This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
Coronary artery bypass grafting with adjunctive
endarterectomy: A mandatory procedure in complex
revascularizations. current results and postoperative
considerations
Clinical and epidemiological profile of patients undergoing total hip arthro...David Sadigursky
Clinical and epidemiological profile of patients undergoing total hip arthroplasty.
Rheumatology and Orthopedic Medicine
Rheumatol Orthop Med, 2017 doi: 10.15761/ROM.1000120
Background: Resectability Criteria for Colorectal Liver Metastases (CRLM) have expanded, and advances in liver surgery have increased the number of patients eligible for resection. Identifying risk factors for early recurrence to help stratify CRLM patients will contribute to targeted management of these patients, including surveillance follow-up.Objectives: To identify risk factors for early recurrence post-resection for CRLM in a contemporary cohort of patients. Early recurrence was defi ned based on unit protocol as evidence of recurrent disease on follow-up imaging within one year of surgery.Methods: From January 2012 to December 2016, 133 patients with CRLM underwent liver resection in our Unit; 115 patients followed up for at least a year were eligible. We analysed pre-operative variables (sex, age, BMI, comorbidities, CEA and Liver function tests (LFTs), lesion number, size of largest liver lesion, neoadjuvant chemotherapy), operative variables (anatomical vs non-anatomical, major vs minor, redo liver surgery, concomitant use of ablation techniques, blood loss, blood transfusions, Pringle’s manoeuvre), and post-operative variables (complications, length of hospital stay, histological parameters) were analysed.
Everolimus eluting stents or bypass surgery finalGOPAL GHOSH
Trials and registry studies have shown lower long-term mortality after CABG than after PCI among patients with multivessel disease.These previous analyses did not evaluate PCI with second-generation drug-eluting stents
Coronary artery bypass grafting with adjunctive
endarterectomy: A mandatory procedure in complex
revascularizations. current results and postoperative
considerations
Clinical and epidemiological profile of patients undergoing total hip arthro...David Sadigursky
Clinical and epidemiological profile of patients undergoing total hip arthroplasty.
Rheumatology and Orthopedic Medicine
Rheumatol Orthop Med, 2017 doi: 10.15761/ROM.1000120
Background: Resectability Criteria for Colorectal Liver Metastases (CRLM) have expanded, and advances in liver surgery have increased the number of patients eligible for resection. Identifying risk factors for early recurrence to help stratify CRLM patients will contribute to targeted management of these patients, including surveillance follow-up.Objectives: To identify risk factors for early recurrence post-resection for CRLM in a contemporary cohort of patients. Early recurrence was defi ned based on unit protocol as evidence of recurrent disease on follow-up imaging within one year of surgery.Methods: From January 2012 to December 2016, 133 patients with CRLM underwent liver resection in our Unit; 115 patients followed up for at least a year were eligible. We analysed pre-operative variables (sex, age, BMI, comorbidities, CEA and Liver function tests (LFTs), lesion number, size of largest liver lesion, neoadjuvant chemotherapy), operative variables (anatomical vs non-anatomical, major vs minor, redo liver surgery, concomitant use of ablation techniques, blood loss, blood transfusions, Pringle’s manoeuvre), and post-operative variables (complications, length of hospital stay, histological parameters) were analysed.
Everolimus eluting stents or bypass surgery finalGOPAL GHOSH
Trials and registry studies have shown lower long-term mortality after CABG than after PCI among patients with multivessel disease.These previous analyses did not evaluate PCI with second-generation drug-eluting stents
Predictors of Ischaemia and Outcomes in Egyptian Patients with Diabetes Mellitus Referred for Perfusion Imaging. Samir Rafla*, Ahmed Abdel-Aaty, Mohamed Ahmed Sadaka, Aly Ahmed Abo Elhoda and Ahmed Mohamed Shams
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
In non-cardioembolic stroke patients, the cardiac manifestations of elevated blood pressure are of particular interest. The value of LV geometry in the prediction of cardiovascular risk is controversial. Many reports detected that left ventricular hypertrophy is independently associated with risk of ischemic stroke. The primary objective of this study was to identify the frequency of different patterns of altered left ventricular geometry in patients with non cardioembolic stroke, and to assess whether a significant number of patients will miss the diagnosis of LV remodeling if the left ventricular relative wall thickness(RWT) is not evaluated or reported. 100 patients were referred within 48 hours after an acute non cardioembolic ischemic stroke for a transthoracic echocardiogram. The echocardiographic findings were analyzed. Mean age was 61.86 ± 12.59 years, 45 % men. Concentric remodeling carried the highest frequency (43%), followed by normal pattern (27%), concentric hypertrophy (22%), and eccentric hypertrophy (8%). The frequency of abnormal left ventricular RWT (61.4%) was significantly higher than that of abnormal LVMI.
Safety, risk of complications and the functional feasibility among different kinds of central venous access are still a matter of debate.Not many clinical trials have reported a comparison of complications and patency of CVCs versus Peripherally Inserted Catheters (PICC) as central venous access for indoor patients with advanced gastrointestinal disorder. The aim of the present study was to compare CVCs and PICCs regarding function, complications and convenience in a controlled clinical study on patients aimed for oncology surgery aimed for cure.
Distributions of patients were comparable. Malignant diagnoses were significantly higher among CVC-patients. CVCs and PICCs were used for treatment during equal number of days, without any signifi cant complication rates and with comparable number of days on antibiotics and other potent drugs. The overall cumulative hazard (risk) for treatment interruptions, due to either full-filled clinical indications or due to any complication among the subgroups of patients did not differ.Central Venous Catheter and Peripheral Inserted Central Venous Catheter, for central venous access, did not differ among consecutive unselected patients with serious gastro-intestinal disorders.
ACC 2011 research highlights: A slideshow presentation theheart.org
http://www.theheart.org/editorial-program/1210493.do
The American College of Cardiology (ACC) 2011 Scientific Sessions took place in New Orleans and key trials presented at the sessions include: PARTNER cohort A, PARTNER cohort B cost analysis, RIVAL, STICH, MAGELLAN, OSCAR, EVEREST II, PRECOMBAT, RESOLUTE, PLATINUM, ISAR CABG and EXCELLENT.
Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Su...Premier Publishers
To study intraoperative blood loss and analyse average blood loss and number of transfusions in patients who underwent pelvic oncological surgeries in this oncology centre in South India from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients who had undergone pelvic oncological surgeries in our institute from January 2012 and December 2018 was done and information regarding blood loss and transfusions was analysed with student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19 patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8 underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and upfront surgeries (531 ml) had less blood loss compared to surgeries done post chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions, infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a learning curve, extensive anatomical knowledge about the procedure during open surgeries made learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy cases leading to less infection rates, better recovery and with increase in duration of surgery, blood loss is more.
