European Journal of Vascular & Endovascular Surgery
Volume 33, Issue 2 , Pages 154-171, February 2007

Systematic Review and Meta-analysis of 12 Years of Endovascular Abdominal Aortic Aneurysm Repair

  • S.C. Franks

      Affiliations

    • Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
    • Corresponding Author InformationCorresponding author. Dr. S. Franks, University of Leicester Vascular Surgery Group, Robert Kilpatrick Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.
    • ,
  • A.J. Sutton

      Affiliations

    • Department of Health Sciences, University of Leicester, Leicester, UK
    • ,
  • M.J. Bown

      Affiliations

    • Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
    • ,
  • R.D. Sayers

      Affiliations

    • Department of Cardiovascular Sciences, University of Leicester, Leicester, UK

Accepted 3 October 2006. published online 14 December 2006.

Article Outline

Background

Endovascular repair (ER) of abdominal aortic aneurysm (AAA) is a new technique, and reported rates of endoleak, conversion to open repair, rupture and mortality vary widely. The aim of this study was to estimate these rates from the published data, and examine how this has changed as more patients have undergone ER.

Methods

A systematic review and meta-analysis of publications identified through searches of the electronic databases EMBASE and Medline. All publications quoting endoleak, conversion to open repair, rupture and mortality rates for a series of patients undergoing ER were included.

Results

163 studies pertaining to 28,862 patients undergoing ER were identified as relevant for the review and meta-analysis. The pooled estimate for operative mortality was 3.3% (95% confidence interval 2.9 to 3.6%). The pooled estimate for type 1 endoleaks was 10.5% (95% confidence interval 9.0 to 12.1%), with an annual rate of 8.4% (95% confidence interval 5.7% to 12.2%). The pooled estimate of type 2,3 and 4 endoleaks was 13.7% (95% confidence interval 12.3 to15.3%), with an annual rate of 10.2% (95% confidence interval 7.4% to 14.1%). The pooled estimate for primary conversion to open repair was 3.8% (95% confidence interval 3.2 to 4.4%), and for secondary conversion to open repair 3.4% (95% confidence interval 2.8 to 4.2%). The pooled estimate for post-operative rupture was 1.3% (95% confidence interval 1.1 to 1.7%), with an annual rupture rate of 0.6% (95% confidence interval 0.5% to 0.8%). Multivariate meta-regression analysis showed that rates of operative mortality, post-operative rupture and total number of endoleaks all fell significantly (p<0.05) over time.

Conclusions

This study demonstrates a low mortality and a gradual reduction in vascular morbidity and mortality associated with endovascular repair since it was first introduced.

Keywords: Abdominal aortic aneurysm (AAA), Endovascular repair, Meta-analysis

 

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Background 

Open surgical repair (OR) is currently the definitive treatment for abdominal aortic aneurysm (AAA). Endoaneurysmorraphy with a prosthetic graft was first described in the literature in 1966,1 and the basic surgical technique has not changed significantly since then. The mortality rate from elective aneurysm repair is widely reported to be just below 5%,2 and this has changed little despite advances in critical care. Approximately 2/3rds of these deaths are the result of cardiac morbidity,3 and the need to reduce the physiological insult caused by clamping the aorta has driven surgeons to find a less dangerous way to repair aortic aneurysms.

Parodi first published his report on minimally invasive aneurysm surgery in 1991.4 Initial results were encouraging, and endovascular repair (ER) has since been employed by many centres worldwide. This approach is a much less invasive procedure than OR, and can be successfully performed under general, regional or local anaesthesia.5

This technique is the first major advance in vascular surgery since 1966. In the UK over 30 centres took part in the EVAR Trials 1 and 2. These were randomised controlled trials which assessed ER compared with OR in patients fit for both types of surgery (EVAR 1) and ER compared to best medical treatment in patients who are unfit for OR (EVAR 2). The EVAR trialists have recently published the results of 4 years of follow-up of ER patients, which have proved that the 3% survival advantage conferred by ER at 30 days is sustained over 4 years in patients who are fit for OR,6 but in those who are unfit for OR, ER does not improve survival.7

Meanwhile, many centres performing ER have published data from case series or case-control series. The majority of these papers report results from single centre experience of small numbers of patients with asymptomatic infrarenal AAA.

