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What is the best treatment for complex abdominal aortic aneurysms?

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Key messages

• There are currently no studies with information available to guide patients' and doctors' choices regarding treatments for complex abdominal aortic aneurysms (AAAs).

• It is difficult to conduct research in this area because relatively few people have this condition and the types of aneurysm they have vary.

• Future research should explore how organisations that fund and oversee healthcare services could require or promote the inclusion of people with AAAs in studies testing different treatments.

What is an abdominal aortic aneurysm?

An abdominal aortic aneurysm (AAA) is a widening of the wall of the aorta (the main artery that carries blood from the heart to the rest of the body) to more than 50% of its original diameter. A diameter of greater than 5.0 to 5.5 cm (depending on a person's sex/gender) is considered potentially life-threatening, with a risk of bursting. When the swelling occurs close to, next to, or above the arteries supplying the kidney, this increases the complexity of surgical treatment options.

How is a complex abdominal aortic aneurysm treated?

There are different treatment options. Open surgical repair involves a major operation to open the abdomen and replace the diseased aorta with a fabric graft.

Endovascular repair involves the use of X-ray guidance to insert metal stents (small, tube-shaped device placed inside a blood vessel) covered with fabric (endografts) via cuts made in the groin. When treating complex AAAs that are near the arteries supplying the kidneys, it is sometimes necessary to use specific endografts with windows (fenestrations) in them that allow for the kidneys and bowel to keep their blood supply when the endograft is inserted. This is called fenestrated endovascular aneurysm repair (FEVAR).

There is also the option of not performing any procedures and counselling patients and their families, and in some cases, prescribing medications to manage their cardiovascular risk factors. This is called conservative management.

It is unclear which treatment is best for people with complex AAAs.

What did we want to find out?

We wanted to find out whether there are randomised controlled trials exploring whether FEVAR, open surgical repair, or conservative management is best for the treatment of complex AAAs. Randomised controlled trials (RCTs) are studies in which participants are assigned randomly to two or more treatment groups. This is the best way to ensure that groups of participants are similar, and that investigators and participants don’t know who is in which group. In other words, RCTs aim to control factors that could impact on the results, such as people's background health, to allow fair comparison of the treatment options.

What did we do?

We searched for randomised controlled trials that compared FEVAR with open surgical repair or conservative management of complex AAAs. We searched for studies performed up to March 2023.

What did we find?

We could not find any studies that met the inclusion criteria. There is a lack of evidence to help us answer the question.

How current is the evidence?

The evidence is current to March 2023.

背景

Abdominal aortic aneurysms (AAAs) are abnormal dilatations of the aorta that most commonly affect its infrarenal segment, but can become more difficult to repair when they are close to or next to the renal arteries. The optimum treatment for these complex AAAs is unknown. One option is fenestrated endovascular aneurysm repair (FEVAR), which involves using fenestrations or scallops in the graft to facilitate access to the visceral arteries.

目的

To assess the benefits and harms of complex stent-graft fenestrated endovascular aneurysm repair (FEVAR) versus open surgical repair (OSR) or conservative (non-operative) management for people with complex AAAs.

搜尋策略

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov without language, publication year or publication status restrictions (published, unpublished, in press or in progress) on 28 March 2023.

選擇標準

We considered all randomised controlled trials (RCTs) and quasi-RCTs, comparing treatment of complex AAA with FEVAR versus open surgical repair or conservative management in adults undergoing primary repair of complex AAA.

資料收集與分析

Two review authors independently screened studies obtained from the search for potential inclusion in the review, in accordance with the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes were all-cause mortality (30 days and one year), aneurysm-related mortality at one year and length of hospital stay. Secondary outcomes were renal dysfunction at one year, reintervention rate at one year, visceral vessel patency at 30 days and one year, participant-reported health-related quality of life at one year, adverse events at one year and aneurysm-related mortality at 30 days.

主要結果

We found no studies fulfilling the inclusion criteria.

作者結論

We did not identify eligible RCTs or quasi-RCTs that compared treatment of complex AAAs with FEVAR versus open surgical repair or conservative management. This is a difficult area in which to conduct research due to low incidence rates and aneurysm heterogeneity. Future studies could consider commissioning agreements mandating patient inclusion in studies to make the generation of high-quality evidence in this area feasible.

引用文獻
Daudu D, Cai PL, Srinivas A, Best LMJ, Cross J, Hammond CJ, Richards T. Fenestrated endovascular repair for abdominal aortic aneurysms. Cochrane Database of Systematic Reviews 2025, Issue 5. Art. No.: CD014226. DOI: 10.1002/14651858.CD014226.pub2.