Systematic Review: Repair of Unruptured Abdominal Aortic Aneurysm

15 May 2007 | Volume 146 Issue 10 | Pages 735-741

Background: Recent recommendations to screen for abdominal aortic aneurysm (AAA) in high-risk populations and the rapidly increasing use of endovascular repair have led to increased interest in evaluating the effectiveness of treatment options for patients with AAA.

Purpose: To compare the effectiveness of treatment options, including active surveillance, open repair, and endovascular repair, for unruptured AAAs.

Data Sources: The authors searched MEDLINE, the Cochrane Library, and www.ClinicalTrials.gov through December 2006 with no language restrictions, searched reference lists, and queried experts and study authors.

Study Selection: Randomized trials that compared open or endovascular AAA repair with another treatment strategy and published clinical outcomes.

Data Extraction: Data were extracted onto standardized, piloted forms and were confirmed.

Data Synthesis: Two trials compared open repair with surveillance for small AAAs (n = 2226). Repair did not improve all-cause mortality (relative risk, 1.01 [95% CI, 0.77 to 1.32]) or AAA-related mortality (relative risk, 0.78 [CI, 0.56 to 1.10]). Four trials compared open repair with endovascular repair (n = 1532). Endovascular repair reduced 30-day mortality (relative risk, 0.33 [CI, 0.17 to 0.64]) but not mid-term (up to 4 years) mortality (relative risk, 0.95 [CI, 0.76 to 1.19]). One trial compared endovascular repair with observation in 338 patients who were unfit for open repair. Endovascular repair did not reduce all-cause mortality or AAA-related mortality, but high crossover and procedural mortality rates complicate interpretation of results.

Limitations: Few trials have been published. Those published were of small to moderate size and were not U.S. trials of endovascular repair.

Conclusions: Repairing AAAs smaller than 5.5 cm has not been shown to improve survival. Endovascular repair is associated with lower operative mortality than open repair, similar mid-term mortality, and unknown long-term mortality and has not been shown to improve survival in patients unfit for open repair. Long-term trial data comparing endovascular repair with open repair are needed, as is another trial comparing endovascular repair with observation in high-risk patients.

Author and Article Information

From the Veterans Affairs Medical Center and University of Minnesota School of Public Health, Minneapolis, Minnesota.

Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the AHRQ or the U.S. Department of Health and Human Services.

Acknowledgment: The authors thank Indy Rutks for assistance in the literature search.

Grant Support: Prepared by the Minnesota AHRQ Evidence-based Practice Center, Minneapolis, Minnesota, under contract no. 290-02-0009 from the AHRQ, U.S. Department of Health and Human Services.

Potential Financial Conflicts of Interest: None disclosed.

Current Author Addresses: Drs. Lederle and Wilt and Mr. MacDonald: Center for Chronic Disease Outcomes Research, Veterans Affairs Medical Center, Minneapolis, MN 55417.

Dr. Kane: Clinical Outcomes Research Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN 55455.

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