Reviews in Cardiovascular Medicine  2020, Vol. 21 Issue (1): 75-92     DOI: 10.31083/j.rcm.2020.01.513 Endovascular and open surgical repair of abdominal aortic aneurysms: A comparative analysis of western and chinese studies Feng Shi1, Yuchen He2, Shiyue Wang2, Fuqiang Jia3, Chao Ji4, Jian Zhang2, Xun Liu5, Yanshuo Han6, *() 1 Department of Medical Record, Shengjing Hospital of China Medical University, Shenyang 110004, China
2 Department of Vascular Surgery, the First Hospital of China Medical University, and Key Laboratory of pathogenesis, prevention and therapeutics of aortic aneurysm Liaoning Province, Shenyang 110001, China
3 Department of Educational Administration, Yingkou Medical School, Yingkou 115000, China
4 Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang 110004, China
5 Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 110004, China
6 School of Life Science and Medicine, Dalian University of Technology, Panjin 116024, China Abstract:

Abdominal aortic aneurysms (AAA) are life-threatening serious conditions that require effective and quick management. Although it is generally acknowledged that patients with AAA obtain the greatest benefit from endovascular repair (EVAR) compared to open surgical repair (OSR), there are few comparisons between the surgical approaches in Western versus Chinese patients. We aimed to perform a meta-analysis of studies in which EVAR was compared with OSR in the management of abdominal aortic aneurysms. We searched the Western literature through PubMed, OVID and Web of Science from 1991 until December 2018 and the Chinese-language literature from 1998 until December 2018. We pooled the results in January 2019 based on standardized inclusion and exclusion criteria and analyzed them using a conventional meta-analysis. Forty-five English papers with 31,074 AAA patients and twenty-one Chinese studies with 1,405 patients were included in this study. Chinese subjects were more likely to undergo endovascular repair than Western subjects (44.5% versus 41.5%, P = 0.012). The 30-day post-discharge mortality rate in Western studies was significantly lower for EVAR than for OSR (odds ratio (OR) = 0.481, P < 0.001). However, there was no significant reduction in the 30-day mortality rate following EVAR compared to OSR (OR = 0.733, P = 0.425) for Chinese patients. In Western patients, the postoperative complication rate of respiratory system and cardiac system was lower in the EVAR group than in the OSR group (OR = 0.270, P < 0.001 and OR = 0.411, P < 0.001, respectively), nevertheless, for Chinese patients, limb ischaemia was more common (OR = 1.539, P = 0.049) in the EVAR group. Whether in Western patients with an eight-year follow-up period or Chinese patients with a maximum four-year follow-up period, there was no significant difference between the EVAR and OSR groups in the all-cause death rate (hazard ratio (HR) = 1.026, P = 0.483 and HR = 1.173, P = 0.247, respectively). Chinese patients were more likely to receive EVAR than OSR and the 30-day mortality was significantly lower for EVAR than for OSR in Western patients but not in Chinese patients. Endovascular repair can be applied to Chinese patients with a reasonable safety margin. Further work is needed to explore the causes of these treatment differences.

Submitted:  21 June 2019      Accepted:  02 December 2019      Published:  30 March 2020      Fund: 
81600370/National Natural Science Foundation of China
2018M640270/China Postdoctoral Science Foundation
DUT19RC(3)076/Fundamental Research Funds for the Central Universities
2019-ZD-0789/Liaoning Provincial Natural Science Foundation of China *Corresponding Author(s):  Yanshuo Han     E-mail:  yanshuohan@cmu.edu.cn Service E-mail this article Add to citation manager E-mail Alert RSS Articles by authors Feng Shi    Yuchen He    Shiyue Wang    Weidong Ren    Chao Ji    Jian Zhang    Xun Liu    Yanshuo Han   

Figure 1.  Flow diagram of this meta-analysis in accordance with the QUOROM statement from Western studies.

Figure 2.  Flow diagram of this meta-analysis in accordance with the QUOROM statement from Chinese studies.

Table 1.  Characteristics of studies comparing endovascular aortic aneurysm repair and open surgical repair in Western patients with elective abdominal aortic aneurysms.