Clinical Profile of Patients with Coronary Tortuosity and its Relation with C...Premier Publishers
Coronary tortuosity is a common angiographic finding. This study was done to observe the clinical profile of patients with coronary tortuosity (CT) and its relation with coronary artery disease (CAD). Method: A total 224 patients undergoing angiography for suspected CAD were included in the study. Coronary tortuosity was defined by the presence of ≥3 consecutive bends of > 45 degree, measured at end-diastole in an epicardial artery ≥2 mm in diameter. Coronary tortuosity was present in 45(20.1%) patients (CT group) in the study and another 45 patients without coronary tortuosity was randomly selected as control (NCT group). Clinical profile of CT and NCT group was compared. Results: Incidence of coronary tortuosity was significantly higher in females (p=0.000) and hypertensives (p=0.001) patients. Coronary tortuosity was most commonly seen in Left circumflex coronary artery. Incidence of CAD was significantly lower in CT group as compare to NCT group (0.02). Risk factors for CAD was associated with reduced incidence of Coronary tortuosity. Majority (88.5%) patient with CT without CAD presented with chronic stable angina out of which (65.2%) had an objective evidence of myocardial ischemia. Conclusion: Coronary tortuosity is more commonly seen females and hypertensive patients. It has negative correlation with CAD but can lead to myocardial ischemia. Risk factors of CAD do not predict CT.
Mean platelet volume and other platelet volume indices in patients with acute...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The mortality rate of perforated peptic ulcer is still high particularly for aged patients and all the existing scoring systems to predict mortality are complicated or based on history taking which is not always reliable for elderly patients. This study’s aim was to develop an easy and applicable scoring system to predict mortality based on hospital admission data.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results
Predictors of Ischaemia and Outcomes in Egyptian Patients with Diabetes Mellitus Referred for Perfusion Imaging. Samir Rafla*, Ahmed Abdel-Aaty, Mohamed Ahmed Sadaka, Aly Ahmed Abo Elhoda and Ahmed Mohamed Shams
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
In non-cardioembolic stroke patients, the cardiac manifestations of elevated blood pressure are of particular interest. The value of LV geometry in the prediction of cardiovascular risk is controversial. Many reports detected that left ventricular hypertrophy is independently associated with risk of ischemic stroke. The primary objective of this study was to identify the frequency of different patterns of altered left ventricular geometry in patients with non cardioembolic stroke, and to assess whether a significant number of patients will miss the diagnosis of LV remodeling if the left ventricular relative wall thickness(RWT) is not evaluated or reported. 100 patients were referred within 48 hours after an acute non cardioembolic ischemic stroke for a transthoracic echocardiogram. The echocardiographic findings were analyzed. Mean age was 61.86 ± 12.59 years, 45 % men. Concentric remodeling carried the highest frequency (43%), followed by normal pattern (27%), concentric hypertrophy (22%), and eccentric hypertrophy (8%). The frequency of abnormal left ventricular RWT (61.4%) was significantly higher than that of abnormal LVMI.
Safety, risk of complications and the functional feasibility among different kinds of central venous access are still a matter of debate.Not many clinical trials have reported a comparison of complications and patency of CVCs versus Peripherally Inserted Catheters (PICC) as central venous access for indoor patients with advanced gastrointestinal disorder. The aim of the present study was to compare CVCs and PICCs regarding function, complications and convenience in a controlled clinical study on patients aimed for oncology surgery aimed for cure.
Distributions of patients were comparable. Malignant diagnoses were significantly higher among CVC-patients. CVCs and PICCs were used for treatment during equal number of days, without any signifi cant complication rates and with comparable number of days on antibiotics and other potent drugs. The overall cumulative hazard (risk) for treatment interruptions, due to either full-filled clinical indications or due to any complication among the subgroups of patients did not differ.Central Venous Catheter and Peripheral Inserted Central Venous Catheter, for central venous access, did not differ among consecutive unselected patients with serious gastro-intestinal disorders.
ACC 2011 research highlights: A slideshow presentation theheart.org
http://www.theheart.org/editorial-program/1210493.do
The American College of Cardiology (ACC) 2011 Scientific Sessions took place in New Orleans and key trials presented at the sessions include: PARTNER cohort A, PARTNER cohort B cost analysis, RIVAL, STICH, MAGELLAN, OSCAR, EVEREST II, PRECOMBAT, RESOLUTE, PLATINUM, ISAR CABG and EXCELLENT.
Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Su...Premier Publishers
To study intraoperative blood loss and analyse average blood loss and number of transfusions in patients who underwent pelvic oncological surgeries in this oncology centre in South India from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients who had undergone pelvic oncological surgeries in our institute from January 2012 and December 2018 was done and information regarding blood loss and transfusions was analysed with student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19 patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8 underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and upfront surgeries (531 ml) had less blood loss compared to surgeries done post chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions, infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a learning curve, extensive anatomical knowledge about the procedure during open surgeries made learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy cases leading to less infection rates, better recovery and with increase in duration of surgery, blood loss is more.
Clinical Profile of Patients with Coronary Tortuosity and its Relation with C...Premier Publishers
Coronary tortuosity is a common angiographic finding. This study was done to observe the clinical profile of patients with coronary tortuosity (CT) and its relation with coronary artery disease (CAD). Method: A total 224 patients undergoing angiography for suspected CAD were included in the study. Coronary tortuosity was defined by the presence of ≥3 consecutive bends of > 45 degree, measured at end-diastole in an epicardial artery ≥2 mm in diameter. Coronary tortuosity was present in 45(20.1%) patients (CT group) in the study and another 45 patients without coronary tortuosity was randomly selected as control (NCT group). Clinical profile of CT and NCT group was compared. Results: Incidence of coronary tortuosity was significantly higher in females (p=0.000) and hypertensives (p=0.001) patients. Coronary tortuosity was most commonly seen in Left circumflex coronary artery. Incidence of CAD was significantly lower in CT group as compare to NCT group (0.02). Risk factors for CAD was associated with reduced incidence of Coronary tortuosity. Majority (88.5%) patient with CT without CAD presented with chronic stable angina out of which (65.2%) had an objective evidence of myocardial ischemia. Conclusion: Coronary tortuosity is more commonly seen females and hypertensive patients. It has negative correlation with CAD but can lead to myocardial ischemia. Risk factors of CAD do not predict CT.
Mean platelet volume and other platelet volume indices in patients with acute...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
The mortality rate of perforated peptic ulcer is still high particularly for aged patients and all the existing scoring systems to predict mortality are complicated or based on history taking which is not always reliable for elderly patients. This study’s aim was to develop an easy and applicable scoring system to predict mortality based on hospital admission data.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results
Right Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement vs. Co...semualkaira
This research aims to compare intraoperative
and postoperative outcomes of Right Anterior Thoracotomy minimally invasive aortic valve replacement (RAT-MIAVR) surgery
with conventional aortic valve replacement (C-AVR) surgery and
analyze the results.