The aim of this study was to estimate the operative mortality, endoleak rate and rate of post-operative AAA rupture, and quantify how these outcome measures have changed over time, in patients undergoing ER. We performed a systematic review, meta-analysis and meta-regression of the relevant literature. This article was prepared according to previously published guidelines for reporting meta-analyses8 with some necessary modifications relating to the specific nature of synthesis of case series data.

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Methods 

Search strategy 

The lead author (SCF) performed the literature search, using the Ovid search engine (Version 19.2; Ovid Technologies Inc NY USA). Both the Medline (January 1966 to August 2003) and EMBASE databases (January 1980 to August 2003) were searched. The following search strategies were used on both databases:

1.Exp Aortic Aneurysm, Abdominal (textword) and exp Stents (textword)

2.Endovascular Surgery (textword) mp and exp Aortic Aneurysm, Abdominal (textword)

3.Exp Aortic Aneurysm, Abdominal (textword) and Stent Grafts mp

4.Exp Stents and Abdominal Aortic Aneurysm (textword) mp

5.Endovascular Surgery (textword) mp and Abdominal Aortic Aneurysm (textword) mp

6.Stent Grafts (textword) mp and Abdominal Aortic Aneurysm (textword) mp

7.Medline search strategy to identify randomised controlled trials from the guidelines of the NHS centre for reviews and dissemination.9

(Where exp indicates a term explosion – i.e. all sub categorisations are included in the search, and mp indicates a multipurpose search).

The search was limited to studies that were in English and human.

The above searches located studies with and without an abstract available on the database queried. At this stage, all available abstracts were searched to establish the relevance of each study and all potentially relevant papers obtained. Those articles remaining that did not have available abstracts were also retrieved in full. Any articles that were not available from the University of Leicester libraries were obtained from the British Library.

Inclusion/Exclusion criteria 

All articles included in this study were case series of a minimum of 5 patients who had undergone ER and provided data for either mortality or endoleak rates. Only those studies published in the English language were included. Articles were rejected if they were review articles or letters, if the studies did not include morbidity or mortality data of a case series of patients, if the subjects in the study were not human, or if the subjects did not have degenerative infrarenal AAA. If the subjects of a study were emergency cases only, the study was excluded from the analysis. Some studies reported data on both elective and emergency cases together. Where possible, emergency cases were removed from the analysis, but if the data sets were amalgamated it was felt better to include the data on ruptured AAA as numbers were low and exclusion of these studies would have lead to loss of valuable outcome data to the meta-analysis. Some studies had to be excluded because the subjects did not undergo ER. Studies were excluded if there was a duplication of data. We used the study centre, mid-timepoint of the study and size of the study cohort to identify duplicated results.

Data extraction 

The lead author (SCF) extracted all data. For all studies included, the total number of patients and the mid-timepoint of the study were recorded. When the mid-time point of the study was not given, it was derived from the publication date and length of follow-up (when available). When given, data on mortality, morbidity, endoleak and conversion to open repair were also recorded. Where data were given as a percentage, actual numbers were calculated, and the definitions used for mortality (“30-day”, “in-hospital” or “peri-operative”) and endoleaks (“proximal”, “distal”, “middle”, “type I”, “type II” or “type III”) used by each study were also recorded. When given, endoleak rates were also recorded according to the time they were diagnosed during the post-operative period (“immediate”, “discharge”, “1 month” or “late”). The number of ER patients who underwent primary (at the time of the initial operation) or secondary (at a subsequent operation) conversion to open repair were also recorded when given. Any data given pertaining to post-operative aneurysm rupture and technical success rates (where technical success was defined as successful implantation of an endovascular graft) were also recorded.

Additionally, individual study characteristics perceived as potentially related to the validity and quality of these particular studies were examined. Whether each study was a multicentre or single-centre study and the level of evidence according to the definitions of Blankensteijn et al.10 were all recorded.

Statistical methods 

As studies reported mortality data using a variety of different definitions, separate meta-analyses were performed for operative mortality (defined by the authors as all “peri-operative”, “in hospital” and “30-day” mortality), all mortality (“peri-operative”, “in hospital”, “30-day” and “late” mortality associated with ER), technical success rates, primary and secondary conversion to open repair, all conversions to open repair, post-operative rupture and death due to post-operative rupture.

