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Editor's Choice – Comparison of Open, Standard, and Complex Endovascular Aortic Repair Treatments for Juxtarenal/Short Neck Aneurysms: A Systematic Review and Network Meta-Analysis

Published:February 24, 2022DOI:https://doi.org/10.1016/j.ejvs.2021.12.042

      Objective

      Abdominal aortic aneurysms (AAAs) with adverse morphology of the aneurysm neck are “complex”. Techniques employed to repair complex aneurysms include open surgical repair (OSR) and a number of on label endovascular techniques such as fenestrated endovascular aneurysm repair (FEVAR) and endovascular aneurysm repair (EVAR) with adjuncts (including chimneys and endo-anchors), as well as off label use of standard EVAR. The aim was to conduct a network meta-analysis (NMA) of published comparative outcomes.

      Data Sources

      An electronic search was performed in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL). These databases were interrogated using the PubMed interface and the Healthcare Databases Advanced Search (HDAS) interface developed by the National Institute of Health and Care Excellence.

      Review methods

      Online databases were interrogated up to April 2020. Studies were included if they compared outcomes between at least two methods of repair for complex aneurysms (those with at least one adverse neck feature: absent/short neck, conicality, angulation, calcification, large diameter, and thrombus). The primary outcome measure was peri-operative death. Pre-registration was done in PROSPERO (CRD42020177482).

      Results

      The search identified 24 observational studies and 7854 patients who underwent OSR, FEVAR, off label EVAR, or chimney EVAR. No comparative studies included EVAR with endo-anchors. NMA was performed on 23 studies that reported outcomes of aneurysms with short/absent infrarenal neck. Compared with OSR, off label EVAR (relative risk [RR] 0.10, 95% confidence interval [CI] 0.01 – 0.41) and FEVAR (RR 0.62, 95% CI 0.32–0.94) were associated with lower peri-operative mortality. This difference was not seen at the midterm follow up (30 months). Compared with OSR, FEVAR was associated with a lower peri-operative myocardial infarction (MI) rate (RR 0.37, 95% CI 0.16 – 0.62) but a higher midterm re-intervention rate (hazard ratio 1.65, 95% CI 1.04 – 2.66). All studies had a “moderate” or “high” risk of bias. Confidence in the network findings (GRADE) was generally “low”.

      Conclusion

      This NMA demonstrated a peri-operative survival benefit for off label EVAR and FEVAR compared with OSR, potentially due to reduced risk of MI. FEVAR carries a greater midterm re-intervention risk than OSR, with potential implications for cost effectiveness. There is paucity of comparative data for cases with adverse neck features other than short length.

      Keywords

      This network meta-analysis (NMA) compares treatments for the repair of complex abdominal aortic aneuryms (AAA), focussing on juxtarenal AAA. Existing meta-analyses predominantly compare Open Surgery and FEVAR only. The statistical techniques employed in a NMA permit the additional inclusion of chimney EVAR and off-label EVAR in the same analysis. The primary finding is perioperative survival benefit for off-label EVAR and FEVAR, as compared to Open Surgery, which is lost by 2.5 years follow-up. This survival benefit may be explained by a higher rate of cardiac events after Open Surgery. There is no perioperative survival benefit to chimney EVAR compared to Open Surgery. This NMA uniquely includes all techniques that have been compared in the literature. It highlights the need for a future study that adjusts for confounding, and includes all methods of complex AAA repair.

      Introduction

      Repair of complex abdominal aortic aneurysms (AAA) carries a greater risk of peri-operative death, complications,
      • Waton S.
      • Johal A.
      • Birmpili P.
      • Li Q.
      • Cromwell D.
      • Pherwani A.
      • et al.
      National Vascular Registry: 2020 Annual Report.
      ,
      • Locham S.
      • Faateh M.
      • Dhaliwal J.
      • Nejim B.
      • Dakour-Aridi H.
      • Malas M.B.
      Outcomes and cost of fenestrated versus standard endovascular repair of intact abdominal aortic aneurysm in the United States.
      and higher costs
      • Locham S.
      • Faateh M.
      • Dhaliwal J.
      • Nejim B.
      • Dakour-Aridi H.
      • Malas M.B.
      Outcomes and cost of fenestrated versus standard endovascular repair of intact abdominal aortic aneurysm in the United States.
      than infrarenal AAA. Aneurysm complexity is predominantly determined by the length and quality of the infrarenal neck, although what exactly constitutes neck complexity is contentious. Endovascular aneurysm repair (EVAR) has provided a pragmatic definition of neck complexity by using objective criteria of a stent graft’s “instructions for use” (IFU) document. This is the clinically relevant definition used by the UK’s National Institute for Health and Care Excellence (NICE).
      National Institute for Health and Care Excellence
      Abdominal aortic aneurysm: diagnosis and management.
      Using real world IFU criteria, up to 60% of all AAAs are complex.
      • Aburahma A.F.
      • Campbell J.E.
      • Mousa A.Y.
      • Hass S.M.
      • Stone P.A.
      • Jain A.
      • et al.
      Clinical outcomes for hostile versus favorable aortic neck anatomy in endovascular aortic aneurysm repair using modular devices.
      This is predominantly based on neck length of < 10 – 15 mm (juxtarenal/pararenal aneurysms), and also takes into consideration other adverse morphological features, including angulation, conicality, large diameter, and excessive calcification or thrombus.
      Techniques for repairing complex AAAs currently include open surgical repair (OSR) and various endovascular options. OSR involves the application of an aortic occlusion clamp at various levels. On label endovascular techniques include fenestrated EVAR (FEVAR) and EVAR with adjunctive measures such as chimney stent grafts (ChEVAR) or endo-anchors. EVAR off IFU is also used widely to treat complex AAAs and should be evaluated as a distinct modality.
      Existing reviews and meta-analyses on this topic have typically used pooled case series of single techniques, comparisons have been largely limited to OSR and FEVAR, or have grouped all endovascular treatments for comparison with OSR.
      • Doonan R.J.
      • Girsowicz E.
      • Dubois L.
      • Gill H.L.
      A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair.
      • Končar I.B.
      • Jovanović A.L.
      • Dučič S.M.
      The role of fEVAR, chEVAR and open repair in treatment of juxtarenal aneurysms: a systematic review.
      • Nordon I.M.
      • Hinchliffe R.J.
      • Holt P.J.
      • Loftus I.M.
      • Thompson M.M.
      Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair – a systematic review.
      • Rao R.
      • Lane T.R.
      • Franklin I.J.
      • Davies A.H.
      Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms.
      Additionally, studies often combine juxtarenal aneurysms, those with adverse neck features, thoraco-abdominal aortic aneurysms (TAAAs) and aneurysms of the visceral aorta, resulting in significant anatomical heterogeneity.
      In a network meta-analysis (NMA), data from multiple separate comparisons are pooled to derive multiple interconnected comparisons of more than two treatments. NMA also allows ranking of multiple interventions. Analyses combine aggregate level pairwise comparisons and infer treatment effects for pairwise comparisons that have not been compared directly (Fig. 1). Advantages to this increasingly popular technique over traditional meta-analysis include the ability to compare more than two treatments, as well as those that have not previously been directly compared in the literature. However, various assumptions regarding the treatment cohorts require rigorous testing to ensure validity, more so than with a standard meta-analysis.
      Figure 1
      Figure 1A diagrammatic representation for an example network of three treatments, A, B, and C. In this example, A vs. B and B vs. C have been directly studied in the literature (in studies i and j, respectively), with effect sizes θA,B and θB,C, respectively. However, A and C have never been directly compared. An indirect inference on the effect size for A vs. C (θA,C) can be made using the equation shown. All direct and indirect effect sizes in the network can then be statistically combined to provide an estimate on A vs. B vs. C.
      The aim was to conduct a systematic review of treatment options for complex AAA and quantitatively compare each modality against every other with a NMA.

      Materials and methods

      This systematic review and network meta-analysis was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines,
      • Hutton B.
      • Salanti G.
      • Caldwell D.M.
      • Chaimani A.
      • Schmid C.H.
      • Cameron C.
      • et al.
      The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
      as per a pre-registered protocol (PROSPERO-CRD42020177482).

      Literature search

      An electronic search of Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL) was done. These databases were interrogated using the PubMed interface and the Healthcare Databases Advanced Search (HDAS) interface developed by NICE. The search date was 24 April 2020. The reference lists of articles meeting the search criteria were also searched to identify further relevant citations. Full search strings can be found in the Supplementary Material.

      Inclusion and exclusion criteria

      Studies providing direct comparison of outcomes between two or more modalities for treating complex AAAs were included (aneurysms with at least one of the following neck features: absence, short length, conicality, excessive angulation, excessive calcification, large diameter, and excessive thrombus). Studies reporting on the outcomes for standard AAAs, ruptured AAAs, and TAAAs (including aneurysms involving the visceral segment at the level of the coeliac artery) were excluded. Studies published before 2000 and non-English language studies were excluded. Studies published as a single technique case series or as an abstract for an oral conference presentation were excluded.