Assessment of Intermediate Coronary Artery Lesion with Fractional Flow Reserv...Premier Publishers
Fraction flow reserve (FFR) is considered the gold standard for assessing intermediate coronary lesions. Retrospective data analyses showed variable relationship between intravascular ultrasound (IVUS) parameters and FFR results. This study aimed to determine the optimal minimum lumen area (MLA) by IVUS that correlates with FFR and to assess the correlation between two modalities in assessing intermediate coronary lesions. Methods: Fifty eight intermediate coronary lesions mainly located in proximal and mid segments of large main coronary vessels with RVD (3-4mm) were analyzed using both IVUS and FFR to assess the significance of coronary stenting and to determine the optimal IVUS-MLA that correlates with FFR value < 0.8. Results: IVUS-MLA ranged from 2.5 to 4.2 mm2 had a highly significant positive correlation with FFR value < 0.8 (p < 0.0001). Using the ROC curve analysis, IVUS-MLA < 3.9 mm2 (84.2% sensitivity, 80% specificity, area under curve (AUC) = 0.68) was the best threshold value for identifying FFR <0.8>< 0.8 in coronary vessels with RVD (3-4mm). Different MLA cutoffs should be used for different vessel diameters.
At the bifurcation, the shear forces peak at the carina, creating areas of high endothelial shear stress.
The development of atherosclerosis in the LMCA has been linked to flow haemodynamics, with atherosclerotic plaques described at areas of low endothelial shear stress in the lateral wall of the bifurcation, opposite to the carina.
Conversely, the carina is often free from disease, probably owing to the protective effect of high shear stress against plaque formation.
The length of the LMCA also influences stenosis location and morphology. In short LMCA (<10 mm), lesions develop more frequently near the ostium than in the bifurcation (55% versus 38%), whereas in long arteries, lesions develop predominantly near the bifurcation (ostium 18% versus bifurcation 77%).
Furthermore, ostial lesions more frequently have negative remodelling, larger luminal areas, and less calcium than distal lesions.
Les NVPO sont un événement fréquent en post-anesthésie puisqu'ils touchent environ un tiers des patients. Les différents scores et prophylaxies utilisées bien que souvent efficaces ne closent pas le chapitre de leur prévention. La gabapentine, antivonvusilvant, a montré par ailleurs son effet analgésique en post-opératoire.
Plus récemment, la gabapentine a montré un effet anti-émétique lorsqu'elle était administrée en prévention dans la chimiothérapie du cancer du sein.
Cette étude est une méta-analyse des essais randomisés de la gabapentine en prévention des NVPO. Elle conclut à son efficacité, efficacité d'autant plus marquée que le propofol n'est pas utilisé comme agent d'induction et/ou d'entretien.
Le degré de relâchement musculaire en chirurgie coelioscopique de la vésicule biliaire fait partie du quotidien des discussions entre anesthésistes et chirurgiens au bloc opératoire. Au fond tous sont convaincus de l'efficacité du curare : le chirurgien qui le demande et l'anesthésiste qui pense lui à sa décurarisation.
Cette étude teste curarisation profonde versus curarisation de routine dans la chirurgie coelioscopique de la vésicule biliaire. Avec comme première question "est-ce qu'une curarisation profonde permet de travaillert avec une pression abdominable moindre?", pression dont on sait qu'elle est pourvoyeuse de douleur post-opératoire.
La réponse est que le degré de curarisation participe de façon marginale au confort du chirurgien... et ne permet pas plus fréquemment de travailler à pression abdominale basse.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
1. REVIEW ARTICLES
Richard P. Cambria, MD, Section Editor
From the Canadian Society for Vascular Surgery
Mortality and reintervention following elective
abdominal aortic aneurysm repair
Mohammad Qadura, MD, PhD,a
Farhan Pervaiz, BSc,a
John A. Harlock, MD, FRCSC,a
Ashraf Al-Azzoni, MD,b
Forough Farrokhyar, PhD,c,d
Kamyar Kahnamoui, MD, MHRM,c,d
David A. Szalay, MD, MEd, FRCSC,a
and Theodore Rapanos, MD, MSc, FRCSC,a
Hamilton, Ontario, Canada
Background: The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality
rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches.
Methods: MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major
vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR)
of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs
EVAR were calculated for short- and long-term mortality and reintervention rates.
Results: The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group
resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs
1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality
between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures
in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but
this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates
attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair.
Conclusions: Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than
with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality
between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group.
Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach
to AAAs can be supported by the meta-analysis. (J Vasc Surg 2013;57:1676-83.)
As a frequent cause of cardiovascular mortality, abdom-
inal aortic aneurysms (AAAs) place a significant burden on
health care systems in developed nations.1,2
Recent studies
have shown a prevalence of AAA as high as 9% in people
65-85 years of age.2
The risk of rupture, which is fatal in
65% of individuals, is directly correlated with the aneu-
rysm’s diameter.3
Surgical intervention is currently the
accepted standard used to prevent mortality from aneurysm
rupture. This can be approached from either a standard
open technique or an endovascular procedure with a stent
graft system. The open approach, practiced by surgeons for
over 50 years, had been the treatment of choice until a less
invasive alternative, endovascular aneurysm repair (EVAR),
was developed.4
With similar indications for both
approaches, deciding on an elective repair method can be
very challenging. Several trials have compared the EVAR
and open approaches, focusing on their effectiveness and
outcomes. However, there are still some controversies in
the literature on the short- and long-term mortality rates
of these approaches.2
Our goal is to review the current
evidence comparing the open and EVAR approaches for
AAA repair by performing a meta-analysis of all the
randomized controlled trials that compared both
approaches with regard to their effectiveness and safety.
METHODS
Design. A systematic review and meta-analysis of
randomized clinical trials were conducted.
Outcome of interest. The primary outcome of
interest was short- and long-term all-cause mortality. We
considered mortality within 30 days after the operation to
represent the short-term mortality rate, whereas mortality
From the Division of Vascular Surgery,a
Division of Cardiology,b
Division of
General Surgery,c
and Department of Clinical Epidemiology and Bio-
statistics,d
McMaster University.
Author conflict of interest: none.
Presented at the Thirty-fourth Annual Meeting of the Canadian Society for
Vascular Surgery, Quebec City, Quebec, Canada, September 28-29, 2012.
Additional material for this article may be found online at www.jvascsurg.org.
Reprint requests: John A. Harlock, MD, FRCSC, Division of Vascular
Surgery, McMaster University, Hamilton General Hospital, 237 Barton
St E, Hamilton, Ontario, Canada L8L 2X2 (e-mail: harlocj@mcmaster.ca).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214/$36.00
Copyright Ó 2013 by the Society for Vascular Surgery.
http://dx.doi.org/10.1016/j.jvs.2013.02.013
1676
2. beyond the 2-year mark was considered to represent the
long-term mortality rate. Secondary outcomes of interest
included cardiovascular-related death, aneurysm-related
death, and reintervention rates.