StudyYear of PublicationStudy PeriodStudy LocationJournal of PublicationNo. of InstitutionsEVAROSRStudy DesignFollow-up EVARFollow-up OSRCommentsMcNally et alJune, 20102004. 7-2007. 7USAJ.Vasc. Surg.single-center173228Retro.……Jetty et alMarch, 20102002. 4. 31-2007. 3. 31CanadaJ.Vasc. Surg.multicenter8885573Retro.55CIHI-DAD Database $Turnbull et alMarch, 20102002. 2. 25-2003. 4. 14USAJ.Vasc. Surg.13 centers166243PNR55eLPS £Steinmetz et alJanuary 8, 20101999. 1-2006. 12FranceEur. J. Vasc. Endovasc. Surg.single-center148134Retro.55Include High-risk exclude low-riskChisci et al20092005. 1-2007. 12Italy and SwedenJ.Endovasc. Ther.2 centers7461Retro.1.62.1Exclude Fenestrated EVARDick et alMarch. 29. 20081998. 1-2002. 12SwitzerlandWorld. J. Surg.single-center68244Retro.4. 64. 9Exclude emergency OSRCronenwett et alDecember, 20072003. 1-2006. 12USAJ.Vasc. Surg.9 hospitals495667PNR11VSGNNE Database†Faizer et alJune, 20071999. 1-2004. 12USAJ.Vasc. Surg.single-center304558Retro.……Chan et alMarch, 20071997. 1-2005. 10UKInt. J. Clin. Pract.single-center157329Retro.……Aljabri et alDecember, 2006NGCanadaJ. Vasc. Surg.single-center4333PNR0.50.5Sicard et alAugust, 2006NGUSAJ. Vasc. Surg.5 IDE‡56561Retro.2.72.5High-riskJohnson et alMarch 15, 20062001. 5. 1- 2003. 9. 30USAAm.J.Surg.123 VA hospitals7171187Retro.11VA-NSQIP Database‖Bush et alJanuary, 2006J.Am.Coll.Surg.Aarts et alAugust 2, 20051998.10-2004. 1NetherlandsAnn. Vasc. Surg.single-center99116Retro.1.91.9Vogel et alAugust 1, 20051998-2003USAAnn. Vasc. Surg.single-center92126PNR……Short Form 36 (SF-36)Soulez et alAugust, 20051998. 9-2002. 7CanadaJ. Vasc. Interv. Radiolsingle-center2020RCT2.42.3Lifeline RegistryJuly, 2005NGUSAJ. Vasc. Surg.4 IDE‡2063334Retro.>5>1AnCure, AneuRx, Excluder , PowerLinkHua et alMarch, 20052000.1. 1-2003. 10. 31USAAm. J. Surg.14 centers460582Retro.……NSQIP-PS Database¶Goueffic et al20051995. 1-2001. 12FranceJ. Endovasc. Ther.single-center209289PNR1.63.3Carpenter et alNovember, 20042000. 7. 18-2003. 3. 31USAJ. Vasc. Surg.15 centers19266PNR11PowerLinkWang et alSeptember, 20084.13.1Cao et alNovember, 20041997. 1-2003. 12ItalyJ. Vasc. Surg.single-center534585PNR2.82.9DREAM (Prinssen)October, 20042000. 11-2003. 12NetherlandsN. Engl. J. Med24+4 centers§171174RCT……Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial GroupDREAM (Blankensteijn)June 9, 200522DREAM (Bruin)May 20, 201066Garcia-Madrid et alOctober, 20041997. 3-2000. 8SpainEur. J. Vasc. Endovasc. Surg.single-center5330Retro.1.62.2Rigberg et alSeptember, 20042001. 1-2002. 12USAArch. Surg.single-center6189Retro.……EVAR trial 1August 25, 20041999. 9. 1-2003. 12UKLancet.34 centers543539RCT……The EVAR trial participantsJune 25, 20052.92.9May 20, 20101999. 9. 1-2004N. Engl. J. Med37 centersɸ62662655Ballard et alApril, 20042000. 11-2003. 5USAJ. Vasc. Surg.single-center22107PNR……PCS-12 and MCS-12ɸElkouri et alMarch, 20041999. 12. 1-2001. 12. 1USAJ. Vasc. Surg.single-center94261Retro.> 0.08> 0.08Lee et alMarch, 20042001. 1. 1-2001. 12. 31USAJ. Vasc.Surg.986 hospitals25654607Retro.……Zeebregts et alJanuary, 20041998. 4-2003. 1NetherlandsBrit. J. Surg.single-center9382PNR1.61.7Exclude former OSRMoore et alJuly, 20031995. 11. 22-1998. 2. 12USAJ. Vasc. Surg.multicenter573111PNR55EGS & Ancure £Jordan et alMay, 20032000. 1. 1-2002. 6. 12USAAnn. Surg.single-center13087Retro.……High-RiskCriado et alApril, 20031999. 3. 24-2000. 9. 19USAJ. Vasc. Surg.17 centers240126PNR1.10.9Talent LPSMatsumura et alFebruary, 20031998. 12-2000. 1USAJ. Vasc. Surg.19 centers23599PNR55ExcluderPeterson et alMay, 2007Hansman et alJanuary, 20031999. 11 - 2002. 1USAAm. J. Surg.single-center5050Retro.……Arko et al20031996. 10-2000. 7USAJ. Endovasc. Ther.single-center153141Retro.……Ligush et alSeptember, 20021999. 12-2001. 6USAJ. Vasc. Surg.single-center3366Retro.……Teufelsbauer et alJuly 29, 20021995. 1-2000. 12AustriaCirculation.single-center206248Retro.2.52.5Cuypers et alApril 15, 20011996. 9-1999. 10NetherlandsBrit. J. Surg.2 centers5719RCT……Brewster et alJune, 19981994. 1-1997. 5USAJ. Vasc. Surg.single-center2828Retro.……

Table 2.  Detailed Overview over the Characteristics of Studies from 21 Chinese Cohorts.