      Study selection and data extraction

      Two authors (S.P. and D.O.) independently assessed the titles and abstracts of articles identified from the search. The full texts of relevant reports were retrieved and discrepancies in decisions for inclusion/exclusion were resolved with further review and discussion. S.P. and D.O. independently extracted data into an electronic spreadsheet, and disagreements were resolved by further review and discussion.

      Outcome measures

      Outcome measures were decided a priori. The primary outcome measure was peri-operative death. Secondary outcome measures were peri-operative renal failure, peri-operative myocardial infarction (MI), early re-intervention, midterm follow up results of all cause mortality rates, re-intervention, aneurysm related mortality, and cost/cost effectiveness.

      Statistical analysis

      A random effects NMA was performed using the BUGSnet package, operated through RStudio (R Foundation for Statistical Computing, Vienna, Austria).
      • Béliveau A.
      • Boyne D.J.
      • Slater J.
      • Brenner D.
      • Arora P.
      BUGSnet: an R package to facilitate the conduct and reporting of Bayesian network Meta-analyses.
      Comparative outputs from the BUGSnet model were relative risks (RRs) for dichotomous event data (peri-operative outcomes) and hazard ratios (HRs) for survival data (midterm outcomes), both with 95% confidence intervals (CIs). Sum under the cumulative ranking (SUCRA) scores were used to rank interventions; this is a measure expressed as a percentage showing the relative probability of an intervention being among the best options.
      The validity of the NMA results were evaluated via assessment of transitivity and consistency. Transitivity was investigated by collecting and comparing available demographic data for patients in each direct comparison. Consistency assumes that indirect estimates of treatment effect are similar to direct estimates. This was assessed using a node splitting technique and inconsistency/consistency modelling to produce leverage and correlation plots. A random effects model was used, and a statistical assessment of heterogeneity was performed for each pairwise comparison (Supplementary Material).
      The Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was completed for the primary outcome measure to estimate degree of certainty (Supplementary Material). This involved risk of bias assessment using the Newcastle–Ottawa Scale (NOS) for cohort studies,
      • Wells G.
      • Shea B.
      • O'Connell D.
      • Peterson J.
      • Welch V.
      • Losos M.
      • et al.
      The Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses.
      and assessment of indirectness, heterogeneity, inconsistency/incoherence, imprecision, and publication bias. A sensitivity analysis was performed on the primary outcome measure, omitting data from sources with a high risk of bias.

      Results

      The search identified 1190 abstracts after de-duplication; 24 studies, on 7854 patients, met the final inclusion criteria for the review (Fig. 2).
      • Chisci E.
      • Kristmundsson T.
      • de Donato G.
      • Resch T.
      • Setacci F.
      • Sonesson B.
      • et al.
      The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts.
      • Bruen K.J.
      • Feezor R.J.
      • Daniels M.J.
      • Beck A.W.
      • Lee W.A.
      Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms.
      • Sultan S.
      • Hynes N.
      Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair.
      • Donas K.P.
      • Eisenack M.
      • Panuccio G.
      • Austermann M.
      • Osada N.
      • Torsello G.
      The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms.
      • Freyrie A.
      • Gargiulo M.
      • Gallitto E.
      • Faggioli G.L.
      • Testi G.
      • Giovanetti F.
      • et al.
      Abdominal aortic aneurysms with short proximal neck: comparison between standard endograft and open repair.
      • Hoshina K.
      • Hosaka A.
      • Takayama T.
      • Kato M.
      • Ohkubo N.
      • Okamoto H.
      • et al.
      Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.
      • Canavati R.
      • Millen A.
      • Brennan J.
      • Fisher R.K.
      • McWilliams R.G.
      • Naik J.B.
      • et al.
      Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair.
      • Barillà D.
      • Sobocinski J.
      • Stilo F.
      • Maurel B.
      • Spinelli F.
      • Haulon S.
      Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR.
      • Lee J.T.
      • Lee G.K.
      • Chandra V.
      • Dalman R.L.
      Comparison of fenestrated endografts and the snorkel/chimney technique.
      • Raux M.
      • Patel V.I.
      • Cochennec F.
      • Mukhopadhyay S.
      • Desgranges P.
      • Cambria R.P.
      • et al.
      A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms.
      • Michel M.
      • Becquemin J.P.
      • Clément M.C.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.
      • Saratzis A.N.
      • Bath M.F.
      • Harrison S.C.
      • Sayers R.D.
      • Bown M.J.
      Impact of Fenestrated endovascular abdominal aortic aneurysm repair on renal function.
      • Shahverdyan R.
      • Majd M.P.
      • Thul R.
      • Braun N.
      • Gawenda M.
      • Brunkwall J.
      F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results.
      • Wooster M.
      • Tanious A.
      • Patel S.
      • Moudgill N.
      • Back M.
      • Shames M.
      Concomitant parallel endografting and fenestrated experience in a regional aortic center.
      • Deery S.E.
      • Lancaster R.T.
      • Gubala A.M.
      • O'Donnell T.F.X.
      • Kwolek C.J.
      • Conrad M.F.
      • et al.
      Early experience with fenestrated endovascular compared to open repair of complex abdominal aortic aneurysms in a high-volume open aortic center.
      • Manunga J.
      • Sullivan T.
      • Garberich R.
      • Alden P.
      • Alexander J.
      • Skeik N.
      • et al.
      Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts.
      • Michel M.
      • Becquemin J.P.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – A study of the cost-effectiveness of fenestrated/branched EVAR compared with open surgery for patients with complex aortic aneurysms at 2 years.
      • Charbonneau P.
      • Hongku K.
      • Herman C.R.
      • Habib M.
      • Girsowicz E.
      • Doonan R.J.
      • et al.
      Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair.
      • Chinsakchai K.
      • Prapassaro T.
      • Salisatkorn W.
      • Hongku K.
      • Moll F.L.
      • Ruangsetakit C.
      • et al.
      Outcomes of open repair, fenestrated stent grafting, and chimney grafting in juxtarenal abdominal aortic aneurysm: is it time for a randomized trial?.
      • Fiorucci B.
      • Speziale F.
      • Kölbel T.
      • Tsilimparis N.
      • Sirignano P.
      • Capoccia L.
      • et al.
      Short- and midterm outcomes of open repair and fenestrated endografting of pararenal aortic aneurysms in a concurrent propensity-adjusted comparison.
      • Locham S.
      • Dakour-Aridi H.
      • Bhela J.
      • Nejim B.
      • Bhavana Challa A.
      • Malas M.
      Thirty-day outcomes of fenestrated and chimney endovascular repair and open repair of juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms using National Surgical Quality Initiative Program Database (2012–2016).
      • Soler R.
      • Bartoli M.A.
      • Faries C.
      • Mancini J.
      • Sarlon-Bartoli G.
      • Haulon S.
      • et al.
      Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms.
      • O'Donnell T.F.X.
      • Boitano L.T.
      • Deery S.E.
      • Schermerhorn M.L.
      • Schanzer A.
      • Beck A.W.
      • et al.
      Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms.
      • Taneva G.T.
      • Donas K.P.
      • Pitoulias G.A.
      • Austermann M.
      • Veith F.J.
      • Torsello G.
      Cost-effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies.
      Figure 2
      Figure 2Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram of identification, screening, eligibility, and inclusion phases of the systematic search for studies providing comparative outcomes between methods of complex abdominal aortic aneurysm (AAA) repair.
      All studies employed a retrospective cohort design. All studies compared at least two of the following: OSR, FEVAR, EVAR off IFU, and ChEVAR. There were no comparative studies including EVAR reinforced with endo-anchors that met the inclusion criteria (Table 1).
      Table 1Characteristics of 24 included studies comparing outcomes between at least two methods of repair for complex abdominal aortic aneurysms
      Study, yearCountry of patientsData sourceCase capture startCase capture endFollow up – moPatients – nOpen

