Meta-analysis Finds Greater Patency, Complications with Aortoiliac Surgery vs. Stenting

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While endovascular treatment of aortoiliac occlusive disease results in shorter hospital stays and less morbidity and mortality, surgical bypass achieves better long-term patency rates. Results of a meta-analysis were published in the August 2013 issue of the Journal of Endovascular Therapy.

Researchers led by Jeffrey E. Indes, MD, of Yale University School of Medicine (New Haven, CT), looked at 29 open bypass (n = 3,733) and 28 endovascular treatment (n = 1,625) studies conducted between 1989 and 2010. The majority (84.2%) of studies were retrospective, and none directly compared the 2 treatments.

Pooled primary and secondary patency rates were higher in the open bypass group versus the endovascular cohort out to 5 years (table 1).

Table 1. Pooled Primary and Secondary Patency

Patients in the open bypass group experienced higher complication (18.0% vs. 13.4%; P < 0.001) and 30-day mortality rates (2.6% vs. 0.7%; P < 0.001) compared with those who had endovascular treatment. However, the following complications trended higher in the stenting cohort (P = 0.08 for all):

• Bleeding: 2.9% vs. 1.5%
• Early thrombosis: 4.9% vs. 3.4%
• Distal embolization: 4.9% vs. 1.2%

Surgically treated patients also had longer mean hospital stays compared with those who received stents (13 vs. 4 days; P < 0.001).

“Direct open repair still remains the more durable option and should be offered to patients who are suitable and able to withstand the rigors of laparotomy,” Dr. Indes and colleagues write. “Endovascular repair is a viable alternative and perhaps an appropriate first-line treatment in certain patients.”

‘Garbage in, Garbage Out’

However, Stephen Ramee, MD, of Ochsner Medical Center (New Orleans, LA), told TCTMD in a telephone interview that “most studies included in this meta-analysis are pretty bad studies: retrospective, self-reported, without any kind of oversight, inclusion/exclusion criteria, or any prespecified endpoints.”

Since the vast majority of surgical studies do not include complications, “this is the weakest kind of data individually,” he said. “Lots and lots of very poor data cannot be combined to make a good study, so multiplying it by 100 doesn’t make it any better. . . . It’s garbage in, garbage out.”

Quick to agree, Christopher J. White, MD, also of Ochsner Heart and Vascular Institute, said that not only is the heterogeneity in this sample size “enormous,” but the fact that the meta-analysis includes studies as old as 15 years is “ridiculous.” Comparing “a 1997 angioplasty study to what we can do today with our current technology with covered stents and DES that were not available then is meaningless. I don’t know what they are trying to say,” he told TCTMD in a telephone interview.

Dr. Ramee also questioned the paper’s conclusion that surgery is better than endovascular treatment because there is less need for repeat revascularization. “But if a patient has surgery and goes to a nursing home, is that better than having a stent and having to come back for restenosis? It’s not specified. We don’t know how many people went to a nursing home after surgery, we just know their hospital stay was longer,” he said, adding that details like stroke and MI rates and frailty were also not measured.

Dr. White took issue with the meta-analysis for not mentioning the high risk of male impotence. “They never even talk about it—like it doesn’t even matter. It matters. [Some physicians] don’t talk that much about this to patients because they don’t think it’s a real complication because it doesn’t hurt anyone, but it’s a quality of life issue,” he stressed.

No Bridges Burned with Stenting

“There’s no question that there are some patients out there who are better suited for surgery,” Dr. White observed. But “in today’s world, most clinicians believe that it should be an [endovascular] first strategy, and if that fails, then surgery should back them up. You don’t burn bridges when you try to do this via an endovascular approach. It’s not a tough sell.”

Patients who have the option between surgery and endovascular repair “would opt for endovascular treatment for aortoiliac disease,” Dr. Ramee said. “It’s less risky.

“If you want to say there’s a difference between the 2 groups, you have to be able to prove it,” he concluded, adding that a randomized trial with prespecified endpoints would be the only way to do so.

In an editorial accompanying the paper, Giacomo Frati, MD, of Sapienza University of Rome (Latina, Italy), and colleagues conclude that while surgery remains “the gold standard and still leads in terms of long-term efficacy,” endovascular therapy should be offered to “those who have lesions that are particularly suitable.” Surgery and stenting should “best be viewed as complementary and synergic tools to improve the prognosis and well-being of our patients,” they write.

 

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Sources:
1. Indes JE, Pfaff MJ, Farrokhyar F, et al. Clinical outcomes of 5358 patients undergoing direct open bypass or endovascular treatment for aortoiliac occlusive disease: A systematic review and meta-analysis. J Endovasc Ther. 2013;20:443-455.

2. Peruzzi M, Biondi-Zoccai G, Frati G. Aortoiliac arteries: Another Waterloo for transcatheter vs. open surgical therapy after aorta, cardiac valves, carotids, coronaries, femorals, and tibials [editorial]? J Endovasc Ther. 2013;20:456-460.

 

 

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