Binary outcomes were combined on the log odds scale and then transformed onto the proportions scale for reporting and interpretation purposes. For incidence rate outcomes, weighted Poisson regression was used. Heterogeneity between studies was assessed using the chi-squared test, and random effects models were used for all analyses to incorporate any heterogeneity present.

Meta-regression analyses (including a random effect) were also performed on operative mortality, post-operative rupture and total number of endoleaks, in an attempt to explain the observed heterogeneity between study estimates. The effect of time (using the mid-time point or derived mid-time point), size of study, length of follow-up, size of aneurysm, average age, geographical location (Americas=0, Europe=1, Australasia=2, Africa=3) and inclusion criteria (aneurysm morphologically suitable for ER=1, patient unfit for OR=2, patient unfit and aneurysm morphology suitable for ER=3, patient unfit or aneurysm morphology suitable for ER=4) were all included individually as covariates in the meta-regression analyses. We took a p-value of <0.05 to represent statistical significance.

Sensitivity analysis was performed, stratifying analyses by the measures of quality identified in the previous section, to examine whether there was systematic variation in results across these quality components. Funnel plots were examined to assess whether publication bias was likely to be a problem.

Statistical analyses were carried out using State Statistical Software, release 8.2 (Stata, College Station, Texas, USA) and WinBUGS, release 1.4.1 (MRC Biostatistics Unit, Cambridge, UK).

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Results 

Literature search 

Database searches located a total of 836 different studies (not including duplicated search results), 200 of which did not have an electronic abstract available. At this stage, all available abstracts were searched to establish the relevance of each study, and 535 studies were rejected (Fig. 1). Articles were rejected if they were case reports, review articles or letters (n=228); or if the studies did not include either endoleak or mortality data of (n=182); if the subjects in the study were not human (n=53); if the subjects did not have degenerative AAA (n=37); if the subjects were emergency cases only (n=11) or if the subjects did not undergo ER (n=24). There remained 200 articles which did not have abstracts and were retrieved in full, and a further 101 studies which were retrieved as they appeared to be relevant from the abstract review.

Any articles that were not available from the University of Leicester libraries were obtained from the British Library. 298 articles were successfully retrieved (3 were untraceable) and of these a further 130 articles were rejected. 64 studies were rejected because they were case reports, letters or review articles; 49 studies did not include any endoleak or mortality data and were also rejected; 2 studies were rejected because their subjects were not human; 12 studies were not about ER of infrarenal aortic aneurysms and were therefore rejected, and a further 8 studies were rejected because they were found, at this stage, to be written in languages other than English.

Study characteristics 

16111, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171 articles were deemed relevant for inclusion in this review and contained data pertaining to 28,862 patients. Ninety-six articles were Blankensteijn level 1b (prospective, hospital-based studies), 43 were level 2b (retrospective hospital-based studies) and the remaining 22 studies did not specify how data had been collected.7

One hundred and thirty studies stated the time period covered by their report, and the mid-time point was derived from the publication date and length of follow-up (when available) for the remaining 31 studies. Fifteen of these studies did not provide follow-up data and the mid-timepoint had to be assumed using the publication date as a guide in these cases. One hundred and twenty of the studies reported on male: female ratios and 131 articles provided an average age for the case series. Ninety-four studies included information on inclusion criteria. Details of individual studies are shown in Table A1 (in the Appendix).

One hundred and thirty-four of the studies included in the analysis gave information on both mortality and endoleaks. Sixteen studies only gave information on mortality and 11 studies only gave information on endoleak rates. Sixty-eight of the studies included in the study contained information pertaining to post-operative aortic rupture, and 148 included conversion to open repair data (see Table A2 in the Appendix).

Pooled outcome estimates 

The overall pooled estimates for mortality, technical success, rupture, mortality associated with rupture, conversion to open repair and endoleaks are shown in Fig. 2. The figures on the right of the diagram are the overall rates and 95% confidence intervals, and they are represented graphically on the left of the diagram. These data represent the total number of patients in the data set who suffered from each of the outcome measures. They do not take length of follow up into account, which varies between studies.