StudyMonth and Year of PublicationStudy PeriodTotalActualEVAROSRFollow-up EVARFollow-up OSRDatabaseLI Honghao et alSeptember, 20102001.1. 1-2008. 12. 3133271116……Sun Yat-sen Memorial HospitalLI Xinxi et alJune, 20102002-200858582533……The First Affiliated Hospital of Xinjiang Medical UniversityLu Shengwei et alJune, 20102005.6-2009. 3626229331.51.5The First Affiliated Hospital of Guangxi Medical UniversityMeng Fanxin et alJune, 20101999.1. 1-2010. 1. 19253$282533.3Peking Union Medical College HospitalYue Wenliang et alMay, 20102004.1-2009. 41121126646……The First Affiliated Hospital of China Medical UniversityQiu Jian et alMay, 20102003-20101201203684££The Second Xiangya Hospital, Central South UniversityJiang Lanshan et alMarch, 20102004-20092323617< 2< 6Mian yang Central HospitalZhang Jinglan et al2010NG90904446……Beijing Anzhen Hospital, Capital Medical UniversityDing Hao et al§October, 20092000.1. 1-2008. 12. 31303082211The First Affiliated Hospital of Anhui Medical UniversityChen Weiqing et al§August, 20092001.6-2008. 131234193.23.2Tianjin Medical University General HospitalZhang Yongjie et al§June, 20092002.1-2007. 7424212302.72.7Central Hospital City of ZiboChen Yushuai et al§December, 20082000.7-2005. 12545420342.72.7First Affiliated Hospital of China Medical UniversityTang Xiaobin et alSeptember, 20082001.1-2007. 7223223821412.72.7Beijing Anzhen Hospital, Capital Medical UniversityYe Jinming et alSeptember, 20082005.2-2007. 675724923……Zhejiang Hospital & Zhongshan Hospital,Fudan UniversityDu Qingguo et al20072002.2-2006. 237371423……The First Affiliated Hospital, Chongqing Medical UniversityYao Chen et alJanuary, 20062003.10-2004. 10343415190.90.9The First Affiliated Hospital, Sun Yat-sen UniversityDong Yifei et alDecember, 20052003.1-2005. 42323320……Lanzhou General Hospital, Lanzhou Command, PLAShu Chang et alJune, 20031999-20022621714……The Second Xiangya Hospital, Central South UniversityFeng Rui et al†February, 20031997.3-2002. 315715711542……Changhai Hospital, Second Military Medical UniversityFu Weiguo et al20031998.9-2001. 109292316122Zhongshan Hospital, Fudan UniversityGuo Wei et alJune, 20001993.6-1999. 852522032……General Hospital, People's Liberation Army (PLA)

Table 3.  Procedure type by racial/ethnic group

Racial/ethnic groupEVAR (N = 13,399)OSR (N = 19.080)Total (N = 32,479)Western population12,774 (41.1%)18,300 (58.9%)31,074Chinese population625 (44.5%)780 (55.5%)1,405

Table 4.  Reviewers’ judgements about each methodological quality item included in the Four Western Randomized Controlled Trial (RCT) Studies.

StudyYear of PublicationEVAROSRCochrane Reviewer’s HandbookJadadAdequate sequence generationAllocation concealmentBlindingWithdrawals and drop outsITTRisk of biasRandomizationDouble blindingWithdrawals and drop outsJadad’s scoreSoulez et alAugust,20052020computermetunclearunmetunclearB2103DREAMOctober,2004
June,2005
May,2010171174computermetdouble blindingmetmetA2215EVAR-1August,2004
June,2005543539computermetdouble blindingmetmetA2215Cuypers et alApril,20015719computermetdouble blindingmetmetA2215

Table 5.  Baseline Characteristics of Patients Undergoing Endovascular Repair (EVAR) or Open Surgical Repair (OSR) for Abdominal Aortic Aneurysms (AAA) in Western and Chinese Studies.

CharacteristicRegionNo. of studiesEVAROSROR/WMD95% CIWeightPn (%)*Nn (%)*NMale Gender-No.Chinese10338 (86.2)392411 (83.7)4911.0070.678,1.4979.250.972Western3410,870 (87.7)12,29014,708 (81.9)17,9541.6921.460,1.96190.75< 0.001Total4411,208 (88.4)12,68215,119 (82.0)18,4451.6141.408,1.849100.00< 0.001Mean age-Year¶Chinese1167.3131363.694333.6300.959,6.30210.500.008Western1973.338,39970.688,5412.4131.845,2.98289.50< 0.001Total3070.328,71267.198,9742.5552.007,3.103100.00< 0.001Hypertension-No.Chinese12209 (51.7)404327 (56.9)5751.1390.711,1.82614.850.588Western287,127 (67.3)10,59310,091 (63.3)15,9341.0960.961,1.25185.150.170Total407,336 (66.7)10,99710,418 (63.1)16,5091.0980.966,1.249100.000.153