Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years

Authors: Janet T. Powell, Michael Sweeting, Pinar Ulug, J D Blankensteijn, F. Lederle, J-P Becquemin, R M Greenhalgh, R M Greenhalgh, Jonathan Beard, Martin Buxton, Louise Brown, Peter L. Harris, Janet T. Powell, John Rose, I T Russell, Mark Sculpher, Simon G. Thompson, Richard Lilford, Peter Bell, R M Greenhalgh, S. C. Whitaker, PA Poole-Wilson, C V Ruckley, William B. Campbell, Michael R. E. Dean, M.S.T. Ruttley, E C Coles, Janet T. Powell, Alison Halliday, S. Julian Gibbs, Louise Brown, David Epstein, Mark Sculpher, Simon G. Thompson, R.J. Hannon, Lynn C. Johnston, Andrew W. Bradbury, Michael Henderson, S D Parvin, David Shepherd, Roger M. Greenhalgh, Adam Mitchell, P. R. Edwards, G. Abbott, D J Higman, A. Vohra, S. Ashley, C Robottom, Mike Wyatt, John Rose, David J. Byrne, Richard Edwards, D P Leiberman, D H McCarter, Peter R. Taylor, John Reidy, A R Wilkinson, Duncan F. Ettles, A E Clason, G.L.S. LEEN, N. Wilson, Mark Downes, Stuart Walker, Janet Lavelle, M.J. Gough, Simon McPherson, D J A Scott, D O Kessell, Ross Naylor, R.D. Sayers, N.G. Fishwick, Peter L. Harris, Debby Gould, Michael G. Walker, NATE CHALMERS, A Garnham, Michael Collins, Jonathan Beard, P.A. Gaines, M Y Ashour, Raman Uberoi, B.D. Braithwaite, Simon C. Whitaker, Jonathan N. Davies, Simon Travis, George Hamilton, Andrew Platts, A A Shandall, Brian A. Sullivan, Mohammed S. Sobeh, Matthew Matson, A.D. Fox, R. Orme, W Yusef, Timothy C. Doyle, M Horrocks, John Hardman, Paul Blair, Peter K. Ellis, Gordon A. Morris, A. Odurny, Rajiv Vohra, Martin Duddy, Matt Thompson, T M Loosemore, Antonio Belli, Robert Morgan, M Adiseshiah, Jocelyn Brookes, C N McCollum, Raymond Ashleigh, M. Aukett, Sara Baker, Ellis Barbé, Naima S. Batson, Jocelyn Bell, John E. Blundell, D Boardley, Simon Boyes, Oliver Brown, J. Bryce, Martin D. Carmichael, Tina Chance, Jonathan Coleman, C Cosgrove, G. Curran, Thomas H. Dennison, Carol Devine, Nikki Dewhirst, Belinda Errington, H Farrell, Charles Fisher, Paul Fulford, Michael J. Gough, Carol Graham, Richard Hooper, G. O. Horne, L. A. Horrocks, B Hughes, Tim Hutchings, M Ireland, Ciaran Judge, Louise Kelly, John D. Kemp, Amy C. Kite, Milja Kivelä, Michelle Lapworth, Cheong Lee, L Linekar, Asif Mahmood, Lyn March, Julio Ellacuriaga San Martin, Nick Matharu, K McGuigen, P Morris-Vincent, Stephen Murray, Ann Marie Murtagh, Gareth Owen, Virin Rajiv Neil Ramoutar, Christine Rippin, J M Rowley, Julia Sinclair, Sarah Spencer, V Taylor, Christopher Tomlinson, Sue Ward, Vera Wealleans, Jason R. West, Katie White, John P. Williams, L Wilson, D. E. Grobbee, J D Blankensteijn, Aneta Bąk, Jaap Buth, Peter M. T. Pattynama, E L G Verhoeven, A E van Voorthuisen, J D Blankensteijn, Ron Balm, Jaap Buth, Philippe W.M. Cuypers, D. E. Grobbee, Monique Prinssen, Marc R.H.M. van Sambeek, E L G Verhoeven, Annette F. Baas, M. G. Myriam Hunink, J M van