There was statistically significant heterogeneity between studies (on the log odds scale), for all outcomes, all tests having p values <0.01 for heterogeneity. The overall operative mortality (i.e.; any mortality rates that were recorded as either “30 day mortality”; “in hospital mortality” or “peri-operative mortality”) was 3.3% (95% confidence interval 2.9% to 3.6%). 1.3% of those patients who survived the operation went on to suffer post-operative rupture of their AAA (95% confidence interval 1.1% to 1.7%); and 44.4% of these patients died (95% confidence interval 35.6% to 53.6%). 10.5% of patients developed a type 1 endoleak at some time in the post-operative period (95% confidence interval 9.0% to 12.1%); and the overall rate of conversion to open repair (at either initial operation or subsequently) was 5.4% (95% confidence interval 3.1% to 4.0%).

Fig. 3 shows the annual rates of endoleak and post-operative ruptures. These data are derived using the length of follow-up of each study to obtain an annual rate for endoleaks and post-operative rupture. We did this analysis because overall estimates for outcomes such as post-operative rupture and endoleak, which can occur at any time during the post-operative period, do not account for the fact that individual studies have different lengths of follow-up in the data set.

Every year, 8.4% of patients developed a new type 1 endoleak (95% confidence interval 5.7% to 12.2%), 10.2% developed a new type 2,3 or 4 endoleak (95% confidence interval 7.4% to 14.1%) and the annual rate of post-operative rupture was 0.6% (95% confidence interval 0.5% to 0.8%).

Meta-regression analysis 

Meta regression was performed as stated in the methods section. The p-values for significance of each of the factors for each outcome are presented in Table 1 (Coefficients for intercepts for each regression equation are not presented for the sake of brevity but are available from the first author on request). In our meta-regression analysis we investigated changes in mortality, rupture and endoleak rates occurring over time, with study size, AAA size, average age of patients in the study, worldwide location of the study and criteria for inclusion in the study. The only factor that had a statistically significant effect at the 5% level across all three outcomes was the mid-timepoint of the study.

Table 1. Meta regression analysis. Analysis of whether or not study setting variables have a statistically significant effect on the outcome measures of mortality, post-operative rupture rate and endoleak rate
Mortality rate (p-value)Rupture rate (p-value)Endoleak rate (p-value)
Study mid-timepoint<0.001<0.0010.001
Study size0.128<0.0010.106
Length of follow up0.0800.0030.527
Average AAA size0.0350.0890.034
Average age0.0760.0650.908
Location of study0.0070.1070.649
Inclusion criteria0.2070.4990.883

Fig. 4, Fig. 5, Fig. 6 show how the annual rates of operative mortality, rupture and endoleak have fallen between 1992 and 2002. Studies are weighted according to size and length of follow-up. It is clear from these diagrams that a few of the larger case series exert a greater influence over the outcome of the meta-regression analysis.

  • View full-size image.
  • Fig. 4 

    Mortality rate over time. Circles represent individual studies; the size of the circle is proportional to the inverse of the variance of the mortality of the estimate for that study, indicating the relative influence of that study in the meta-analysis.

Assessment of study quality 

One hundred and thirteen studies were reported as Blankensteijn level 1b and 39 were Blankensteijn level 2b. There was no information on how data was collected in the remaining 10 studies. Little difference was observed between all mortality between the 2 types of study (3.4% (95% confidence interval 2.8% to 4.1%) versus 3.5% (95% confidence interval 2.9% to 4.1%)).

Assessment of bias 

Funnel plots of operative mortality, rupture rate and endoleak rates were constructed in order to assess the degree of publication bias. Bias is represented by asymmetry around the vertical axis of the plot. It is clear from Fig. 7, Fig. 8, Fig. 9 that there is a large degree of heterogeneity in this data set, as the points representing individual studies are not converging to a point at the axis of the plot. Individual points tend to “line up” further away from the axis due to sparse data and single events in some of the studies included in the data set.

