Mastracci Tara M, Garrido-Olivares Luis, Cinà Claudio S, Clase Catherine M
Departments of Surgery and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
J Vasc Surg. 2008 Jan;47(1):214-221. doi: 10.1016/j.jvs.2007.07.052.
The perioperative mortality for people with ruptured abdominal aortic aneurysms (RAAA) has not changed for two decades. Of patients who survive long enough to undergo open repair for ruptured aneurysms, half die (48%; 95% confidence interval [CI] 46 to 50). Randomized trials have shown that endovascular aneurysm repair (EVAR) for nonruptured abdominal aortic aneurysms decreases perioperative mortality compared with open repair. EVAR may similarly benefit patients with RAAA. We aimed to summarize studies of patients undergoing EVAR for ruptured aneurysms.
Two reviewers searched Medline and EMBASE databases from 1994 to July 2006, Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, the Cochrane Central Register of Controlled Trials, Best Evidence 1994 to 2006, reference lists, clinical trial registries, and conference proceedings; we also contacted authors. All published and unpublished studies in which a group of people with ruptured aneurysms, assessed objectively by imaging, was treated with EVAR (REVAR) were eligible. We used the generic inverse variance function of the REVMAN software to pool results for death in hospital. Sensitivity analyses, using prespecified subgroups, explored heterogeneity between studies.
Pooled mortality in 18 observational studies describing 436 people who underwent REVAR was 21% (95% CI 13 to 29); however, 90% of the heterogeneity between studies was not explained by chance alone. Surgical volume explained substantial heterogeneity. According to study-specific criteria, 47% (95% CI 39 to 55) of people with ruptured aneurysms were potentially eligible for REVAR.
Mortality in people who underwent REVAR is lower than that in historical reports of unselected people undergoing open repair. Further investigation is needed to determine whether the difference in mortality is attributable to patient selection alone or to this new approach to treatment.
腹主动脉瘤破裂（RAAA）患者的围手术期死亡率二十年来一直没有变化。在那些存活时间足够长、能够接受破裂动脉瘤开放修复术的患者中，有一半会死亡（48%；95%置信区间[CI]为46%至50%）。随机试验表明，与开放修复术相比，非破裂腹主动脉瘤的血管内动脉瘤修复术（EVAR）可降低围手术期死亡率。EVAR可能同样使RAAA患者受益。我们旨在总结对接受破裂动脉瘤EVAR治疗患者的研究。
两名审阅者检索了1994年至2006年7月的Medline和EMBASE数据库、Cochrane系统评价数据库、疗效评价文摘数据库、Cochrane对照试验中心注册库、1994年至2006年的最佳证据、参考文献列表、临床试验注册库和会议论文集；我们还联系了作者。所有已发表和未发表的研究，只要其中一组经影像学客观评估为腹主动脉瘤破裂的患者接受了EVAR（REVAR）治疗，均符合条件。我们使用REVMAN软件的通用逆方差函数汇总住院死亡结果。采用预先设定的亚组进行敏感性分析，探讨研究之间的异质性。
18项观察性研究描述了436例接受REVAR治疗的患者，汇总死亡率为21%（95%CI为13%至29%）；然而，研究之间90%的异质性并非仅由偶然因素解释。手术量解释了相当大的异质性。根据研究特定标准，47%（95%CI为39%至55%）的腹主动脉瘤破裂患者可能适合接受REVAR治疗。
接受REVAR治疗患者的死亡率低于未经选择的患者接受开放修复术的历史报告中的死亡率。需要进一步研究以确定死亡率差异是否仅归因于患者选择还是归因于这种新的治疗方法。