      n
      FEVAR

      n
      EVAR off IFU

      n
      ChEVAR

      n
      Taneva,
      • Taneva G.T.
      • Donas K.P.
      • Pitoulias G.A.
      • Austermann M.
      • Veith F.J.
      • Torsello G.
      Cost-effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies.
      2020
      GermanySingle centreJan 13Jan 1737.21480370111
      O’Donnell,
      • O'Donnell T.F.X.
      • Boitano L.T.
      • Deery S.E.
      • Schermerhorn M.L.
      • Schanzer A.
      • Beck A.W.
      • et al.
      Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms.
      2020
      USA/CanadaVQI databaseJan 12Dec 18242 5721 89467800
      Soler,
      • Soler R.
      • Bartoli M.A.
      • Faries C.
      • Mancini J.
      • Sarlon-Bartoli G.
      • Haulon S.
      • et al.
      Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms.
      2019
      FranceSingle centreJan 05Dec 15271911345700
      Locham,
      • Locham S.
      • Dakour-Aridi H.
      • Bhela J.
      • Nejim B.
      • Bhavana Challa A.
      • Malas M.
      Thirty-day outcomes of fenestrated and chimney endovascular repair and open repair of juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms using National Surgical Quality Initiative Program Database (2012–2016).
      2019
      USANSQIP vascular databaseJan 12Dec 1611 1918651620164
      Fiorucci,
      • Fiorucci B.
      • Speziale F.
      • Kölbel T.
      • Tsilimparis N.
      • Sirignano P.
      • Capoccia L.
      • et al.
      Short- and midterm outcomes of open repair and fenestrated endografting of pararenal aortic aneurysms in a concurrent propensity-adjusted comparison.
      2019
      ItalyMulticentreJan 98Mar 16481431024100
      Chinsakchai,
      • Chinsakchai K.
      • Prapassaro T.
      • Salisatkorn W.
      • Hongku K.
      • Moll F.L.
      • Ruangsetakit C.
      • et al.
      Outcomes of open repair, fenestrated stent grafting, and chimney grafting in juxtarenal abdominal aortic aneurysm: is it time for a randomized trial?.
      2019
      ThailandSingle centreJan 10Dec 1636.7753220023
      Charbonneau,
      • Charbonneau P.
      • Hongku K.
      • Herman C.R.
      • Habib M.
      • Girsowicz E.
      • Doonan R.J.
      • et al.
      Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair.
      2019
      CanadaMulticentreApr 03Aug 1663.642622402020
      Michel,
      • Michel M.
      • Becquemin J.P.
      • Clément M.C.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.
      ,
      • Michel M.
      • Becquemin J.P.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – A study of the cost-effectiveness of fenestrated/branched EVAR compared with open surgery for patients with complex aortic aneurysms at 2 years.
      2015, 2018
      FranceWINDOWS + PMSI databasesSep 09Dec 12241 5661 38218400
      Manunga,
      • Manunga J.
      • Sullivan T.
      • Garberich R.
      • Alden P.
      • Alexander J.
      • Skeik N.
      • et al.
      Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts.
      2018
      USASingle centreJan 10Feb 1731153698400
      Deery,
      • Deery S.E.
      • Lancaster R.T.
      • Gubala A.M.
      • O'Donnell T.F.X.
      • Kwolek C.J.
      • Conrad M.F.
      • et al.
      Early experience with fenestrated endovascular compared to open repair of complex abdominal aortic aneurysms in a high-volume open aortic center.
      2018
      USASingle centreJan 10Sep 1526116981800
      Wooster,
      • Wooster M.
      • Tanious A.
      • Patel S.
      • Moudgill N.
      • Back M.
      • Shames M.
      Concomitant parallel endografting and fenestrated experience in a regional aortic center.
      2017
      USASingle centreJan 10Jun 1510.393039054
      Shahverdyan,
      • Shahverdyan R.
      • Majd M.P.
      • Thul R.
      • Braun N.
      • Gawenda M.
      • Brunkwall J.
      F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results.
      2015
      GermanySingle centreApr 99Jul 1445.569343500
      Saratzis,
      • Saratzis A.N.
      • Bath M.F.
      • Harrison S.C.
      • Sayers R.D.
      • Bown M.J.
      Impact of Fenestrated endovascular abdominal aortic aneurysm repair on renal function.
      2015
      UKSingle centreJan 08Oct 1420.5116585800
      Raux,
      • Raux M.
      • Patel V.I.
      • Cochennec F.
      • Mukhopadhyay S.
      • Desgranges P.
      • Cambria R.P.
      • et al.
      A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms.
      2014
      France/USADual centreJul 01Aug 1211891474200
      Lee,
      • Lee J.T.
      • Lee G.K.
      • Chandra V.
      • Dalman R.L.
      Comparison of fenestrated endografts and the snorkel/chimney technique.
      2014
      USASingle centreSep 09Mar 13630015015
      Barillà,
      • Barillà D.
      • Sobocinski J.
      • Stilo F.
      • Maurel B.
      • Spinelli F.
      • Haulon S.
      Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR.
      2014
      France/ItalyDual centreJan 06Dec 10Not stated100505000
      Canavati,
      • Canavati R.
      • Millen A.
      • Brennan J.
      • Fisher R.K.
      • McWilliams R.G.
      • Naik J.B.
      • et al.
      Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair.
      2013
      UKSingle centreJan 06Dec 101107545300
      Hoshina,
      • Hoshina K.
      • Hosaka A.
      • Takayama T.
      • Kato M.
      • Ohkubo N.
      • Okamoto H.
      • et al.
      Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.
      2012
      JapanDual centreJan 03Nov 104250220280
      Freyrie,
      • Freyrie A.
      • Gargiulo M.
      • Gallitto E.
      • Faggioli G.L.
      • Testi G.
      • Giovanetti F.
      • et al.
      Abdominal aortic aneurysms with short proximal neck: comparison between standard endograft and open repair.
      2012
      ItalySingle centreJan 05Dec 0926.282440380
      Donas,
      • Donas K.P.
      • Eisenack M.
      • Panuccio G.
      • Austermann M.
      • Osada N.
      • Torsello G.
      The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms.
      2012
      GermanySingle centreJan 08Dec 1014.2903129030
      Sultan,
      • Sultan S.
      • Hynes N.
      Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair.
      2011
      IrelandSingle centreOct 01Oct 0932.5118660520
      Bruen,
      • Bruen K.J.
      • Feezor R.J.
      • Daniels M.J.
      • Beck A.W.
      • Lee W.A.
      Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms.
      2011
      USASingle centreJan 08Dec 09142210021
      Chisci,
      • Chisci E.
      • Kristmundsson T.
      • de Donato G.
      • Resch T.
      • Setacci F.
      • Sonesson B.
      • et al.
      The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts.
      2009
      Italy/SwedenMulticentreJan 05Dec 0719.51876152740
      FEVAR = fenestrated endovascular aneurysm repair; EVAR off IFU = endovascular aneurysm repair off instructions for use; ChEVAR = chimney endovascular aneurysm repair; VQI = Vascular Quality Initiative; NSQIP = National Surgical Quality Improvement Program (American College of Surgeons); PMSI = Programme de médicalisation des systemes d’information (national hospital discharge database).
      Of the 24 studies, 19 reported comparative outcomes for the repair of juxtarenal and/or pararenal aneurysms (i.e., had inclusion criteria based on absent/short neck length alone),
      • Sultan S.
      • Hynes N.
      Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair.
      • Donas K.P.
      • Eisenack M.
      • Panuccio G.
      • Austermann M.
      • Osada N.
      • Torsello G.
      The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms.
      • Freyrie A.
      • Gargiulo M.
      • Gallitto E.
      • Faggioli G.L.
      • Testi G.
      • Giovanetti F.
      • et al.
      Abdominal aortic aneurysms with short proximal neck: comparison between standard endograft and open repair.
      ,
      • Canavati R.
      • Millen A.
      • Brennan J.
      • Fisher R.K.
      • McWilliams R.G.
      • Naik J.B.
      • et al.
      Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair.
      ,
      • Lee J.T.
      • Lee G.K.
      • Chandra V.
      • Dalman R.L.
      Comparison of fenestrated endografts and the snorkel/chimney technique.
      • Raux M.
      • Patel V.I.
      • Cochennec F.
      • Mukhopadhyay S.
      • Desgranges P.
      • Cambria R.P.
      • et al.
      A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms.
      • Michel M.
      • Becquemin J.P.
      • Clément M.C.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.
      • Saratzis A.N.
      • Bath M.F.
      • Harrison S.C.
      • Sayers R.D.
      • Bown M.J.
      Impact of Fenestrated endovascular abdominal aortic aneurysm repair on renal function.
      • Shahverdyan R.
      • Majd M.P.
      • Thul R.
      • Braun N.
      • Gawenda M.
      • Brunkwall J.
      F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results.
      • Wooster M.
      • Tanious A.
      • Patel S.
      • Moudgill N.
      • Back M.
      • Shames M.
      Concomitant parallel endografting and fenestrated experience in a regional aortic center.
      • Deery S.E.
      • Lancaster R.T.
      • Gubala A.M.
      • O'Donnell T.F.X.
      • Kwolek C.J.
      • Conrad M.F.
      • et al.
      Early experience with fenestrated endovascular compared to open repair of complex abdominal aortic aneurysms in a high-volume open aortic center.
      • Manunga J.
      • Sullivan T.
      • Garberich R.
      • Alden P.
      • Alexander J.
      • Skeik N.
      • et al.
      Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts.
      • Michel M.
      • Becquemin J.P.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – A study of the cost-effectiveness of fenestrated/branched EVAR compared with open surgery for patients with complex aortic aneurysms at 2 years.
      ,
      • Chinsakchai K.
      • Prapassaro T.
      • Salisatkorn W.
      • Hongku K.
      • Moll F.L.
      • Ruangsetakit C.
      • et al.
      Outcomes of open repair, fenestrated stent grafting, and chimney grafting in juxtarenal abdominal aortic aneurysm: is it time for a randomized trial?.
      • Fiorucci B.
      • Speziale F.
      • Kölbel T.
      • Tsilimparis N.
      • Sirignano P.
      • Capoccia L.
      • et al.
      Short- and midterm outcomes of open repair and fenestrated endografting of pararenal aortic aneurysms in a concurrent propensity-adjusted comparison.
      • Locham S.
      • Dakour-Aridi H.
      • Bhela J.
      • Nejim B.
      • Bhavana Challa A.
      • Malas M.
      Thirty-day outcomes of fenestrated and chimney endovascular repair and open repair of juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms using National Surgical Quality Initiative Program Database (2012–2016).
      • Soler R.
      • Bartoli M.A.
      • Faries C.
      • Mancini J.
      • Sarlon-Bartoli G.
      • Haulon S.
      • et al.
      Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms.
      • O'Donnell T.F.X.
      • Boitano L.T.
      • Deery S.E.
      • Schermerhorn M.L.
      • Schanzer A.
      • Beck A.W.
      • et al.
      Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms.
      • Taneva G.T.
      • Donas K.P.
      • Pitoulias G.A.
      • Austermann M.
      • Veith F.J.
      • Torsello G.
      Cost-effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies.
      four studies included patients if they met one of several adverse neck morphology criteria (i.e., cases with one or more “off IFU” characteristic),
      • Chisci E.
      • Kristmundsson T.
      • de Donato G.
      • Resch T.
      • Setacci F.
      • Sonesson B.
      • et al.
      The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts.
      ,
      • Bruen K.J.
      • Feezor R.J.
      • Daniels M.J.
      • Beck A.W.
      • Lee W.A.
      Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms.
      ,
      • Barillà D.
      • Sobocinski J.
      • Stilo F.
      • Maurel B.
      • Spinelli F.
      • Haulon S.
      Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR.
      ,
      • Charbonneau P.
      • Hongku K.
      • Herman C.R.
      • Habib M.
      • Girsowicz E.
      • Doonan R.J.
      • et al.
      Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair.
      and one study included cases only if “massive neck atheroma” was present.
      • Hoshina K.
      • Hosaka A.
      • Takayama T.
      • Kato M.
      • Ohkubo N.
      • Okamoto H.
      • et al.
      Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.
      These details, adverse neck feature definitions, and methods of accounting for confounders are presented in Table 2. The study that included only cases of neck thrombus was excluded from quantitative analysis.
      • Hoshina K.
      • Hosaka A.
      • Takayama T.
      • Kato M.
      • Ohkubo N.
      • Okamoto H.
      • et al.
      Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.
      As all other studies either exclusively included, or included as a majority, cases with a short or absent infrarenal neck, they were included in the NMA.
      Table 2Anatomical inclusion criteria with definitions, and methods employed to account for confounding across 24 included studies comparing outcomes between at least two methods of repair for complex abdominal aortic aneurysms with at least one adverse neck feature: absent/short neck, conicality, angulation, calcification, large diameter, or thrombus
      StudyComparisonMethod of addressing confoundingInclusion criteria with definitions
      Absent/short neck, pararenal/juxtarenal – mean/median neck lengthAngulatedCalcifiedThrombusConicalLarge diameter
      Taneva
      • Taneva G.T.
      • Donas K.P.
      • Pitoulias G.A.
      • Austermann M.
      • Veith F.J.
      • Torsello G.
      Cost-effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies.
      FEVAR vs. ChEVARNil3–9 mmNININININI
      O’Donnell
      • O'Donnell T.F.X.
      • Boitano L.T.
      • Deery S.E.
      • Schermerhorn M.L.
      • Schanzer A.
      • Beck A.W.
      • et al.
      Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms.
      Open vs. FEVARPropensity weighted adjustmentProximal extent at/below highest RANININININI
      Soler
      • Soler R.
      • Bartoli M.A.
      • Faries C.
      • Mancini J.
      • Sarlon-Bartoli G.
      • Haulon S.
      • et al.
      Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms.
      Open vs. FEVARNilUp to inter-renal aorta as per Ayari et al.
      • Ayari R.
      • Paraskevas N.
      • Rosset E.
      • Ede B.
      • Branchereau A.
      Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification.
      NININININI
      Locham
      • Locham S.
      • Dakour-Aridi H.
      • Bhela J.
      • Nejim B.
      • Bhavana Challa A.
      • Malas M.
      Thirty-day outcomes of fenestrated and chimney endovascular repair and open repair of juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms using National Surgical Quality Initiative Program Database (2012–2016).
      Open vs. FEVAR vs. ChEVARNilAs listed in NSQIP databaseNININININI
      Fiorucci
      • Fiorucci B.
      • Speziale F.
      • Kölbel T.
      • Tsilimparis N.
      • Sirignano P.
      • Capoccia L.
      • et al.
      Short- and midterm outcomes of open repair and fenestrated endografting of pararenal aortic aneurysms in a concurrent propensity-adjusted comparison.
      Open vs. FEVARPropensity matchingNot providedNININININI
      Chinsakchai
      • Chinsakchai K.
      • Prapassaro T.
      • Salisatkorn W.
      • Hongku K.
      • Moll F.L.
      • Ruangsetakit C.
      • et al.
      Outcomes of open repair, fenestrated stent grafting, and chimney grafting in juxtarenal abdominal aortic aneurysm: is it time for a randomized trial?.
      Open vs. FEVAR vs. ChEVARNilNo normal aorta available for infrarenal clamp (7.5 mm open, 1 mm FEVAR, 4 mm ChEVAR)NININININI
      Charbonneau
      • Charbonneau P.
      • Hongku K.
      • Herman C.R.
      • Habib M.
      • Girsowicz E.
      • Doonan R.J.
      • et al.
      Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair.
      Open vs.