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Discussion 

The data set analysed in this study has yielded an operative mortality estimate of 3.3% following endovascular aneurysm repair. The rupture estimate was 1.3%, and 10.5% of patients developed a type 1 endoleak after this kind of surgery. This study also demonstrates that the rates of the above outcomes have all fallen in first decade since ER was introduced. Mortality rates in 1992 can be estimated from the regression line in Fig. 4 as approximately 7.5%, but by 2002 had fallen to approximately 1.4%. The regression line in Fig. 5 gives an estimate for rupture rate as 5.0% in 1992 and 0.4% in 2002. Using the regression line from Fig. 6 the endoleak rate can be estimated as 43% in 1992 and 13.5% in 2002.

This rate of improvement over time is unlikely to continue, as this would imply that the operative mortality from ER could eventually reach zero. It is much more likely that future figures would have a less steep regression line. It is not possible to predict how low mortality and post-operative complication rates will fall from these regression lines.

The literature search performed traced a large number of case series, case reports and letters, each containing data on a small number of patients. It was not possible to have two authors performing the data extraction as the number of studies included in the meta-analysis was so large. However, any questionable studies or data was discussed between the co-authors for a consensus decision. Studies were excluded if there were fewer than five patients involved, and as a result some data may have been lost to the meta-analysis. However, the inclusion of these smaller publications may have increased the possibility that data was repeated, and as letters and case reports are low level evidence it was felt prudent to exclude them from the analysis. Identification of duplicated data was harder. We compared study centre, mid-timepoint of study and the size of each data set in an attempt to identify any data that had been published more than once. Some studies were excluded, but it was not possible to completely rule out the possibility that results had been published more than once.

Meta regression analysis of study size, length of follow up, average AAA size, average age, study location and inclusion criteria found no consistent statistically significant association with the three main outcomes (operative mortality, rupture rate and endoleak rate). However, inadequate statistical power cannot be ruled out as a reason for the lack of associations, as data on these study characteristics was often missing from the publications included.

This meta-analysis reports on data from 28,862 patients- the largest analysis of its kind in the published literature. Our meta-regression techniques have also provided an analysis of trends in post-operative complications and morbidity since ER was introduced. These statistical techniques have not, to our knowledge, been applied to such a large data set of this type until now.

The estimates for operative mortality and endoleak rates are higher than the recently published EVAR trial14 year results6, 7 and a recently published systematic review, which analysed data from 19,804 patients undergoing ER between January 2000 and September 2004.172 These differences may be a result of the fact that this analysis includes studies which contained data from early experience of ER, when equipment was new, clinicians were less experienced (there is a recognised learning curve associated with ER171), and exclusion criteria for ER were not clearly established. Twenty-nine of the studies in this data set used unfitness for OR as an inclusion criteria for their studies.

Assessment of study quality is difficult when performing a meta-analysis of case series. The results of pooled outcome estimates of the 2 subgroups of level of evidence are difficult to interpret in this case as there is an uneven spread of studies across the 2 groups (113 level 1b versus 39 level 2b).

The funnel plots clearly demonstrate the large degree of between study heterogeneity in this data set, and as a result, publication bias is difficult to assess. The variability in results is likely to be due to 2 factors. First is the fact that ER is such a new technique and therefore there are a large number of case series with small numbers of patients published in the literature. Secondly, these studies often included results from those cases that were performed during the surgeon's passage through the established learning curve for ER.171

It is also possible that some data in this set has been repeated, as updated case series are published by the same author or from the same institution. Such results are very difficult to identify or test for, and therefore there may be repetition of data in this analysis. As a result, any changes in mortality and morbidity with the passage of time will be distorted, as there is a greater propensity for “early” data to be counted multiple times.

This study has shown that mortality and complication rates associated with ER are improving significantly over time. It is important that these results are borne in mind when considering the results of the large randomised controlled trials currently underway. As time progresses, techniques and equipment may continue to improve, and any simultaneous reduction in morbidity and mortality should be considered when interpreting long-term results from large studies.