Engelshoven, Michael J. Jacobs, Bas A.J.M. de Mol, J. Hajo van Bockel, Ron Balm, Jim A. Reekers, Xander Tielbeek, E L G Verhoeven, Willem Wisselink, N. Boekema, L.M. Heuveling, I. Sikking, Monique Prinssen, Ron Balm, J D Blankensteijn, Jaap Buth, Philippe W.M. Cuypers, Marc R.H.M. van Sambeek, E L G Verhoeven, Jorg L. de Bruin, Annette F. Baas, J D Blankensteijn, Monique Prinssen, Erik Buskens, Jacob Buth, Alexander V. Tielbeek, J D Blankensteijn, Ron Balm, Jim A. Reekers, Marc R.H.M. van Sambeek, Peter M. T. Pattynama, E L G Verhoeven, Taco Jan Prins, Arie C. van der Ham, J.J.I.M. van der Velden, Steven M.M. van Sterkenburg, G.B. ten Haken, C.M.A. Bruijninckx, Hans van Overhagen, R.P. Tutein Nolthenius, Tadek R. Hendriksz, Joep A.W. Teijink, Henk F. Odink, A.A.E.A. de Smet, Dammis Vroegindeweij, R.M.M. van Loenhout, Matthieu Rutten, Jaap F. Hamming, L. E. H. Lampmann, M.H. Bender, Hella Pasmans, A.C. Vahl, Claire de Vries, A. J. C. Mackaay, L.M.C. van Dortmont, A.J. van der Vliet, Leo J. Schultze Kool, J.H.B. Boomsma, H.R. van Dop, J.C.A. de Mol van Otterloo, T.P.W. de Rooij, T.M. Smits, Ercüment Yılmaz, Willem Wisselink, F.G. van den Berg, Michel J T Visser, E van der Linden, Geert Willem H. Schurink, Mariëtte de Haan, H.J. Smeets, P. Stabel, F. Van Elst, J Poniewierski, Frank Vermassen, F. Lederle, Julie A. Freischlag, Ted R. Kohler, E Latts, Junya Matsumura, Frank T. Padberg, Tassos C. Kyriakides, Kristi M. Swanson, Peter Guarino, Peter Peduzzi, Michele Antonelli, Clinton Cushing, Elizabeth A. Davis, Lydia Durant, Susan J. Joyner, Alice Kossack, Tassos C. Kyriakides, Mary LeGwin, V. A. McBride, Thomas P. O’Connor, Joanne Poulton, Samuel J. Stratton, Stephen R. Zellner, Amanda J. Snodgrass, J Thornton, Kristi M. Swanson, Clair Haakenson, Kevin T. Stroupe, Yvonne Jonk, J W Hallett, Norman Hertzer, Jonathan Towne, David A. Katz, T. Karrison, John P. Matts, Richard A. Marottoli, S. V. Kasl, Rina Mehta, Robert Feldman, W Farrell, Heather Allore, Elizabeth Perry, James C. Niederman, Fiona Randall, Marcin Zeman, David G. Beckwith, Timothy J. O’Leary, Grant D. Huang, E Latts, M Bader, Erika R. Ketteler, D D Kingsley, John Marek, Richard J. Massen, Brian Matteson, John D. Pitcher, Mark Langsfeld, John D. Corson, James M. Goff, Karthikeshwar Kasirajan, Christina Paap, Diane C. Robertson, Atef A. Salam, Ravi Veeraswamy, Ross Milner, Karthikeshwar Kasirajan, Jane Guidot, Brajesh K. Lal, Steven J. Busuttil, Michael Lilly, Melita Braganza, Katrina L. Ellis, Mark A. Patterson, William D. Jordan, David Whitley, Steve M. Taylor, Marc A. Passman, Deanna Kerns, Clive Inman, Jennifer Poirier, J Ebaugh, J.D. Raffetto, D Chew, Subhash Lathi, Christopher Owens, Kirsty Hickson, Hasan H. Dosluoglu, Karen Eschberger, Melina R. Kibbe, Henry Baraniewski, Junya Matsumura, Masayuki Endo, Anna Busman, Wendy Meadows, Mary E. Evans, Joseph S. Giglia, Hosam El Sayed, Amy B. Reed, Murad Ruf, Stephanie