NR)	-	-	-	-
>8 years	HR (95% CIs): 1.05 (0.91–1.22)	p = 0.48	HR(95% CIs): 1.07 (0.89–1.28)	not significant (significance level NR)	-	-	-	-
0–10 years	-	-	-	-	HR (95% CIs): 1.04^¥ § (0.91–1.21)	p = 0.78	OR (95% CIs): 0.90^§ (0.76–1.06)	p = 0.20
0–15 years	HR (95% CIs): 1.02 (0.93–1.13)	p = 0.62	HR (95% CIs): 1.04^§ (0.93–1.17) HR (95% CIs): 1.03^† (0.98–1.18)	not significant (significance level NR)	-	-	-	-

*Without DREAM trial, ¥ Without long-term results from OVER trial, § Includes ACE trial, † Includes ACE trial and Soulez 2005.

Legend: NR – not reported, HR – hazard ratio, OR – odds ratio.

Figure 2. Two-stage approach: all-cause mortality EVAR versus OSR (risk-ratio metrics).

Figure 3. Two-stage approach: all-cause mortality EVAR versus OSR (odds-ratio metrics).

Figure 4. One stage approach: all-cause mortality EVAR versus OSR.

OSR: Open surgical repair, EVAR: endovascular aneurysm repair,

Table 4. One-stage meta-analysis approach resultswith patients from all randomized control trials (DREAM, OVER, and EVAR-1).

Model	Results (Hazard ratio and 95% CI)	P-value	Test
Semiparametric models
Cox proportional hazards model	1.03 (0.94–1.12)	p = 0.587	-
Parametric models
Weibull AFT model	0.98 (0.92–1.05)	p = 0.285	AIC:12,313, BIC:12,330
Weibull proportional hazards model	1.03 (0.94–1.13)	p = 0.285	AIC: 12313, BIC: 12330
Exponential	1.03 (0.94–1.12)	p = 0.296	AIC: 12524, BIC: 12535
Gamma	1.02 (0.94–1.10)	p = 0.320	AIC: 12381, BIC: 12398
Log-normal	1.02 (0.93–1.13)	p = 0.318	AIC: 12831, BIC: 12848
Log-logistic	0.99 (0.92–1.08)	p = 0.446	AIC: 12592, BIC: 12610
Generalised Gamma	0.97 (0.93–1.01)	p = 0.086	AIC: 12119, BIC: 12142
Gompertz	1.03 (0.94–1.13)	p = 0.272	AIC: 12135, BIC: 12153.

CI: confidence interval.

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