      EVAR off IFU
      Propensity weighted adjustment4–14 mm> 60°NININI33–34 mm
      Michel
      • Michel M.
      • Becquemin J.P.
      • Clément M.C.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.
      ,
      • Michel M.
      • Becquemin J.P.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – A study of the cost-effectiveness of fenestrated/branched EVAR compared with open surgery for patients with complex aortic aneurysms at 2 years.
      Open vs. FEVARNilSuprarenal clamp without visceral vessel reconstructionNININININI
      Manunga
      • Manunga J.
      • Sullivan T.
      • Garberich R.
      • Alden P.
      • Alexander J.
      • Skeik N.
      • et al.
      Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts.
      Open vs. FEVARNilNot providedNININININI
      Deery
      • Deery S.E.
      • Lancaster R.T.
      • Gubala A.M.
      • O'Donnell T.F.X.
      • Kwolek C.J.
      • Conrad M.F.
      • et al.
      Early experience with fenestrated endovascular compared to open repair of complex abdominal aortic aneurysms in a high-volume open aortic center.
      Open vs. FEVARNilNot providedNININININI
      Wooster
      • Wooster M.
      • Tanious A.
      • Patel S.
      • Moudgill N.
      • Back M.
      • Shames M.
      Concomitant parallel endografting and fenestrated experience in a regional aortic center.
      FEVAR vs. ChEVARNil< 4 mm (3 mm FEVAR, 5 mm ChEVAR)NININININI
      Shahverdyan
      • Shahverdyan R.
      • Majd M.P.
      • Thul R.
      • Braun N.
      • Gawenda M.
      • Brunkwall J.
      F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results.
      Open vs. FEVARNil≤ 10 mm or requiring a suprarenal clampNININININI
      Saratzis
      • Saratzis A.N.
      • Bath M.F.
      • Harrison S.C.
      • Sayers R.D.
      • Bown M.J.
      Impact of Fenestrated endovascular abdominal aortic aneurysm repair on renal function.
      Open vs. FEVARCase matchingNot provided (8 mm FEVAR, 9 mm open)NININININI
      Raux
      • Raux M.
      • Patel V.I.
      • Cochennec F.
      • Mukhopadhyay S.
      • Desgranges P.
      • Cambria R.P.
      • et al.
      A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms.
      Open vs. FEVARPropensity matchingRequiring suprarenal (or higher) clampNININININI
      Lee
      • Lee J.T.
      • Lee G.K.
      • Chandra V.
      • Dalman R.L.
      Comparison of fenestrated endografts and the snorkel/chimney technique.
      FEVAR vs. ChEVARNilNot provided (4.5 mm FEVAR, 1.1 mm ChEVAR)NININININI
      Barilla
      • Barillà D.
      • Sobocinski J.
      • Stilo F.
      • Maurel B.
      • Spinelli F.
      • Haulon S.
      Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR.
      Open vs. FEVARCase matching< 10 mm≥ 60°> 50%> 50% circumferenceIncluded but no definition provided> 31 mm
      Canavati
      • Canavati R.
      • Millen A.
      • Brennan J.
      • Fisher R.K.
      • McWilliams R.G.
      • Naik J.B.
      • et al.
      Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair.
      Open vs. FEVARRisk adjustment (V-POSSUM)< 10 mmNININININI
      Hoshina
      • Hoshina K.
      • Hosaka A.
      • Takayama T.
      • Kato M.
      • Ohkubo N.
      • Okamoto H.
      • et al.
      Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.
      Open vs.