A. Ross, Jessie Jean-Claude, Gilles Pinault, Peipei Kang, Nadine E White, Matthew Eiseman, Rhondda Jones, Carlos H. Timaran, J. Gregory Modrall, M. Burress Welborn, John J. López, Tammy Nguyen, John K.Y. Chacko, Kenneth Granke, Angela G. Vouyouka, Erin Olgren, Prabhat Chand, Brenda Allende, Michael J. Ranella, Claudia Yales, Thomas A. Whitehill, William C. Krupski, Mark R. Nehler, Stephen Johnson, Darrell N. Jones, Pamela K. Strecker, Michelle A. Bhola, Cynthia K. Shortell, John Gray, Jeffrey H. Lawson, Richard L. McCann, M Sebastian, Jean Kistler Tetterton, Catherine Blackwell, Patricia A. Prinzo, Nathaniel Lee, Frank T. Padberg, Joaquim J. Cerveira, Brajesh K. Lal, Robert W. Zickler, Karen Hauck, Scott A. Berceli, W.A. Lee, C. Keith Ozaki, Peter R. Nelson, A S Irwin, Richard A. Baum, Bernadette Aulivola, Heron E. Rodríguez, Fred N. Littooy, H.P. Greisler, Mary T. O'Sullivan, Panagiotis Kougias, Peter H. Lin, Ruth L. Bush, Gene Guinn, Carlos F. Bechara, Catherine Cagiannos, George Pisimisis, Neal R. Barshes, Sherilyn Pillack, Barbara Guillory, Dolores F. Cikrit, Stephen G. Lalka, Gary W. Lemmon, R. F. Nachreiner, Mitzi Rusomaroff, Eoin OʼBrien, Joseph J. Cullen, Jamal J. Hoballah, William J. Sharp, Jeanne L. McCandless, Vickie Beach, David J. Minion, Thomas H. Schwarcz, J. Kimbrough, Laura Ashe, Anna K. Rockich, Jill Warner-Carpenter, Mohammed Moursi, John F. Eidt, Susannah Brock, C Bianchi, Veronica Bishop, Ian L. Gordon, Roy M. Fujitani, S M Kubaska, Mina Behdad, R. Azadegan, Christine Ma Agas, Kathy Zalecki, John R. Hoch, Sandra C. Carr, Charles W. Acher, Michaël Schwarze, Girma Tefera, Matthew W. Mell, Brett I. Dunlap, J. Rieder, John McDouall Stuart, Darryl S. Weiman, Omran Abul-Khoudoud, H. Edward Garrett, Siún Walsh, Karen L. Wilson, Gary R. Seabrook, Robert A. Cambria, K R Brown, Bradley Lewis, Susan Framberg, Christa Kallio, Roderick A. Barke, Steven M. Santilli, Alexandre C. d’Audiffret, Nancy Oberle, Catherine Proebstle, L L Johnson, Glenn R. Jacobowitz, Neal S. Cayne, Caron Rockman, Mark A. Adelman, Paul J. Gagne, Matthew N. Nalbandian, Leah J. Caropolo, Iraklis I. Pipinos, Jason M. Johanning, Thomas G. Lynch, Holly DeSpiegelaere, Georgia Purviance, Wei Zhou, Ronald L. Dalman, Jung Tae Lee, Bassem Safadi, Sheila M. Coogan, Sherry M. Wren, Doghdoo D. Bahmani, Deanna Maples, Shawna Thunen, Michael A. Golden, Marc Mitchell, Ron Fairman, Sophia Reinhardt, Mark A. Wilson, Edith Tzeng, S C Muluk, Nina Peterson, Michael A. Foster, James M. Edwards, Gregory L. Moneta, Gregory J. Landry, Lloyd M. Taylor, Richard Yeager, Eleanor Cannady, Gerald S. Treiman, Stephanie Hatton-Ward, Barbara Salabsky, N Kansal, Edward H. Owens, Mark Estes, Betty A. Forbes, Cinda Sobotta, Joseph H. Rapp, Linda M. Reilly, Sandra L. Perez, Kun Yan, Rajabrata Sarkar, Shelley Dwyer, Sonia A. Perez, K Chong, Ted R. Kohler, Thomas S. Hatsukami, David G. Glickerman, Michael E. Sobel, Thomas S. Burdick, K