Criteria for study selection. All randomized
controlled trials comparing the mortality rates of EVAR
vs open AAA repair were included. Study selection
included randomized controlled trials (RCTs) published
until 2012 that (1) enrolled patients for elective repair
of AAAs with a size $5 cm or AAAs of 4.5 cm that are
rapidly enlarging; (2) all patients were good surgical candi-
dates; and (3) the studies reported all-cause mortality
Table I. Description of the included trials (RCTs)
Source
Age, mean 6 SD, years
Number of
patients
Inclusion criteria Key exclusion criteria
Follow- up
durationOpen EVAR Open EVAR
ACE 20111
70 6 7.1 68.9 6 7.7 148 150 (1) CT scan finding:
AAA >50 mm in
men, >45 mm in
women, common
iliac artery aneu-
rysm >30 mm
(2) Upper neck free of
major thrombus or
calcification
(3) $15 mm in length
(4) Angle between
neck and axis of
aneurysm <60
mm
(5) Clinical assessment
graded patients in
categories of 0-2
according to
comorbidity score
of SVS/AAVS
(1) Previous AAA
surgery
(2) Ruptured aneurysm
(3) Mycotic aneurysm
(4) Severe iodine
allergy
(5) Life expectancy
deemed <6 months
(6) Category 3 of
SVS/AAVS
4.8 years
DREAM 201014
69.6 þ 6.8 70.7 þ 6.6 178 173 (1) Elective repair
(2) AAA size >5 cm
(3) Suitable for
operation as per
cardiology/inter-
nist for open and
endograft-
dependent
anatomic criteria
for EVAR
(1) Emergency repair
(2) Inflammatory
aneurysm
(3) Anatomic variation
(4) Connective tissue
disease
(5) History of organ
transplant
(6) Life expectancy less
than 2 years
6.4 years
EVAR 112
2011 74.1 6 6.1 74.1 6 6.1 626 626 (1) Elective repair
(2) AAA >5.5 cm
(3) Surgical candidate
(4) Age >60 years
NA 8 years
OVER15
2009 70.5 6 7.8 69.6 6 7.8 437 444 (1) Elective repair
(2) AAA >5 cm
(3) AAA of 4.5 cm
and a rapidly
enlarging
aneurysm
(4) Surgical candidate
(5) An associated iliac
aneurysm with
a maximum diam-
eter of at least 3
cm
(1) Previous abdominal
aortic surgery
(2) Needed urgent
report. Unwilling
or unable to give
informed consent
or follow the
protocol
2 years
AAVS, American Association for Vascular Surgery; AAA, abdominal aortic aneurysm; ACE, Anévrisme de L’aorte Abdominale: Chirurgie versus Endo-
prothése; DREAM, Dutch Randomized Endovascular Aneurysm Repair; EVAR 1, United Kingdom Endovascular Aneurysm Repair 1; NA, not available;
OVER, Open Versus Endovascular Repair; RCT, randomized controlled trial; SVS, Society for Vascular Surgery.
JOURNAL OF VASCULAR SURGERY
Volume 57, Number 6 Qadura et al 1677
3. (short-term/long-term), aneurysm-related mortality, car-
diovascular disease (CVD)-related mortality (including
congestive heart failure, myocardial infarction, cardiac
arrest), stroke-related mortality, and surgical reintervention
rates. We excluded RCTs that had (1) patients with
previous abdominal aortic surgery, (2) patients who needed
urgent surgery for ruptured AAAs; (3) patients unwilling or
unable to give informed consent or follow the protocol;
and (4) studies with a mean follow-up of less than 2 years.
Literature search and study selection. Studies were
identified by electronic literature searches in the Cochrane
Central Register of Controlled Trials, MEDLINE, and
EMBASE from 1988 to 2012 using combinations of the
following terms: aortic graft, endovascular, EVAR, open,
abdominal aortic aneurysm, AAA, and repair. We also con-
tacted trials’ authors for further data as needed. Our litera-
ture search also included reviewing the references of recent
articles published on this topic including the issues from
the past 12 months of the Journal of Vascular Surgery. All
available data were utilized including full publications,
abstracts, and online late breaking presentations. We identi-
fied 2245 reports that were reviewed by two independent
reviewers (M.Q., F.P.); a third reviewer (T.R.) settled any
discrepancies. A previous meta-analysis was published on
this topic; however, this meta-analysis does not include the
results from the most recent RCTs.5
We also did an analysis
of a number of prospective RCTs but did not include these
in our meta-analysis as per the inclusion criteria.
Data collection. Two authors (M.Q., F.P.) indepen-
dently identified the trials for inclusion and exclusion
criteria as mentioned above. For all published trials, the
following information was tabulated according to the
randomization group by two authors (M.Q., F.P.): (1)
information about the trial’s clinical characteristics, the
number of participating patients, mean age, and duration
of clinical follow-up (Table I); and (2) aneurysm related
mortality, CVD related mortality (including congestive
heart failure, myocardial infarction, cardiac arrest), stroke
related mortality, surgical reintervention rates, short-term
all-cause mortality (<30 days) and long-term mortality
(>2 years with short-term deaths excluded). If no resolu-
tion of agreement was achieved between the reviewers,
a senior author (T.R.) was consulted to settle the discrep-
ancy. The level of agreement between the two authors
(M.Q., F.P.) varied from 83% to 100%.
Assessment of quality and risk of bias. The risk of
bias was assessed according to the guidelines of The
Cochrane Collaboration tool for assessing risk of bias.6-11
The assessment of risk of bias in the trials was based on
consequence generation; allocation concealment; blinding
of participants, personnel, and outcome assessors; incom-
plete outcome data; selective outcome reporting; and other
sources of bias such as baseline imbalance, early stopping
bias, academic bias, and source of funding bias.6
M.Q. and
F.P. assessed the risk of bias in all trials with a third reviewer
(T.R.) to settle any discrepancies.
Statistical analysis. The reliability between the two
reviewers for literature search, kappa score for the
included/excluded studies, data collection, and quality
assessment was measured using kappa statistics and SPSS
software (IBM, Armonk, NY). For dichotomous
outcomes, risk ratio (RR) of open vs EVAR repair with
confidence intervals (CIs) and P value are reported. Results
were considered statistically significant at P # .05. Because
of the possibility of a small number of studies and between-
study heterogeneity, the pooled RR was calculated with the
Mantel-Haenszel method for random effects.6
A random-
effects model meta-analysis assumes that the true under-
lying effects vary between trials. An intention-to-treat
analysis was performed by using the same end point defi-
nitions as in the primary studies. To assess heterogeneity
across trials, we used the Cochrane c2
test based on the
pooled RR. Heterogeneity was considered statistically
significant at P # .1 because the heterogeneity test is
underpowered when small numbers of studies are included.
Also, the I2
statistic was used to quantify heterogeneity;
a value of <25% is considered small heterogeneity, a value
of 25%-50% is considered as moderate heterogeneity,
whereas a value >50% is considered as a large heteroge-
neity.6
Cochrane c2
statistic with P value and I2
value are
reported. A funnel plot is used to explore publication bias,6
but it is not recommended for less than 10 studies because
asymmetry could appear because of chance.12
Review
Manager, v. 5.0 (Cochrane Collaboration, Copenhagen,
Denmark), was used to generate the forest plots and RRs.