There is a large volume of published literature on the subject of ER, although these publications tend to consist of small, single centre case series. Outcome reporting between these studies was also very variable. Many studies did not describe how their data had been collected, and definitions for types of endoleak were often unclear. The way in which endoleaks were reported also varied a great deal between studies, with some centres reporting all the endoleaks which occurred during the follow-up period and others only reporting immediate post-operative endoleaks or type 1 endoleaks. Definitions of types of endoleak were also variable- especially prior to the publication of White et al.'s definition of endoleaks and classifications of types of endoleaks.172, 173, 174

The EVAR trialists have recently published the results of 4 years of follow-up for EVAR trials 1 and 2. They have proved that the 3% survival advantage conferred by ER at 30 days is sustained over 4 years in patients who are fit for OR,6 but in those who are unfit for OR, ER does not improve survival.7

The DREAM trialists have also published their long-term results, but the study was not powered, and ultimately under-recruited by 12%. The 30-day mortality was similar to EVAR 1, but the p-value was not significant because of low power. At 2 years it was decided to look at all cause mortality rather than AAA mortality, and this showed that there was no reduction in all cause mortality.175

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Conclusions 

This study proves that results from ER of AAA are improving rapidly, and that while this technique is in its infancy it is impossible to know how low morbidity and mortality rates may ultimately fall. The authors have demonstrated a definite improvement in results during the first decade of ER despite a data set with high heterogeneity due to the nature of the current evidence base.

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Appendix. 

