Quality of life after abdominal aortic aneurysm repair: endovascular repair vs open repair

1. Quality of life after abdominal aortic aneurysm repair: endovascular repair vsopen repair A Systematic Review

2. Faculty of Medicine of Oporto UniversityBiostathistic 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

3. Introduction • Abdominal 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. 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. • 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

4. Introduction • 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. Image rights www.emedicine.com

5. AAA No treatment Treatment Rupture leadind to death Open surgery Endovascular surgery Differences in the QOL after both surgical interventions

6. Aim To compare quality of life of patients older than forty years after open or endovascular aortic repair of abdominal aneurysm.

7. 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).

8. Venn Diagram

9. 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”)

10. Initial tracing (inclusion): Reading of abstracts and titles performed by five groups, composed by two reviewers. Third reviewer: solving disagreement points.

11. 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).

12. 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.

13. 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.

14. Flow Chart Methods Description

19. 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

20. 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

21. 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

22. 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

23. Results Until 2 months after the intervention: QoL EVAR > QoL OPEN At 2 months and beyond: QoL EVAR < QoL OPEN

24. GANTT’S MAP • Mapa_de_Gantt_-_Ta_2urm0.mpp

25. 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.

26. 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, …)

27. 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.

28. Evar... or Open. That is the question!