      EVAR off IFU
      NilNININI≥ 5 mm thickness and ≥ 75% circumference and length ≥ 5 mmNINI
      Freyrie
      • Freyrie A.
      • Gargiulo M.
      • Gallitto E.
      • Faggioli G.L.
      • Testi G.
      • Giovanetti F.
      • et al.
      Abdominal aortic aneurysms with short proximal neck: comparison between standard endograft and open repair.
      Open vs.

      EVAR off IFU
      Nil≤ 10 mm (7.1 mm open, 8 mm EVAR)NININININI
      Donas
      • Donas K.P.
      • Eisenack M.
      • Panuccio G.
      • Austermann M.
      • Osada N.
      • Torsello G.
      The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms.
      Open vs. FEVAR vs. ChEVARNil< 9 mm or extension to inter-renal aortaNININININI
      Sultan
      • Sultan S.
      • Hynes N.
      Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair.
      Open vs.

      EVAR off IFU
      NilRequiring suprarenal clamp and infrarenal anastomosisNININININI
      Bruen
      • Bruen K.J.
      • Feezor R.J.
      • Daniels M.J.
      • Beck A.W.
      • Lee W.A.
      Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms.
      Open vs. ChEVARNilIncluded but no definition provided (3 mm Open, 0 mm ChEVAR)Included, but no definition providedNINIIncluded, but no definition providedNI
      Chisci
      • Chisci E.
      • Kristmundsson T.
      • de Donato G.
      • Resch T.
      • Setacci F.
      • Sonesson B.
      • et al.
      The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts.
      Open vs. FEVAR vs. EVAR Off IFUNil≤ 15 mm (9 mm open, 10 mm EVAR, 7.5 mm FEVAR)≥ 60°NI> 50% circumference≥ 2 mm diameter increase over 10 mm length≥ 28 mm
      FEVAR = fenestrated endovascular aneurysm repair; EVAR off IFU = endovascular aneurysm repair off instructions for use; ChEVAR = chimney endovascular aneurysm repair; NI = not included; RA = renal artery; NSQIP = National Surgical Quality Improvement Program (American College of Surgeons).

      Risk of bias

      Risk of bias assessment was performed using the NOS system for cohort studies. Four of the 24 studies were assessed as having high bias risk and 20 as having a moderate risk of bias. Overall, across studies, there was poor compensation for selection bias arising from variation in physiological fitness and neck length between endovascular and open treatment arms, as well as between subtypes of endovascular treatment options (Supplementary Material).

      Primary outcome measure

      Peri-operative mortality

      Twenty-two studies reported peri-operative mortality, defined either as death within 30 days of the aneurysm repair or death during the same admission as the primary procedure. A total of 7 804 patients (two arm studies: n = 18; three arm studies: n = 4) were included in this NMA, with 309 (3.9%) deaths reported in this network (Fig. 3A).
      Figure 3
      Figure 3Literature summary network plots for all cause mortality (A) peri-operatively (7 804 patients across 22 studies) and at (B) midterm follow up (3 481 patients across 16 studies) in studies providing comparative outcomes between methods of complex abdominal aortic aneurysm repair. The size of each red node corresponds to the number of study arms included for a treatment across all comparisons. The width of each grey line corresponds to the number of studies (superimposed on the line) comparing the two interventions directly. FEVAR = fenestrated endovascular aneurysm repair; EVAR off IFU = endovascular aneurysm repair off instructions for use; ChEVAR = chimney endovascular aneurysm repair.
      Unweighted pooled peri-operative mortality rates were 4.4% (235 deaths/5 366 patients) for OSR, 3.1% (52 deaths/1 654 patients) for FEVAR, 4.8% (20 deaths/418 patients) for ChEVAR, and 0.5% (2 deaths/366 patients) for EVAR off IFU. The NMA results showed that both EVAR off IFU (RR 0.10, 95% CI 0.01 – 0.41) and FEVAR (RR 0.62, 95% CI 0.32 – 0.94) were associated with lower peri-operative mortality than OSR. Compared with FEVAR, EVAR off IFU was associated with lower peri-operative mortality (RR 0.17, 95% CI 0.02 – 0.74). There was no statistically significant difference in peri-operative mortality between OSR and ChEVAR (RR 1.15, 95% CI 0.50 – 2.44) (Figure 4, Figure 5A ).
      Figure 4
      Figure 4Forest plots for comparative all cause mortality network meta-analysis (A) peri-operatively (7 804 patients across 22 studies; open surgery 5 366 patients, FEVAR 1 654 patients, ChEVAR 418 patients, and EVAR off IFU 366 patients) and (B) at midterm follow up (3 481 patients across 16 studies; open surgery 2 266 patients, FEVAR 699 patients, ChEVAR 224 patients, and EVAR off IFU 292 patients) in studies providing comparative outcomes between methods of complex abdominal aortic aneurysm repair. Error bars represent 95% confidence intervals. Mean midterm follow up was 30.63 months. FEVAR = fenestrated endovascular aneurysm repair; EVAR off IFU = endovascular aneurysm repair off instructions for use; ChEVAR = chimney endovascular aneurysm repair.
      Figure 5
      Figure 5Heat plot matrices for comparative all cause mortality network meta-analysis at (A) peri-operatively (7 804 patients across 22 studies; open surgery 5 366 patients, FEVAR 1 654 patients, ChEVAR 418 patients, and EVAR off IFU 366 patients) and (B) midterm follow up (3 481 patients across 16 studies; open surgery 2 266 patients, FEVAR 699 patients, ChEVAR 224 patients, and EVAR off IFU 292 patients). The colour scale represents the size of relative treatment effects. Peri-operative results (A) are presented as risk ratio (95% confidence interval [CI]) and midterm results (B) as hazard ratio (95% CI). Mean midterm follow up was 30.63 months. ∗p < .050. FEVAR = fenestrated endovascular aneurysm repair; EVAR off IFU = endovascular aneurysm repair off instructions for use; ChEVAR = chimney endovascular aneurysm repair.
      A rankogram showed that EVAR off IFU had the highest probability of being the safest intervention (99% at rank #1) (Fig. 6A). SUCRA scoring rated EVAR off IFU as the intervention with the highest ranking for peri-operative safety, followed by FEVAR as the next safest, followed by OSR. ChEVAR ranked bottom for peri-operative safety. In a sensitivity analysis, after removal of studies deemed to be at “high risk” of bias, there were no changes to these findings (Supplementary Material).
      Figure 6
      Figure 6Rankograms for all cause mortality network meta-analysis (A) peri-operatively (7 804 patients across 22 studies; open surgery 5 366, FEVAR 1 654, ChEVAR 418, and EVAR off IFU 366 patients) and (B) at midterm follow up (3 481 patients across 16 studies; open surgery 2 266 patients, FEVAR 699 patients, ChEVAR 224 patients, and EVAR off IFU 292 patients), displaying the probability that each treatment is the best treatment, where higher rankings are associated with smaller outcome values. Mean midterm follow up was 30.63 months. FEVAR = fenestrated endovascular aneurysm repair; EVAR off IFU = endovascular aneurysm repair off instructions for use; ChEVAR = chimney EVAR.
      GRADE assessment for certainty of this primary outcome measure was performed, considering the following domains: risk of bias; heterogeneity; incoherence; indirectness; imprecision; and publication bias. Full assessment details can be viewed in the Supplementary Material, but, in brief, apart from OSR vs. EVAR off IFU (“moderate” level of certainty), all other comparisons in the network carried, at best, a “low” level of certainty.

      Secondary outcome measures

      Midterm all cause mortality

      Sixteen studies reported midterm all cause mortality. The mean follow up time point was 30.63 months. A total of 3 481 patients (two arm studies: n = 15; three arm studies, n = 1) were included in this NMA, with 536 deaths reported in this network (Fig. 3B).
      Compared with OSR, EVAR off IFU was associated with a higher midterm all cause mortality (HR 1.78, 95% CI 1.24 – 2.54). Compared with OSR, there was no difference in midterm all cause mortality with either ChEVAR (HR 1.05, 95% CI 0.59 – 1.85) or FEVAR (HR 0.95, 95% CI 0.70 – 1.28). Compared with EVAR off IFU, FEVAR was associated with a lower midterm all cause mortality (HR 0.53, 95% CI 0.33 – 0.85) (Figure 4, Figure 5B).
      A rankogram showed that EVAR off IFU had the highest probability of being the worst intervention for midterm all cause mortality (Fig. 6B). SUCRA scoring rated FEVAR as the intervention with the best (lowest) midterm all cause mortality, followed by OSR, followed by ChEVAR, followed by EVAR off IFU.