Table A1. Study characteristics 

AuthorMid-date of studyn ERAverage agen femaleLevel of evidenceInclusion criteria
Gordon MK16/07/19943274 1b2
May J01/05/19941087082b2
Berman SS01/02/2000977.9 1b4
Hill BB01/01/200179 112b
Ingle H16/12/1998587302b1
Miahle C04/04/19957969.542b3
Matsumura JS07/02/1994687362b
Henretta JP09/08/19974774.4 1b
Colburn MD01/08/199519 2b1
Arko FR01/11/19977073.9 2b
Cuypers PH01/06/1996646861b1
Kretschmer G16/10/1995307021b4
Pfammater T01/03/19996679101b3
Parodi JC16/10/199124 11b2
Broeders IAMJ01/04/1994266831b
Holzenbein TJ01/03/1996507241b1
Papazoglou K01/06/1996277421b2
Cuypers PH01/04/199689969 1b2
Thomas SM01/06/199761172 2b3
Sultan S16/07/19983672111b2
Blum U16/11/1995266801b1
Murphy KD01/08/1995963.201b2
Duda SH16/04/199614
Silberzweig JE01/03/199554752 2
Chuter TAM16/02/199750 2 2
Gorich J01/04/19977069.2111b
Baum RA01/05/199950 2
Gorich J01/12/19967369.8131b
Mita T01/09/19974973.712
May J01/01/19942870.32
Chuter TAM01/01/199652 4
Stelter W01/01/19962016917 1
Chuter TAM01/01/199557 71b
Blum U01/09/199514967 1b1
Moore WS07/01/19944671.651b1
Chuter TAM01/05/199541 41b
Brewster DC01/04/199530 1
Ouriel K01/03/199970375981b
Sampram ESK18/06/200170375982b
Matsumura JS28/10/200123570312b1
Greenberg RK15/09/199952873631b3
Bush RL01/02/1997104 1b4
May J16/02/199514870.6112b1
Becquemin JP16/01/19977569.651b1
Resch T16/09/199381 91b
Naslund TC01/01/20003469.711b1
Yusuf SW01/02/19953072 2b2
Chavan A23/08/19982266.80 1
Kinney EV01/11/199815073341b1
Koskas F16/03/199794 1
Cohnert TU16/05/19973767.911b
Parodi JC16/06/1992507352b4
Criado FJ21/06/1999471 2b3
Matsumura JS20/05/1998297621b
Holzenbein TJ16/01/199717373.2181b4
May J16/02/199519072151b
Wolf YG16/11/1998189 262b1
Faries PL16/09/200036875.8552b2
Brener BJ13/04/20002969.821b1
Schlensak C16/02/199615069.681b1
Carpenter JP29/01/20011187381b
Coppi G16/11/1995666931b1
Schunn CD16/12/199519068.7141b
Ligush J Jr.01/09/20003370.412 1
Cartes-Zumelzu01/09/1999727462b1
de Virgilio C01/08/199822974.3 1b
Teufelsbauer H16/05/199720673.4212b1
Villareal RP01/10/1998127442b2
Bolke E01/01/19982072.161b
Resch T16/07/199716470211b
Marek J16/05/20004969.601b1
Hovsepian DM01/03/200014472231b
Becker GJ16/08/199730574241b
Haussegger KA16/01/19973070.521b1
Tonnessen BH01/07/199810573.214 1
Amesur NB01/05/1997577292b
Patterson MA16/02/1999417461b1
Alric P01/10/199423692
Ayerdi J01/03/20009672.6111b
Uflacker R11/09/19961065.5 1b1
Kaufman J04/07/1998576 1b1
Criado FJ17/12/199924075.5241b1
Zarins CK01/07/19971193 1b2
Kato N07/07/1996157121b1
Cao P01/01/199811969.81141b
Chuter TAM01/12/199711675 1b2
Buth J01/08/19961554701331b
Zarins CK01/02/19981067 1b2
Rehring TF01/02/19985175.23
Bove PG16/07/1999287562b
Abraham CZ16/02/20001167562b1
Cao P16/03/199814869.8 1b4
Lobato AC16/01/1998357561b1
Chaikof EL16/09/1997236 1b
Bertrand M16/09/199819372112b
Howell MH16/01/200021572231b
May J16/11/1994156 2b
Lawrence-Brown16/10/1996108 1b
Tutein RP01/05/199710470.871b
May J01/01/199824372171b1
Moore WS01/01/199510073.8201b
Zannetti S16/09/199826670161b1
Ohki T26/08/199823976362b
Howell MH16/04/19988972.7131b
Edwards WH01/06/19941169.611b
May J07/11/199312 1b
Nasim A01/09/1994107211b
Blum U02/06/1995154 1b
Resch T01/08/199715871181b
Yusuf SW03/09/19935 1b1
Ramaiah VG16/03/200041974121b
Lobato AC01/01/199627773411b1
Aadahl P01/01/1996216741b1
Adelman MA01/01/1995130 2b
Thompson MM01/01/1996257102b1
Nasim A16/03/1995297211b
Lyden SP01/03/1998237112b1
Liewald F01/11/199713068131b1
Haulon S16/11/1998966811b
Laheij RJF16/03/19972863 1b
von Segesser L24/03/20018869 1b
Albertini JN01/11/1998185 131b
Scharrer-Palmer01/03/19983166.122b
Moore WS16/04/19931075 1b
Becquemin JP01/02/199773 2b1
Lundbom J01/07/199610070 1b1
May J01/11/199412871111b1
Ricco MD01/05/19994772.211b
Lee WA01/07/199815074.7192b1
Walker SR01/04/1996847652b
Coppi G16/12/1994276821b
Du Toit DF05/10/19971272.522b3
Blum U11/04/200029570 1b1
Aho PS01/11/1998218 1b1
Vignali C01/08/19996469.921b1
Zarins CK01/02/199719073191b
Allen BT01/09/199734 1b
Walker SR16/04/199622172511b1
Wirthlin DJ01/07/2000145 1b
Zarins CK16/09/1998149 1b1
Deaton DH01/06/1997287221b
Lee AM18/01/1996257342b1
Tutein RP01/05/199710470.872b1
Treharne GD16/05/1996496872b1
Matsumura JS31/01/1994687362b1
Hansman MF16/12/20015072.5201b
Makaroun MD01/02/199750728
Dorffner R16/08/1995287022b1
Ivancev K01/05/19954573 2b1
Lobato AC01/03/1997508272b1
Lee WA01/11/199767749 4
May J16/06/1994121
Arko FR16/05/199815374.2261b
Espinosa G16/06/199913470.7142b4
Ivancev K16/03/1995817191b
Broeders IAMJ01/08/19953069 1b1
Van Schie GP01/03/19961087817 1
Blum U01/02/199622867
Alric P16/01/19998872.66 2
Pereira AH16/08/1998577082b
Gordon MK16/07/19943274 1b