Pedersen, Patricia A. Cleary, Martin R. Back, Dennis F. Bandyk, Brad Johnson, Murray L. Shames, Rebecca Reinhard, S C Thomas, Glenn C. Hunter, Lisa R. Leon, Alex Westerband, Robert J. Guerra, M Riveros, Joseph L. Mills, John Hughes, Andréa M. Escalante, Shemuel B. Psalms, Nancy N. Day, Robyn Macsata, Anton N. Sidawy, Jonathan Weiswasser, Subodh Arora, Brenda J. Jasper, Alan Dardik, Vivian Gahtan, Bart E. Muhs, Bauer E. Sumpio, Richard J. Gusberg, Myron Spector, Jeffrey Pollak, John Aruny, E. Lowell Kelly, James Wong, Penny Vasilas, Carmelene Joncas, Hugh A. Gelabert, Christian DeVirgillio, David A. Rigberg, L R Cole, J-P Becquemin, J. Marzelle, J-P Becquemin, Marc Sapoval, J-P Becquemin, J-P Favre, J Watelet, Patrick Lermusiaux, Marc Sapoval, Éric Lepage, F. Hémery, Guillaume Dolbeau, N Hawajry, Patrick Cunin, Peter L. Harris, L Stockx, Gilles Châtellier, Claude Mialhe, J-N Fiessinger, L Pagny, H. Kobeiter, Christian Boissier, Philippe Lacroix, François Ledru, J J Pinot, J-F Deux, B. Tzvetkov, P Duvaldestin, J Watelet, Cécile Jourdain, Victor A. David, D Enouf, Nimrod Ady, Amor Krimi, N Boudjema, Y. Jousset, B Enon, V. Blin, Jean Picquet, Philippe Lhoste, F. Thouveny, H. Borie, S Kowarski, J. M. Pernes, Mario Auguste, J-P Becquemin, Pascal Desgranges, Éric Allaire, J. Marzelle, Hicham Kobeiter, P-Y Meaulle, D Chaix, P Juliae, J N Fabiani, P. Chevalier, Myriam Combes, Agathe Seguin, Denis Belhomme, Marc Sapoval, Javier Martin Reyes Baque, Olivier Pellerin, J.-P. Favre, Xavier Barral, C Veyret, J Watelet, Christophe Peillon, D. Plissonier, P. Thomas, E Clavier, Patrick Lermusiaux, Robert Martinez, François Bleuet, C Dupreix, Jean Philippe Verhoye, T Langanay, J.-F. Heautot, M. Koussa, Stéphan Haulon, Pascal Halna, Laurence Destrieux, Christophe Lions, S Wiloteaux, Jean-Paul Bérégi, Patrice Bergeron, J J Pinot, Philippe Patra, Alain Costargent, P Chaillou, A D'Alicourt, Yann Gouëffic, Émile Cheysson, A. Parrot, P Garance, A. Demon, A Tyazi, J Pillet, F Lescalié, G Tilly, Éric Steinmetz, Claire Favier, R Brenot, D. Krausé, JP Cercueil, O Vahdat, M. Sauer, Philippe Soula, A Querian, Olivier Garcia, M Levade, Daniel Colombier, J-M Cardon, Alexandre Joyeux, P Borrelly, G Dogas, P-É Magnan, A Branchereau, J-M Bartoli, Réda Hassen‐Khodja, Michel Batt, P-F Planchard, P.-J. Bouillanne, Pierre Haudebourg, Jason Bayne, Pierre Gouny, Ali Badra, J Braesco, Michel Nonent, A. Lucas, Alain Cardon, Y Kerdiles, Yves Rolland, Maria Kassab, C. Brillu, F Goubault, L Tailboux, H Darrieux, Olivier Briand, J N Maillard, K. Varty, Claire Cousins - British journal of surgery 2017 cited by 422

BACKGROUND: The erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation. METHODS: An individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention. RESULTS: The analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization. CONCLUSION: The early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575.