RESULTS
Our search identified 2245 abstracts. After review of
the abstracts, we identified four randomized controlled
trials that met our inclusion criteria (Fig 1). All were pub-
lished within the past 4 years. All of the presented results in
this study summarize the findings from the RCTs. None of
the studies was blinded.
The Cohen’s k scores for the interobserver reliabilities
for the literature search process and quality assessment are
Fig 1. Literature research for selected studies.
JOURNAL OF VASCULAR SURGERY
1678 Qadura et al June 2013
4. 0.88, and 0.9, respectively. The data harvest level of agree-
ment among M.Q. and F.P. varied from 83% to 100%.
The literature review also yielded a study by P. W. M.
Cuypers et al 2001.13
However, we have decided not to
include this study in the calculations that are presented.
This article did not elicit the data necessary for our system-
atic review. The only outcome measure presented was
short-term all-cause mortality. The mortality was not sub-
divided by cause, which makes it difficult to compare
with the other studies included in this meta-analysis. To
determine if the exclusion of this study skews the results,
short-term mortality and all-cause mortality were calcu-
lated including this study. The results showed that the
inclusion or exclusion of this study did not alter the overall
outcome (data not shown).
Our literature review identified four trials that are used
in our analysis. These studies reported outcomes of open
repair vs EVAR repair of AAAs in patients who were candi-
dates for both procedures (n ¼ 2783).1,14-17
Table II
summarizes the characteristics of the four RCTs that evalu-
ated AAA repair. Sample size varied from 298 to 1252 with
a similar number of participants in study groups. The mean
age varied from 69 to 74 years, but it was similar between
the groups for all studies. The mean follow-up time varied
from 2 years (United Kingdom Endovascular Aneu-
rysm Repair 1 [EVAR 1], 2011) to 8 years (Anévrisme
de L’aorte Abdominale: Chirurgie versus Endoprothése
[ACE], 2011), but all reported 30-day mortality as short
term. The loss to follow-up for the ACE, Dutch Random-
ized Endovascular Aneurysm Repair (DREAM), EVAR 1,
and Open Versus Endovascular Repair (OVER) studies
was small: 8, 0, 17, and 2 patients, respectively.
Fig 2 shows a significant increased 30-day postopera-
tive all-cause mortality in open repair compared with
EVAR repair (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-
4.94). Findings were consistent across the studies. The
between-study heterogeneity was of small size (I2
¼
23%). We also compared the long-term all-cause mortality
between open and EVAR repair. As shown in Fig 3, there is
no statistically significant difference in the long-term all-
cause mortality between open and EVAR repair. RR was
0.95 (95% CI, 0.84-1.10) with no heterogeneity.
A comparison of reintervention rates in both groups
was conducted and summarized in Fig 4. Although there
was no statistical difference in the long-term all-cause
mortality, it is shown in Fig 4 that reintervention proce-
dures in the open repair group were 50% lower than in
the EVAR repair group (9.3% vs 18.9%; RR, 0.49; 95%
Table II. The assessment of risk of bias in the trials was based on sequence generation; allocation concealment; blinding
of participants, personnel, and outcome assessors; incomplete outcome data; selective outcome reporting; and other
sources of bias such as baseline imbalance, early stopping bias, academic bias, and source of funding bias
Bias DREAM EVAR 1 OVER ACE
Sequence generation Low Moderate Moderate High
Allocation concealment Low Low Low Low
Blinding participants and personnel Moderate-high Moderate-high Moderate-high Moderate-high
Blinding outcome assessment Moderate-high Moderate-high Moderate-high Moderate-high
Incomplete outcome data Low Low Low High
Selective outcome reporting Low Low Low Low
Other sources Moderate Low Low Low
ACE, Anévrisme de L’aorte Abdominale: Chirurgie versus Endoprothése; DREAM, Dutch Randomized Endovascular Aneurysm Repair; EVAR 1, United
Kingdom Endovascular Aneurysm Repair 1; OVER, Open Versus Endovascular Repair.
Study or Subgroup
ACE1
DREAM16
EVAR 114
OVER17
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.18; Chi² = 3.90, df = 3 (P = .27); I² = 23%
Test for overall effect: Z = 2.45 (P = .01)
M-H, Random, 95% CI
0.50 [0.05-5.49]
3.89 [0.84-18.05]
2.36 [1.18-4.74]
10.16 [1.31-79.03]
2.72 [1.22-6.08]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Open Favors EVAR
0.01 0.1 1 10 100
Fig 2. Forest plot of randomized trials comparing 30-day mortality rate after endovascular aneurysm repair (EVAR) and
open repair of unruptured abdominal aortic aneurysms (AAAs). Endovascular in comparison to open repair has a lower
30-day postoperative all-cause mortality. ACE, Anévrisme de L’aorte Abdominale: Chirurgie versus Endoprothése;
CI, confidence interval; DREAM, Dutch Randomized Endovascular Aneurysm Repair; EVAR 1, United Kingdom
Endovascular Aneurysm Repair 1; OVER, Open Versus Endovascular Repair.
JOURNAL OF VASCULAR SURGERY
Volume 57, Number 6 Qadura et al 1679
5. CI, 0.40-0.60). However, the large between-study hetero-
geneity of 82% undermines the validity of pooled RR for
reintervention.
The long-term mortality was further divided by cause
(cardiovascular, aneurysm related and stroke), and these
were compared in both groups. Fig 5, A-C demonstrate
no statistical difference in long-term mortality rates due
to CVD, aneurysm related and stroke after EVAR or
open repair of AAAs. CVD (RR, 0.9; 95% CI, 0.6-1.2)
and stroke (RR, 0.9; 95% CI, 0.5-1.6) were in favor of
open repair, but aneurysm-related deaths were (RR, 1.1;
95% CI, 0.5-2.5) were in favor of EVAR repair. Heteroge-
neity (I2
¼ 47%) of close to moderate size was present
for aneurysm-related deaths that might be attributable to
the small number of events in ACE 2011 and DREAM
2010 trials.
We have also refined our literature search to include
nonrandomized prospective studies that compared the
short- and long-term mortality events post-EVAR and
open repair of AAAs.18-23
Unlike the results we obtained
from RCT studies, the analysis of the prospective studies
showed no statistical difference in the short-term all-cause
mortality between open repair and EVAR repair
(RR, 1.66; 95% CI, 1.05-2.62). The results from the
long-term all-cause mortality from prospective cohort
studies were not reliable because of the large between-
study heterogeneity (80%). Hatala et al24
recommended
not to pool the results when heterogeneity is larger than
50%. The analysis of the prospective cohort studies showed
no statistical difference in the long-term all-cause mortality
between open repair and EVAR repair (RR, 0.75; 95% CI,
0.53, 1.06).