      Peri-operative renal failure

      Sixteen studies reported peri-operative renal failure rates. Definitions of acute renal failure were varied and included a rise in creatinine of > 0.5 mg/dL, a rise to ≥ 1.5 mg/dL, a twofold increase in creatinine, a rise of > 50%, and a rise of > 30%. A total of 5 690 patients (two arm studies, n = 14; three arm studies, n = 2) were included in this NMA, with 868 cases of renal failure reported in this network. There were no statistically significant differences in renal failure rates between the four treatment options.

      Peri-operative myocardial infarction

      Seventeen studies reported peri-operative MI rates. Definitions of MI consistently included troponin rise with or without electrocardiographic changes of ischaemia, although exact troponin threshold values were rarely provided. A total of 6 325 patients (two arm studies, n = 16; three arm study, n = 1) were included in this NMA, with 246 MIs reported in this network.
      Unweighted pooled peri-operative MI rates were 4.2% for OSR, 2.5% for FEVAR, 3.8% for ChEVAR, and 5.1% for EVAR off IFU. Both EVAR off IFU (RR 0.42, 95% CI 0.12 – 0.89) and FEVAR (RR 0.37, 95% CI 0.16 – 0.62) were associated with a lower risk of peri-operative MI than OSR. There were no statistically significant differences in peri-operative MI risk between any of the endovascular treatment modalities.

      Peri-operative re-intervention

      Nine studies reported peri-operative re-intervention rates. A total of 3 890 patients (two arm studies, n = 7; three arm studies, n = 2) were included in this NMA, with 358 events (cases of peri-operative re-intervention) reported in this network.
      Unweighted pooled peri-operative re-intervention rates were 9.7% for OSR, 7.9% for FEVAR, 9.1% for ChEVAR, and 5.8% for EVAR off IFU. There were no statistically significant differences in peri-operative re-intervention risk between any of the treatment modalities.

      Midterm re-intervention

      Eleven studies reported on midterm re-intervention rates. The mean follow up time point was 28.68 months. A total of 1 336 patients (two arm studies, n = 9; three arm studies, n = 2) were included in this NMA, with 135 midterm re-interventions reported in this network. FEVAR had a higher rate of midterm re-intervention than OSR (HR 1.65, 95% CI 1.04 – 2.66). There were no statistically significant differences between any of the other combinations of complex AAA repair. Rankogram analysis suggested that OSR had the highest probability of being the intervention with the lowest re-intervention risk vs. all three endovascular techniques. SUCRA scoring ranked OSR as being the best treatment (lowest rate of re-intervention) followed by EVAR off IFU, followed by FEVAR, followed by ChEVAR. It is unclear whether late hernia repair was included as an indication for re-intervention in most studies reporting on OSR (it was only explicitly mentioned in two studies). Intervention for type 2 endoleak without sac enlargement was a rare occurrence, only described in one of seven studies reporting on FEVAR, on one occasion. All seven studies reporting on FEVAR described graft related endoleaks and visceral stent complications as the principal indications for re-intervention.

      Midterm aneurysm related mortality

      Eleven studies reported aneurysm related mortality, which was defined as any peri-operative death around the primary aneurysm repair, any death within 30 days of a re-intervention to the aneurysm repair or any death from an aneurysm related complication. The mean follow up time point was 30.01 months. A total of 2 987 patients (two arm studies, n = 10; three arm studies, n = 1) were included in this NMA, with 138 aneurysm related deaths reported. There were no statistically significant differences in midterm aneurysm related mortality rates between the four treatment options.

      Cost/cost effectiveness

      As only three studies reported on cost or cost effectiveness, it was not possible to perform a meaningful quantitative analysis. Taneva et al.
      • Taneva G.T.
      • Donas K.P.
      • Pitoulias G.A.
      • Austermann M.
      • Veith F.J.
      • Torsello G.
      Cost-effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies.
      performed a cost analysis comparing FEVAR with ChEVAR. The cost of the primary procedure was €42 116 vs. €22 171, and total cost (including re-admissions and re-interventions) after three years was €42 128 vs. €22 872. They concluded that FEVAR was more expensive than ChEVAR.
      Michel et al.
      • Michel M.
      • Becquemin J.P.
      • Clément M.C.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.
      performed microcosting and cost effectiveness analysis comparing OSR with FEVAR. For pararenal/juxtarenal aneurysms, total costs (primary procedure and re-admissions) at 30 days were €14 907 and €34 425, respectively. In a later two year analysis,
      • Michel M.
      • Becquemin J.P.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – A study of the cost-effectiveness of fenestrated/branched EVAR compared with open surgery for patients with complex aortic aneurysms at 2 years.
      total costs were €21 142 and €41 786, respectively. It was found that FEVAR was not cost effective, with an incremental cost effectiveness ratio of €110 216 700 per death averted.
      Sultan and Hynes
      • Sultan S.
      • Hynes N.
      Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair.
      compared OSR with EVAR off IFU for pararenal aneurysms. Over three years, EVAR off IFU costs (including follow up and re-intervention) averaged €20 375 per patient (0.90 quality adjusted life years [QALYs]) and OSR costs averaged €23 928 per patient (0.86 QALYs). It was concluded that EVAR off IFU was cost effective.

