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@article{Powell:2017:10.1002/bjs.10430,
author = {Powell, JT and Sweeting, MJ and Ulug, P and Blankensteijn, JD and Lederle, FA and Becquemin, JP and Greenhalgh, RM},
doi = {10.1002/bjs.10430},
journal = {British Journal of Surgery},
pages = {166--178},
title = {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},
url = {http://dx.doi.org/10.1002/bjs.10430},
volume = {104},
year = {2017}
}

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TY  - JOUR
AB  - BackgroundThe 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.MethodsAn 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.ResultsThe 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.ConclusionThe 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
AU  - Powell,JT
AU  - Sweeting,MJ
AU  - Ulug,P
AU  - Blankensteijn,JD
AU  - Lederle,FA
AU  - Becquemin,JP
AU  - Greenhalgh,RM
DO  - 10.1002/bjs.10430
EP  - 178
PY  - 2017///
SN  - 1365-2168
SP  - 166
TI  - 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
T2  - British Journal of Surgery
UR  - http://dx.doi.org/10.1002/bjs.10430
UR  - http://hdl.handle.net/10044/1/44093
VL  - 104
ER  -

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