DISCUSSION
These results represent an up-to-date meta-analysis of
the randomized trials for comparing open vs EVAR repair
of AAAs. Open repair has long been accepted as the gold
standard repair for AAAs because of its acceptable low
risk, predictability for expected outcomes, and durability.
EVAR has been established to help reduce short-term
Study or Subgroup
ACE1
DREAM16
EVAR 114
OVER17
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.00; Chi² = 0.91, df = 3 (P = .82); I² = 0%
Test for overall effect: Z = 0.45 (P = .65)
M-H, Random, 95% CI
0.73 [0.35-1.54]
0.93 [0.68-1.28]
0.98 [0.85-1.12]
1.11 [0.67-1.85]
0.97 [0.86-1.10]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Open Favors EVAR
0.5 0.7 1 1.5 2
Fig 3. Forest plot of randomized trials comparing long-term mortality rate after endovascular aneurysm repair (EVAR)
and open repair of unruptured abdominal aortic aneurysms (AAAs). There was no statistical difference in long-term all-
cause mortality between endovascular and open repair of AAAs. ACE, Anévrisme de L’aorte Abdominale: Chirurgie
versus Endoprothése; CI, confidence interval; DREAM, Dutch Randomized Endovascular Aneurysm Repair; EVAR 1,
United Kingdom Endovascular Aneurysm Repair 1; OVER, Open Versus Endovascular Repair.
Study or Subgroup
ACE1
DREAM16
EVAR 114
OVER17
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.21; Chi² = 16.44, df = 3 (P = .0009); I² = 82%
Test for overall effect: Z = 2.71 (P = .007)
M-H, Random, 95% CI
0.17 [0.06-0.47]
0.61 [0.41-0.91]
0.38 [0.28-0.51]
0.88 [0.59-1.32]
0.49 [0.29-0.82]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Open Favors EVAR
0.05 0.2 1 5 20
Fig 4. Forest plot of randomized trials comparing reintervention rates after endovascular aneurysm repair (EVAR) or
open repair of unruptured abdominal aortic aneurysms (AAAs). Open in comparison to endovascular repair has a lower
reintervention rate. ACE, Anévrisme de L’aorte Abdominale: Chirurgie versus Endoprothése; CI, confidence interval;
DREAM, Dutch Randomized Endovascular Aneurysm Repair; EVAR 1, United Kingdom Endovascular Aneurysm
Repair 1; OVER, Open Versus Endovascular Repair.
JOURNAL OF VASCULAR SURGERY
1680 Qadura et al June 2013
6. mortality associated with elective AAA repair.17
These
initial benefits of EVAR, though, are not sustained on
longer-term follow-up as confirmed with the EVAR 1,
DREAM, and OVER trials as shown in this current
meta-analysis. The French ACE trial found different results
when it came to perioperative outcomes, as no early
survival advantage was attributed to EVAR compared
with open repair. They also found that in low-risk patients,
open repair was as safe as EVAR, but with less
reinterventions.
As demonstrated on most of the trials, the reinterven-
tion rate was higher in the EVAR group of patients. The
DREAM and OVER trials appear to have counted reinter-
vention rates for open and EVAR patients as graft-related
indications, wound-related indications (incisional hernia
and wound infection), and local or systemic indications
(bleeding, endoleak, and small bowel obstructions). The
EVAR 1 and ACE trials appear to have counted reinterven-
tion rates for open and EVAR patients as graft-related
interventions including graft rupture, endoleak, para-
anastomotic aneurysm, graft replacement, and graft occlu-
sions/stenoses. The lifetime need for reintervention in
patients who undergo an EVAR repair approaches 20%.
The OVER trial, though, considered more specifically
surgical complications than both the DREAM and EVAR
1 trials and recorded a 5% rate of patients needing incisional
hernia repairs. As such, OVER did not demonstrate a differ-
ence for reintervention rate between the types of repair. In
Study or Subgroup
ACE1
DREAM16
EVAR 114
OVER17
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.00; Chi² = 1.54, df = 2 (P = .46); I² = 0%
Test for overall effect: Z = 0.64 (P = .52)
M-H, Random, 95% CI
Not estimable
1.05 [0.51-2.16]
0.93 [0.66-1.32]
0.45 [0.14-1.46]
0.91 [0.67-1.23]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Open Favors EVAR
Study or Subgroup
ACE1
DREAM16
EVAR 114
OVER17
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.28; Chi² = 5.67, df = 3 (P = .13); I² = 47%
Test for overall effect: Z = 0.26 (P = .80)
M-H, Random, 95% CI
0.17 [0.02-1.38]
2.92 [0.12-71.10]
1.00 [0.69-1.45]
2.20 [0.84-5.74]
1.11 [0.50-2.46]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Open Favors EVAR
Study or Subgroup
DREAM16
EVAR 114
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.00; Chi² = 0.32, df = 1 (P = .57); I² = 0%
Test for overall effect: Z = 0.46 (P = .64)
M-H, Random, 95% CI
1.30 [0.29-5.71]
0.82 [0.44-1.51]
0.88 [0.50-1.54]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Open Favors EVAR
A
B
C
0.1 0.2 0.5 1 2 5 10
0.01 0.1 1 10 100
0.1 0.2 0.5 1 2 5 10
Fig 5. Forest plot of randomized trials comparing long-term mortality rates due to cardiovascular disease (CVD) (A),
aneurysm related (B), and stroke (C) after endovascular aneurysm repair (EVAR) or open repair of unruptured
abdominal aortic aneurysms (AAAs), respectively. There is no statistical difference in long-term mortality rates because
of CVD, aneurysm related and stroke after EVAR, or open repair of AAAs. ACE, Anévrisme de L’aorte Abdominale:
Chirurgie versus Endoprothése; CI, confidence interval; DREAM, Dutch Randomized Endovascular Aneurysm Repair;
EVAR 1, United Kingdom Endovascular Aneurysm Repair 1; OVER, Open Versus Endovascular Repair.
JOURNAL OF VASCULAR SURGERY
Volume 57, Number 6 Qadura et al 1681
7. the ACE trial, there was a statistically significant difference
when it came to wound complications between the open
surgical repair and EVAR arms with 25% of patients under-
going open repair having complications vs 0.7% in the
EVAR group. The ACE trial lists did not specifically record
the incidence of abdominal wall reconstruction or incisional
repairs following open repair group. The incidence of bowel
obstruction associated with open surgery was also not re-
ported. This may have affected the outcomes of their stated
reintervention rate, such as with the OVER trial, as we know
that incisional complications following open repair for
AAA are not negligible.25
The weight of the ACE trial,
though, did not bear out in the Forest plot to affect the
overall swing toward EVAR as requiring a higher rate of
reintervention. This trend is also echoed in the EURO-
STAR registry in which there was an overall 14% reinterven-
tion rate, with complications occurring more frequently in
AAAs >5.5 cm.26
In this current meta-analysis, we found
a higher risk of reintervention for EVAR compared with
open repair. However, the large heterogeneity between
studies undermines the validity of the pooled RR for reinter-
vention. This large heterogeneity might be due to the
definition of and the reasons for reintervention that might
differ from study to study.