      Discussion

      This is the first systematic review to include a NMA that compared different treatments for the repair of complex AAA, namely OSR, FEVAR, ChEVAR, and EVAR off IFU. The main finding was that EVAR off IFU and FEVAR have lower peri-operative mortality than OSR for the repair of AAAs with short or absent infrarenal necks (10 fold and sixfold reduction, respectively).
      This difference could be due to a difference in peri-operative MI, as the NMA also revealed significantly lower incidence of MI after both EVAR off IFU and FEVAR compared with OSR. However, MI was the most commonly reported complication across studies and therefore amenable to NMA. Other complications not analysed in this work may contribute to the treatment effect. There was no difference in the incidence of acute kidney injury between treatment methods, although this finding should be considered with caution given the heterogeneity of definitions used across studies. These peri-operative findings would mirror randomised controlled trial evidence of standard EVAR vs. OSR for the repair of infrarenal aneurysms.
      • Stather P.W.
      • Sidloff D.
      • Dattani N.
      • Choke E.
      • Bown M.J.
      • Sayers R.D.
      Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm.
      ChEVAR had equivalent peri-operative survival to OSR, but the precision of this estimate is low. Although studies reporting on ruptured aneurysms were excluded from this analysis, ChEVAR cohorts included urgent operations, reflecting an “off the shelf” solution. This may explain the apparent loss of peri-operative survival benefit, which is expected with endovascular techniques over OSR. ChEVAR also carries the risk of specific complications that could elevate the mortality rate; this includes stroke, which was not amenable to NMA owing to inconsistent reporting across treatment arms.
      This NMA shows a “catch up” in all cause mortality between OSR and FEVAR (equivalent survival at 2.5 years). However, EVAR off IFU had worse midterm survival than OSR (HR 1.78, 95% CI 1.24 – 2.54). Owing to the non-randomised nature of all the studies included in this analysis, this is likely to reflect confounding from variation in baseline physiological fitness between the two groups. It is possible that clinicians choose to offer EVAR off IFU as a simpler solution for their least fit patients. Unfortunately, adequate data regarding functional measures of fitness were lacking to permit testing of this supposition.
      FEVAR carries a higher re-intervention rate than OSR at the 20 month follow up. Coupled with its high cost, there is potential concern for re-interventions to contribute to poor cost effectiveness compared with OSR.
      • Michel M.
      • Becquemin J.P.
      • Marzelle J.
      • Quelen C.
      • Durand-Zaleski I.
      Editor's Choice – A study of the cost-effectiveness of fenestrated/branched EVAR compared with open surgery for patients with complex aortic aneurysms at 2 years.
      It should be noted, however, that detail on re-interventions after OSR were often lacking. Although three of seven studies seemed to provide details regarding hernia repairs and amputations at midterm follow up, four of seven studies provided no such reassurance that these cases were counted.
      In this NMA, an attempt was made to remedy several limitations of the existing literature. Firstly, original comparisons and meta-analyses have often produced results that are difficult to interpret owing to anatomical heterogeneity.
      • Bannazadeh M.
      • Beckerman W.E.
      • Korayem A.H.
      • McKinsey J.F.
      Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution.
      • O'Donnell T.F.X.
      • Patel V.I.
      • Deery S.E.
      • Li C.
      • Swerdlow N.J.
      • Liang P.
      • et al.
      The state of complex endovascular abdominal aortic aneurysm repairs in the vascular quality initiative.
      • Jones A.D.
      • Waduud M.A.
      • Walker P.
      • Stocken D.
      • Bailey M.A.
      • Scott D.J.A.
      Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10years.
      • Antoniou G.A.
      • Juszczak M.T.
      • Antoniou S.A.
      • Katsargyris A.
      • Haulon S.
      Editor's Choice - Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time to event propensity score matched data.
      Anatomical heterogeneity was minimised by only searching for studies reporting on cases with adverse infrarenal neck features (including juxtarenal/pararenal aneurysms) but excluded TAAAs and those affecting the visceral aorta (at the level of the coeliac artery). Additionally, only studies reporting on short/absent infrarenal necks were included in the quantitative NMA.
      Secondly, meta-analyses have often focused on OSR vs. FEVAR alone, neglecting other commonly used methods of complex aneurysm repair, and pooling case series data with data from comparative studies, thus introducing significant bias.
      • Nordon I.M.
      • Hinchliffe R.J.
      • Holt P.J.
      • Loftus I.M.
      • Thompson M.M.
      Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair – a systematic review.
      ,
      • Rao R.
      • Lane T.R.
      • Franklin I.J.
      • Davies A.H.
      Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms.
      Occasionally, comparative studies and meta-analyses have included other methods of repair but have combined all endovascular treatment techniques together and compared them with OSR.
      • Doonan R.J.
      • Girsowicz E.
      • Dubois L.
      • Gill H.L.
      A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair.
      ,
      • Orr N.T.
      • Davenport D.L.
      • Minion D.J.
      • Xenos E.S.
      Comparison of perioperative outcomes in endovascular versus open repair for juxtarenal and pararenal aortic aneurysms: a propensity-matched analysis.
      This is of limited value as each treatment technique is distinct, with its unique advantages and disadvantages. This NMA avoided such “combined cohorts” and considered OSR, FEVAR, ChEVAR, and EVAR Off IFU as distinct treatment modalities.
      Finally, most published meta-analyses included studies published up to 2000 – 2010.
      • Nordon I.M.
      • Hinchliffe R.J.
      • Holt P.J.
      • Loftus I.M.
      • Thompson M.M.
      Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair – a systematic review.
      ,
      • Rao R.
      • Lane T.R.
      • Franklin I.J.
      • Davies A.H.
      Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms.
      The present systematic search provides a more contemporaneous assessment, with 14/24 studies published in and beyond 2015, and the findings are therefore less likely to suffer from a learning curve effect.
      Several limitations should be noted when interpreting the findings of this NMA. All studies provided non-randomised comparisons between treatment methods and are therefore subject to selection bias based on variations in physiological fitness and the exact anatomy of the infrarenal neck. For example, FEVAR was often only offered if patients were unfit for OSR, and ChEVAR was only offered if FEVAR was anatomically not possible or if the cases were urgent. Only seven of 24 studies attempted to account for such confounding with a form of statistical adjustment. Although anatomical heterogeneity was limited by excluding studies reporting on TAAAs and visceral segment aneurysms at the level of the coeliac artery, there was often no detail provided on exact neck length or the comparative incidence of other adverse neck features between treatment groups. This introduces the possibility of neck length variation between treatment groups. Indeed, the definitions of a short neck varied slightly across studies (Table 2), and so the OSR group may have been heterogenous with respect to clamp level. Additionally, five of 24 studies reported “re-do” cases as a small proportion of their study population, with a predominant use of ChEVAR in this situation.
      From a statistical point of view, this NMA was valid with non-violated transitivity and consistency on assumption testing, low heterogeneity, low concern for imprecision in most comparisons, and no suggestion of publication bias (Supplementary Material). However, the GRADE rating for certainty of evidence was, overall, “low” for the majority of pairwise comparisons, reflecting the inherent biases carried by non-randomised observational studies.
      Although the original aim was to analyse comparative outcomes for the repair of a wide variety of complex aneurysm subtypes (a wide range of adverse neck features), the results of the search meant that, pragmatically, NMA was only possible for the repair of juxtarenal/pararenal aneurysms and not AAAs with adverse neck features other than short/absent length. Analysis was also limited to OSR, FEVAR, EVAR off IFU, and ChEVAR, as comparative outcomes of standard EVAR with adjuvant endo-anchors were not available. This would be of interest as it is a licensed technique for short neck aneurysms.
      The findings of this NMA re-confirm the widely accepted observation that endovascular techniques are associated with significantly lower peri-operative mortality than OSR for complex aneurysms. Recommendation 96 in the European Society of Vascular Surgery guidelines states that “In complex endovascular repair of juxtarenal abdominal aortic aneurysm, endovascular repair with fenestrated stent grafts should be considered the preferred treatment option when feasible”.
      • Wanhainen A.
      • Verzini F.
      • Van Herzeele I.
      • Allaire E.
      • Bown M.
      • Cohnert T.
      • et al.
      Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.
      However, this is allocated a Class II rating: that there is “conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure”. Meaningful take home messages around complex aneurysm repair are hindered by inconsistent reporting of baseline characteristics and outcomes. New reporting standards and guideline definitions would increase confidence when interpreting pooled data.
      Lack of equipoise around peri-operative safety explains reluctance among practising clinicians to support a randomised controlled trial comparing treatments for complex AAA. An acceptable alternative may be a large scale study that compares all treatment methods currently being used in a “real world” analysis, which rigorously adjusts for physiological risk between groups and accurately stratifies cases by exact neck length and morphology.

      ConflictS of interest

      Professor S.R. Vallabhaneni is the Chief Investigator of the Globalstar Registry, which received unrestricted research grants from Cook Medical and Terumo Aortic .

      Funding

      None.

      Appendix A. Supplementary data

      The following is the Supplementary data to this article:

