Quality of life after abdominal aortic aneurysm repair:
endovascular repair vs
open repair
A Systematic Review
Faculty of Medicine of Oporto University
Biostathistic and Medical Informatics Department
Introduction to Medicine – 1st Year
BRANDÃO, C, CARVALHO, M, COUTINHO, L, OLIVEIRA, J, PINHO, A, REBELO, R, RIBEIRO, E, RAMOS, P, SOUSA, J, VALE, S
2007/2008
IntroductionAbdominal aortic aneurysm:
•Focal enlargement of the abdominal aorta (usually envolving the infrarenal portion);
•Diameter >50% larger than normal or to >3 cm in its largest true transverse dimension1.
1. Hodges TC, Cronenwett J. Abdominal aortic and iliac artery aneurysms: clinical presentation, natural history and indications for intervention. In: Perler BA, Becker GJ, editors. Vascular Intervention: A Clinical Approach. New York: Thieme, 1998.
2, Allaqaband S, Slis J, Kazemi S, Bajwa T. Envovascular Treatment of Peripheral Vascular Disease. In: Curr Probl Cardiol, 2006
Indications for repair in patients with AAA include2 a diameter of 5 cm or larger (4.5 to 5.0 for women),
with a growth rate higher than 10mm/year.
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• The abdominal aortic aneurysm is one of the most studied because of his bigger incidence on the population: it affects about 5% ou 7% of world population;
• Generally, abdominal aortic aneurysm is 5 times more common in men than in women;
• In men, the process appears to begin at approximately age 40 years and reaches peak incidence from 75 to 79 years.
Introduction
Treatment
Endovascular surgeryOpen surgery
No treatment
Rupture leadind to death
Differences in the QOL after both surgical interventions
AAA
Aim
To compare quality of life of patients older than forty years after open or endovascular aortic repair of abdominal aneurysm.
Methods
• Systematic review searching in online medical databases:– Medline (Pubmed);– The Controlled Trials Register (The Cochrane
Library);– ISI Web of Knowledge
• Searching criteria: • From the earliest paper available until our
data acquisition (December 2007).
Venn Diagram
Methods
• Query
(“Abdominal Aortic Aneurysm” [MeSH] OR “AAA”) AND (“Quality of Life” OR “Health Care Quality Indicators” [MeSH] OR “QOL”) AND (“Endovascular Repair” OR “Endoluminal Repair” [MeSH] OR “EVAR”) AND (“Open Repair” OR “Surgery Repair”)
Initial tracing (inclusion):
Reading of abstracts and titles performed by five groups, composed by two reviewers.
Third reviewer: solving disagreement points.
Inclusion Criteria:
Compare quality of life after EVAR and open repair;
Include patients over forty years in the sample analysed;
Use SF-36 to evaluate quality of life parameters;
Mention the methods used and results;
Studies in humans;
Language: English;
Date of publication: From the earliest paper available until our data acquisition (December 2007).
Exclusion Criteria
• Studies with a follow-up period inferior to 1 month;
• Unobtainable full-text paper;• Use patients submitted to EVAR but unfit
to open.
Outcomes
Primary: the considered outcomes were the comparison of quality of life, between EVAR and open repair obtained from SF-36 total scores .
Secundary: comparison of singular parameters scores from SF-36, between EVAR and open.
Obtained six papers.
Flow Chart
Methods Description
Start
Define query:(“Abdominal Aortic Aneurysm” [MeSH] OR “AAA”) AND (“Quality of Life”
OR “Health Care Quality Indicators” [MeSH] OR “QOL”) AND (“Endovascular Repair” OR “Endoluminal Repair” [MeSH] OR “EVAR”) AND (“Open Repair” OR “Surgery Repair”)
Research on:
98 papers obtained (65 were not repeated between the medical search engines)
Read Titles and Abstracts by 5 groups of 2 Reviewers
Apply inclusion/exclusion criteria
Article excluded by at least 2 reviewers
Yes
Article included by at least 2 reviewers?
No
No
Consult a third reviewer3 papers
Yes
13Papers obtained
(2 paper non acessible)
Read full text by 5 groups of 2 reviewes
Apply inclusion/exclusion criteria
Article excluded by at least 2 reviewers
Yes
Article included by at least 2 reviewers?
No
No
Consult a third reviewer
Yes
6 papers obtained
Extract data to SPSS
Statistical analysis
End
Design data base
Paper WritingAdmission for
Publication
Preliminar Research
Pubmed Isi web of knowlegde Cochrane
36 papers obtained
52 papers obtained
10 papers obtained
Preliminar reading (28 papers)
15 excluded papers
5 papers excluded
Results
First month:
Paper 1: score difference of -1.90
Paper 4: score difference of -2.50
Paper 5: score difference of -15.50
QoL scores EVAR > QoL scores OPEN
Results
Third month:
Paper 3: score difference of 0.06
Paper 5: score difference of 15.38
Paper 6: score difference of 5.00
QoL scores OPEN > QoL scores EVAR
Results
Sixth month:
Paper 1: score difference of 13.60
Paper 2: score difference of 4.00
Paper 6: score difference of 5.00
QoL scores OPEN > QoL scores EVAR
Results
One year:
Paper 3: score difference of -0.21
Paper 4: score difference of 2.00
Paper 6: score difference of 8.50
QoL scores OPEN > QoL scores EVAR
Results
Until 2 months after the intervention:
QoL EVAR > QoL OPEN
At 2 months and beyond:
QoL EVAR < QoL OPEN
GANTT’S MAP
• Mapa_de_Gantt_-_Ta_2urm0.mpp
Discussion
Secondary outcome (still in progress)
Comparison of absolute scores:
1 month the OR group had significantly lower scores on physical function, social functioning, role-emotional, mental health, bodily pain and general health
6 months postoperatively physical function, social functioning, mental health, vitality, bodily pain and general health scores in the OR was significantly higher than in the EVAR group
12 months the physical-function, social-functioning, role-physical, mental health, vitality, bodily pain and general health scores were significantly higher in the OR group.
Discussion
Limitations:
the data provided by each one of the analysed papers was collected in different stages of post-operative period nevertheless they had few common points.
some papers include only SF-36 global scores and didn’t analyse individual score criteria making it difficult to perform an analysis focused on the differences between each domain (e.g. mental health, pain, …)
Conclusion
• Until 2 months after the intervention:– there is a small yet significante QoL
advantage of EVAR compared to OR;
• At 2 months and beyond:– patients reported a better QoL after OR
than after EVAR.
Evar... or Open.
That is the question!