In performing this meta-analysis, we were able to look
at the current RCT literature for open vs EVAR repair as
a whole. Any initial benefit that was gained with an
EVAR approach was lost on longer-term follow-up in these
studies. There is no statistical difference in the long-term
mortality comparing open vs EVAR repair. This might be
due to the fact that the length of follow-up varied between
studies from 2 to 8 years.
Further study of long-term mortality by listed cause
demonstrates no difference when comparing either CVD-
related mortality, aneurysm-related mortality, or stroke-
related mortality. This is not overly surprising, as those
who survive the initial periprocedural period often return
back to their baseline risk, independent of type of proce-
dure for AAA repair.
Based on this meta-analysis, we are able to demonstrate
the short-term mortality benefits of an EVAR approach.
For those patients with a life expectancy <2 years, an indi-
vidualized treatment plan is prudent and thoughtful discus-
sion with the patient in regard to overall goals of care
should be had, based on the results of the EVAR 2 trial.27
This group of patients that were deemed unfit to undergo
open AAA repair were not included in our meta-analysis
based on our inclusion criteria.
Although most patients in the DREAM, OVER, and
EVAR 1 were fit for surgery, baseline characteristics may
not be fully identical, and a similar distribution of risk
factors does not fully take into account the association of
risks. The OVER trial used the Research ANd Develop-
ment (RAND) surgical risk score with 53% patients consid-
ered as low risk for surgery. However, the risk assessment
of patients in the EVAR 1 or DREAM was left to each
center’s appreciation. This difference in patient risk assess-
ment may account for the heterogeneity in clinical findings
between the different studies. The ACE trial looked at
patients who were low to moderate risk for undergoing
surgical repair and excluded patients who had a life expec-
tancy of less than 6 months, or were in category 3 of the
Society for Vascular Surgery/American Association for
Vascular Surgery comorbidity score for the clinical assess-
ment. These differences might account for the between-
study heterogeneity for 30-day postoperative mortality.
As with any meta-analysis, the results depend on the
quality and quantity of the studies that were included in
the analysis. Here, the four major randomized controlled
trials for EVAR open repairs have been analyzed, as they
met our search criteria. This includes over 2700 patients
randomized. Other prospective studies were excluded, as
they did not meet our full criteria of randomized trials or
reporting of outcomes beyond 2 years. This does limit our
breadth of studies captured but does help to create a clearer
picture with similar patient groups. Although, as discussed
in our Results section, the inclusion of a number of prospec-
tive nonrandomized trials reaffirms the long-term mortality
equivalency of EVAR and open repairs, but also found
a similar short-term equivalency. These results are inter-
esting and confirm our data for long-term morality. The
difference in the short-term mortality between prospective
studies and RCTs can be attributed to the lack of random-
ization and selection bias of patients. These studies might
have recruited younger patients with few comorbidities
who are better fit to undergo an open repair and the older
patients, or those with more medical comorbidities to
undergo an endovascular repair. Therefore, we must
analyze the prospective studies with caution since they are
prone to selection bias and information bias. Also, because
of the lack of randomization, a higher potential for con-
founding factors can sometimes be observed in prospective
studies.
The strength of this systematic review and meta-
analysis is that any potential biases for search strategy,
inclusion and exclusion of the studies, and data collection
are minimized by an independent review process. Also,
only randomized controlled trials are included, appropriate
statistical methods are used and study heterogeneity is
accounted for in the analysis. The weakness of this study
is the small number of the included studies; we, however,
ensured that all eligible studies were included and our sepa-
rate analysis of nonrandomized prospective trials did not
add much to the conclusions drawn.
CONCLUSIONS
Through this meta-analysis, we are able to confer with
most recent studies on EVAR for AAAs. EVAR reduces the
short-term mortality associated with surgical repair, but
this benefit is not sustained on longer-term follow-up. It
is also confirmed that the reintervention rate was higher
with an EVAR repair. This is an up-to-date review of the
most recent randomized controlled trials comparing open
with EVAR repair for AAAs. This meta-analysis supports
the notion of an endovascular-first approach to AAAs
JOURNAL OF VASCULAR SURGERY
1682 Qadura et al June 2013
8. attributable to the short-term benefit of EVAR and the
long-term mortality equivalency.
AUTHOR CONTRIBUTIONS
Conception and design: MQ, FP, AA, JH
Analysis and interpretation: MQ, FP, AA, JH, FF, KK, DS
Data collection: MQ, FP
Writing the article: MQ, FP, AA, FF, JH
Critical revision of the article: MQ, JH, FF, KK, DS
Final approval of the article: MQ, DS, JH
Statistical analysis: MQ, FF, KK
Obtained funding: Not applicable
Overall responsibility: JH
REFERENCES
1. Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y,
Lermusiaux P, et al. A randomized controlled trial of endovascular
aneurysm repair versus open surgery for abdominal aortic aneurysm in
low-to-moderate-risk patients. J Vasc Surg 2011;53:1167-73.
2. Sakalihasan N, Limet R, Defaw OD. Abdominal aortic aneurysm.
Lancet 2005;365:1577-89.
3. Kniemeyer HW, Kessler T, Reber PU, Ris HB, Hakki H, Widmer MK.
Treatment of ruptured abdominal aortic aneurysm, a permanent chal-
lenge or a waste of resources? Prediction of outcome using a multi-
organ-dysfunction score. Eur J Vasc Endovasc Surg 2000;19:190-6.
4. Eliason JL, Upchurch GR Jr. Endovascular abdominal aortic aneurysm
repair. Circulation 2008;117:1738-44.
5. Sajid MS, Desai M, Haider Z, Baker DM, Hamilton G. Endovascular
aortic aneurysm repair (EVAR) has significantly lower perioperative
mortality in comparison to open repair: a systematic review. Asian J
Surg 2008;31:119-23.
6. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of
Interventions 2011: Version 5.1.0. The Cochrane Collaboration.
Available at: www.cochrane-handbook.org. Accessed March 2012.
7. Kjaergard LL, Villumsen J, Gluud C. Reported methodologic quality
and discrepancies between large and small randomized trials in meta-
analyses. Ann Intern Med 2001;135:982-9.
8. Moher D, Pham B, Jones A, Cook DJ, Jadad AR, Moher M, et al. Does
quality of reports of randomised trials affect estimates of intervention
efficacy reported in meta-analyses? Lancet 1998;352:609-13.
9. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of
bias. Dimensions of methodological quality associated with estimates of
treatment effects in controlled trials. JAMA 1995;273:408-12.
10. Wood L, Egger M, Gluud LL, Schulz KF, Juni P, Altman DG, et al.
Empirical evidence of bias in treatment effect estimates in controlled
trials with different interventions and outcomes: meta-epidemiological
study. BMJ 2008;336:601-5.