Table A2. Study outcomes 

AuthorPost-op RuptureConv to openOperative DeathsType 1 endoleaksType 234 endoleaksTotal endoleaks
Gordon MK222 11
May J0206 13
Berman SS 0
Hill BB 2 13
Ingle H0969211
Miahle C 09 7
Matsumura JS119030535
Henretta JP000 5
Colburn MD 40 5
Arko FR01041216
Cuypers PH033 13
Kretschmer G 311559
Pfammater T 219 21
Parodi JC00110115
Broeders IAMJ 115 10
Holzenbein TJ 5 10013
Papazoglou K 205819
Cuypers PH 03119 295
Thomas SM6 3915813710
Sultan S 322 6
Blum U 21155
Murphy KD 01 4
Duda SH 4 4
Silberzweig JE 0922
Chuter TAM 00 6
Gorich J 0 21
Baum RA 1113816
Gorich J11 9
Mita T 1 3
May J1203 5
Chuter TAM 215 12
Stelter W1137 37
Chuter TAM041421167
Blum U2 1 20
Moore WS 4081217
Chuter TAM09215211
Brewster DC2100927
Ouriel K131216151
Sampram ESK3131221130162
Matsumura JS3121 28
Greenberg RK 34872186
Bush RL3713 18
May J 54 18
Becquemin JP252 27
Resch T1007207
Naslund TC 71 3
Yusuf SW 32 3
Chavan A 41 15
Kinney EV005 6
Koskas F222 5
Cohnert TU 82328
Parodi JC 05268
Criado FJ10338 6
Matsumura JS 0 28
Holzenbein TJ00542456
May J128164037
Wolf YG 2 43
Faries PL 7 43
Brener BJ24010337
Schlensak C001 73
Carpenter JP2221 19
Coppi G041 11
Schunn CD 52 65
Ligush J Jr.131345203
Cartes-Zumelzu0 13 21
de Virgilio C 10318
Teufelsbauer H 5 3
Villareal RP 1 7
Bolke E 0
Resch T 7 43
Marek J 231202318
Hovsepian DM 13 1648
Becker GJ 8 75
Haussegger KA 1 5
Tonnessen BH 3 18
Amesur NB180255021
Patterson MA 214110
Alric P145998
Ayerdi J 5 41
Uflacker R 11 104
Kaufman J2100171
Criado FJ 1 48
Zarins CK 12222166
Kato N 1 14
Cao P 60 18
Chuter TAM15532 15
Buth J 14095346
Zarins CK 40711
Rehring TF 1051011
Bove PG 270 4
Abraham CZ9232 16
Cao P 1 17
Lobato AC 135
Chaikof EL1010 46
Bertrand M 46
Howell MH 10 31
May J 7 20
Lawrence-Brown 6 15
Tutein RP 328238
May J3238 50
Moore WS 2
Zannetti S 232620
Ohki T 3420381220
Howell MH 120 36
Edwards WH 60317
May J2507132
Nasim A 21 3
Blum U 1 24
Resch T 272 43
Yusuf SW 203
Ramaiah VG 3291538
Lobato AC 2342023
Aadahl P001 3
Adelman MA005 37
Thompson MM 152 4
Nasim A 23 4
Lyden SP11231225
Liewald F 522 21
Haulon S 724 65
Laheij RJF1 85
von Segesser L 6261513
Albertini JN 12184716
Scharrer-Palmer161070 7
Moore WS 60 4
Becquemin JP222 17
Lundbom J 2 16
May J 264 14
Ricco MD0108915
Lee WA 42 59
Walker SR 23 2
Coppi G 3874
Du Toit DF 20 2
Blum U1122 24
Aho PS2723170
Vignali C 1 20
Zarins CK385 7039
Allen BT 41 7
Walker SR158825
Wirthlin DJ 2 21
Zarins CK 12 84
Deaton DH360 9
Lee AM0414175
Tutein RP 32 8
Treharne GD00327
Matsumura JS 3 35
Hansman MF 21 8
Makaroun MD 1 17
Dorffner R 19026917
Ivancev K 151711
Lobato AC0324136
Lee WA 1213434
May J 867411
Arko FR 41
Espinosa G 14 9
Ivancev K1155 14
Broeders IAMJ 1 11
Van Schie GP 133615
Blum U1141 21
Alric P 644711
Pereira AH 32 9
Gordon MK15291211

Conv to open=all conversions to open AAA repair.

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PII: S1078-5884(06)00584-3

doi:10.1016/j.ejvs.2006.10.017

European Journal of Vascular & Endovascular Surgery
Volume 33, Issue 2 , Pages 154-171, February 2007

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