      References

        • Waton S.
        • Johal A.
        • Birmpili P.
        • Li Q.
        • Cromwell D.
        • Pherwani A.
        • et al.
        National Vascular Registry: 2020 Annual Report.
        The Royal College of Surgeons of England, 2020 (Available at:)
        • Locham S.
        • Faateh M.
        • Dhaliwal J.
        • Nejim B.
        • Dakour-Aridi H.
        • Malas M.B.
        Outcomes and cost of fenestrated versus standard endovascular repair of intact abdominal aortic aneurysm in the United States.
        J Vasc Surg. 2019; 69: 1036-1044
        • National Institute for Health and Care Excellence
        Abdominal aortic aneurysm: diagnosis and management.
        (NICE Guideline NG156 2020. Available at:)
        https://www.nice.org.uk/guidance/ng156
        Date accessed: December 7, 2021
        • Aburahma A.F.
        • Campbell J.E.
        • Mousa A.Y.
        • Hass S.M.
        • Stone P.A.
        • Jain A.
        • et al.
        Clinical outcomes for hostile versus favorable aortic neck anatomy in endovascular aortic aneurysm repair using modular devices.
        J Vasc Surg. 2011; 54: 13-21
        • Doonan R.J.
        • Girsowicz E.
        • Dubois L.
        • Gill H.L.
        A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair.
        J Vasc Surg. 2019; 70: 2054-2064
        • Končar I.B.
        • Jovanović A.L.
        • Dučič S.M.
        The role of fEVAR, chEVAR and open repair in treatment of juxtarenal aneurysms: a systematic review.
        J Cardiovasc Surg (Torino). 2020; 61: 24-36
        • Nordon I.M.
        • Hinchliffe R.J.
        • Holt P.J.
        • Loftus I.M.
        • Thompson M.M.
        Modern treatment of juxtarenal abdominal aortic aneurysms with fenestrated endografting and open repair – a systematic review.
        Eur J Vasc Endovasc Surg. 2009; 38: 35-41
        • Rao R.
        • Lane T.R.
        • Franklin I.J.
        • Davies A.H.
        Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms.
        J Vasc Surg. 2015; 61: 242-255
        • Hutton B.
        • Salanti G.
        • Caldwell D.M.
        • Chaimani A.
        • Schmid C.H.
        • Cameron C.
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
        • Béliveau A.
        • Boyne D.J.
        • Slater J.
        • Brenner D.
        • Arora P.
        BUGSnet: an R package to facilitate the conduct and reporting of Bayesian network Meta-analyses.
        BMC Med Res Methodol. 2019; 19: 196
        • Wells G.
        • Shea B.
        • O'Connell D.
        • Peterson J.
        • Welch V.
        • Losos M.
        • et al.
        The Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses.
        (Available at:)
        • Chisci E.
        • Kristmundsson T.
        • de Donato G.
        • Resch T.
        • Setacci F.
        • Sonesson B.
        • et al.
        The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts.
        J Endovasc Ther. 2009; 16: 137-146
        • Bruen K.J.
        • Feezor R.J.
        • Daniels M.J.
        • Beck A.W.
        • Lee W.A.
        Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms.
        J Vasc Surg. 2011; 53: 895-904
        • Sultan S.
        • Hynes N.
        Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair.
        J Endovasc Ther. 2011; 18: 181-196
        • Donas K.P.
        • Eisenack M.
        • Panuccio G.
        • Austermann M.
        • Osada N.
        • Torsello G.
        The role of open and endovascular treatment with fenestrated and chimney endografts for patients with juxtarenal aortic aneurysms.
        J Vasc Surg. 2012; 56: 285-290
        • Freyrie A.
        • Gargiulo M.
        • Gallitto E.
        • Faggioli G.L.
        • Testi G.
        • Giovanetti F.
        • et al.
        Abdominal aortic aneurysms with short proximal neck: comparison between standard endograft and open repair.
        J Cardiovasc Surg (Torino). 2012; 53: 617-623
        • Hoshina K.
        • Hosaka A.
        • Takayama T.
        • Kato M.
        • Ohkubo N.
        • Okamoto H.
        • et al.
        Outcomes after open surgery and endovascular aneurysm repair for abdominal aortic aneurysm in patients with massive neck atheroma.
        Eur J Vasc Endovasc Surg. 2012; 43: 257-261
        • Canavati R.
        • Millen A.
        • Brennan J.
        • Fisher R.K.
        • McWilliams R.G.
        • Naik J.B.
        • et al.
        Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair.
        J Vasc Surg. 2013; 57: 362-367
        • Barillà D.
        • Sobocinski J.
        • Stilo F.
        • Maurel B.
        • Spinelli F.
        • Haulon S.
        Juxtarenal aortic aneurysm with hostile neck anatomy: midterm results of minilaparotomy versus f-EVAR.
        Int Angiol. 2014; 33: 466-473
        • Lee J.T.
        • Lee G.K.
        • Chandra V.
        • Dalman R.L.
        Comparison of fenestrated endografts and the snorkel/chimney technique.
        J Vasc Surg. 2014; 60: 849-856
        • Raux M.
        • Patel V.I.
        • Cochennec F.
        • Mukhopadhyay S.
        • Desgranges P.
        • Cambria R.P.
        • et al.
        A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms.
        J Vasc Surg. 2014; 60: 858-863
        • Michel M.
        • Becquemin J.P.
        • Clément M.C.
        • Marzelle J.
        • Quelen C.
        • Durand-Zaleski I.
        Editor's Choice – Thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.
        Eur J Vasc Endovasc Surg. 2015; 50: 189-196
        • Saratzis A.N.
        • Bath M.F.
        • Harrison S.C.
        • Sayers R.D.
        • Bown M.J.
        Impact of Fenestrated endovascular abdominal aortic aneurysm repair on renal function.
        J Endovasc Ther. 2015; 22: 889-896
        • Shahverdyan R.
        • Majd M.P.
        • Thul R.
        • Braun N.
        • Gawenda M.
        • Brunkwall J.
        F-EVAR does not impair renal function more than open surgery for juxtarenal aortic aneurysms: single centre results.
        Eur J Vasc Endovasc Surg. 2015; 50: 432-441
        • Wooster M.
        • Tanious A.
        • Patel S.
        • Moudgill N.
        • Back M.
        • Shames M.
        Concomitant parallel endografting and fenestrated experience in a regional aortic center.
        Ann Vasc Surg. 2017; 38: 54-58
        • Deery S.E.
        • Lancaster R.T.
        • Gubala A.M.
        • O'Donnell T.F.X.
        • Kwolek C.J.
        • Conrad M.F.
        • et al.
        Early experience with fenestrated endovascular compared to open repair of complex abdominal aortic aneurysms in a high-volume open aortic center.
        Ann Vasc Surg. 2018; 48: 151-158
        • Manunga J.
        • Sullivan T.
        • Garberich R.
        • Alden P.
        • Alexander J.
        • Skeik N.
        • et al.
        Single-center experience with complex abdominal aortic aneurysms treated by open or endovascular repair using fenestrated/branched endografts.
        J Vasc Surg. 2018; 68: 337-347
        • Michel M.
        • Becquemin J.P.
        • Marzelle J.
        • Quelen C.
        • Durand-Zaleski I.
        Editor's Choice – A study of the cost-effectiveness of fenestrated/branched EVAR compared with open surgery for patients with complex aortic aneurysms at 2 years.
        Eur J Vasc Endovasc Surg. 2018; 56: 15-21
        • Charbonneau P.
        • Hongku K.
        • Herman C.R.
        • Habib M.
        • Girsowicz E.
        • Doonan R.J.
        • et al.
        Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair.
        J Vasc Surg. 2019; 70: 1823-1830
        • Chinsakchai K.
        • Prapassaro T.
        • Salisatkorn W.
        • Hongku K.
        • Moll F.L.
        • Ruangsetakit C.
        • et al.
        Outcomes of open repair, fenestrated stent grafting, and chimney grafting in juxtarenal abdominal aortic aneurysm: is it time for a randomized trial?.
        Ann Vasc Surg. 2019; 56: 114-123
        • Fiorucci B.
        • Speziale F.
        • Kölbel T.
        • Tsilimparis N.
        • Sirignano P.
        • Capoccia L.
        • et al.
        Short- and midterm outcomes of open repair and fenestrated endografting of pararenal aortic aneurysms in a concurrent propensity-adjusted comparison.
        J Endovasc Ther. 2019; 26: 105-112
        • Locham S.
        • Dakour-Aridi H.
        • Bhela J.
        • Nejim B.
        • Bhavana Challa A.
        • Malas M.
        Thirty-day outcomes of fenestrated and chimney endovascular repair and open repair of juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms using National Surgical Quality Initiative Program Database (2012–2016).
        Vasc Endovascular Surg. 2019; 53: 189-198
        • Soler R.
        • Bartoli M.A.
        • Faries C.
        • Mancini J.
        • Sarlon-Bartoli G.
        • Haulon S.
        • et al.
        Fenestrated endovascular aneurysm repair and open surgical repair for the treatment of juxtarenal aortic aneurysms.
        J Vasc Surg. 2019; 70: 683-690
        • O'Donnell T.F.X.
        • Boitano L.T.
        • Deery S.E.
        • Schermerhorn M.L.
        • Schanzer A.
        • Beck A.W.
        • et al.
        Open versus fenestrated endovascular repair of complex abdominal aortic aneurysms.
        Ann Surg. 2020; 271: 969-977
        • Taneva G.T.
        • Donas K.P.
        • Pitoulias G.A.
        • Austermann M.
        • Veith F.J.
        • Torsello G.
        Cost-effectiveness analysis of chimney/snorkel versus fenestrated endovascular repair for high-risk patients with complex abdominal aortic pathologies.
        J Cardiovasc Surg (Torino). 2020; 61: 18-23
        • Stather P.W.
        • Sidloff D.
        • Dattani N.
        • Choke E.
        • Bown M.J.
        • Sayers R.D.
        Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm.
        Br J Surg. 2013; 100: 863-872
        • Bannazadeh M.
        • Beckerman W.E.
        • Korayem A.H.
        • McKinsey J.F.
        Two-year evaluation of fenestrated and parallel branch endografts for the treatment of juxtarenal, suprarenal, and thoracoabdominal aneurysms at a single institution.
        J Vasc Surg. 2020; 71: 15-22
        • O'Donnell T.F.X.
        • Patel V.I.
        • Deery S.E.
        • Li C.
        • Swerdlow N.J.
        • Liang P.
        • et al.
        The state of complex endovascular abdominal aortic aneurysm repairs in the vascular quality initiative.
        J Vasc Surg. 2019; 70: 369-380
        • Jones A.D.
        • Waduud M.A.
        • Walker P.
        • Stocken D.
        • Bailey M.A.
        • Scott D.J.A.
        Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10years.
        BJS Open. 2019; 3: 572-584
        • Antoniou G.A.
        • Juszczak M.T.
        • Antoniou S.A.
        • Katsargyris A.
        • Haulon S.
        Editor's Choice - Fenestrated or branched endovascular versus open repair for complex aortic aneurysms: meta-analysis of time to event propensity score matched data.
        Eur J Vasc Endovasc Surg. 2021; 61: 228-237
        • Orr N.T.
        • Davenport D.L.
        • Minion D.J.
        • Xenos E.S.
        Comparison of perioperative outcomes in endovascular versus open repair for juxtarenal and pararenal aortic aneurysms: a propensity-matched analysis.
        Vascular. 2017; 25: 339-345
        • Wanhainen A.
        • Verzini F.
        • Van Herzeele I.
        • Allaire E.
        • Bown M.
        • Cohnert T.
        • et al.
        Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms.
        Eur J Vasc Endovasc Surg. 2019; 57: 8-93
        • Ayari R.
        • Paraskevas N.
        • Rosset E.
        • Ede B.
        • Branchereau A.
        Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification.
        Eur J Vasc Endovasc Surg. 2001; 22: 169-174

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