11. Gluud C, Nikolova D, Klingenberg S, Alexakis N, Als-Nielsen B,
D’Amico G, et al. Cochrane Hepato-Biliary Group. About the Cochrane
Collaboration (Cochrane Review Groups [CRGs]). Chapter 8. Art. No.
LIVER. 2008;4: Available at: http://www.mrw.interscience.wiley.com/
cochrane/cochrane_clsysrev_crglist_fs.html. Accessed November 6, 2009.
12. Duval S, Tweedie R. Trim and fill: a simple funnel-plot based method
of testing and adjusting for publication bias in meta-analysis. Biometrics
2000;56:455-63.
13. Cuypers PW, Gardien M, Buth J, Peels CH, Charbon JA, Hop WC.
Randomized study comparing cardiac response in endovascular and
open abdominal aortic aneurysm repair. Brit J Surg 2001;88:1059-65.
14. EVAR Trial Participants. Endovascular aneurysm repair versus open
repair in patients with abdominal aortic aneurysm (EVAR Trial 1):
randomised controlled trial. Lancet 2005;365:2179-86.
15. Brown LC, Thompson SG, Greenhalgh RM, Powell JT. Incidence of
cardiovascular events and death after open or endovascular repair of
abdominal aortic aneurysm in the randomized EVAR trial 1. Brit J Surg
2011;98:935-42.
16. De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven E, Cuypers P,
et al. Long-term outcome of open or endovascular repair of abdominal
aortic aneurysm. N Engl J Med 2010;362:1881-9.
17. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT Jr,
Matsumura JS, Kohler TR, et al; Open Versus Endovascular Repair
(OVER) Veterans Affairs Cooperative Study Group. JAMA 2009;302:
1535-42.
18. Lifeline Registry of EVAR Publications Committee. Lifeline registry of
endovascular aneurysm repair: long-term primary outcome measures.
J Vasc Surg 2005;42:1-10.
19. Cao P, Verzini F, Parlani G, Romano L, De Rango P, Pagliuca V, et al.
Clinical effect of abdominal aortic aneurysm endografting: 7-year
concurrent comparison with open repair. J Vasc Surg 2004;40:841-8.
20. Sicard GA, Zwolak RM, Sidawy AN, White RA, Siami FS. Endovas-
cular abdominal aortic aneurysm repair: long-term outcome measures
in patients at high-risk for open surgery. J Vasc Surg 2006;44:229-36.
21. Moore WS, Matsumura JS, Makaroun MS, Katzen BT, Deaton DH,
Decker M, et al. Five-year interim comparison of the Guidant bifur-
cated endograft with open repair of abdominal aortic aneurysm. J Vasc
Surg 2003;38:46-55.
22. Garcia-Madrid C, Josa M, Riambau V, Mestres CA, Muntana J,
Mulet J. Endovascular versus open surgical repair of abdominal aortic
aneurysm: a comparison of early and intermediate results in patients
suitable for both techniques. Eur J Vasc Endovasc Surg 2004;28:
365-72.
23. Bush RL, Johnson ML, Hedayati N, Henderson WG, Lin PH,
Lumsden AB. Performance of endovascular aortic aneurysm repair in
high-risk patients: results from the Veterans Affairs National Surgical
Quality Improvement Program. J Vasc Surg 2007;45:227-33; discus-
sion: 233-5.
24. Hatala R, Keitz S, Wyer P, Guyatt G. Tips for learners of evidence-
based medicine: 4. Assessing heterogeneity of primary studies in
systematic reviews and whether to combine their results. CMAJ
2005;172:661-5.
25. Raffetto JD, Cheung Y, Fisher JB, Cantelmo NL, Watkins MT,
Lamorte WW, et al. Incision and abdominal wall hernias in patients
with aneurysm or occlusive aortic disease. J Vasc Surg 2003;37:1150-4.
26. Leurs LJ, Buth J, Laheiji RJ; EUROSTAR Collaborators. Long-term
results of endovascular abdominal aortic aneurysm treatment with the
first generation of commercially available stent grafts. Arch Surg
2007;142:33-41.
27. United Kingdom EVAR Trial Investigators. Endovascular repair of
aortic aneurysm in patients physically ineligible for open repair. N Engl
J Med 2010;362:1872-80.
28. Peterson BG, Matsumura JS, Brewster DC, Makaroun MS. Five-year
report of a multicenter controlled clinical trial of open versus endo-
vascular treatment of abdominal aortic aneurysms. J Vasc Surg
2007;45:885-90.
Submitted Oct 25, 2012; accepted Feb 2, 2013.
Additional material for this article may be found online
at www.jvascsurg.org.
JOURNAL OF VASCULAR SURGERY
Volume 57, Number 6 Qadura et al 1683
9. Study or Subgroup
Bush23
Cao19
Garcia-Madrid22
Lifeline registry18
Moore21
Sicard20
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.09; Chi² = 6.81, df = 5 (P = .24); I² = 27%
Test for overall effect: Z = 2.19 (P = .03)
M-H, Random, 95% CI
1.53 [1.00-2.35]
4.38 [1.68-11.40]
1.77 [0.26-11.91]
0.71 [0.26-1.96]
1.55 [0.43-5.54]
1.74 [0.52-5.79]
1.66 [1.05-2.62]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Open Favors EVAR
0.1 0.2 0.5 1 2 5 10
Supplementary Fig 1 (online only). Forest plot of prospective studies comparing 30-day mortality rate after
endovascular aneurysm repair (EVAR) and open repair of unruptured abdominal aortic aneurysms (AAAs). Endo-
vascular and open repair had similar 30-day postoperative all-cause mortality. CI, Confidence interval.
Study or Subgroup
Bush23
Cao19
Garcia-Madrid22
Lifeline registry18
Moore21
Peterson28
Sicard20
Total (95% CI)
Total events
Heterogeneity: Tau² = 0.19; Chi² = 34.15, df = 6 (P < .00001); I² = 82%
Test for overall effect: Z = 1.66 (P = .10)
M-H, Random, 95% CI
1.33 [1.03-1.71]
0.73 [0.56-0.95]
2.43 [0.58-10.09]
0.51 [0.38-0.70]
0.77 [0.47-1.26]
0.36 [0.19-0.67]
0.60 [0.36-1.01]
0.73 [0.50-1.06]
oitaRksiRoitaRksiR
M-H, Random, 95% CI
Favors Control Favors EVAR
0.1 0.2 0.5 1 2 5 10
Supplementary Fig 2 (online only). Forest plot of prospective studies comparing long-term mortality rate after
endovascular aneurysm repair (EVAR) and open repair of unruptured abdominal aortic aneurysms (AAAs). There was
no statistical difference in long-term all-cause mortality between endovascular and open repair of AAAs. CI, Confidence
interval.
JOURNAL OF VASCULAR SURGERY
1683.e1 Qadura et al June 2013