State of the art and meta-analysis of secondary open aortic procedure after abdominal endovascular aortic repair.

Background: Secondary open aortic procedures (SOAP) treat complications of endovascular aneurysm repair, when further endovascular options are exhausted. We aimed at depicting the state of the art of SOAP with high-level evidence.

Methods: A systematic review of the SOAP literature, with a meta-analysis of its outcomes (primary outcome operative mortality; secondary outcome major morbidity) and metaregression of risk factors for mortality (PROSPERO 42017075631).

Results: Twenty-eight studies (1093 patients) were elected for analysis. SOAP was performed within the same hospitalization of or 30 days from domestic endovascular aneurysm repair (early SOAP) in 0.2% of the patients (85/40,256), and in a nonelective setting in 24.3% (95% confidence interval, 21.8-26.9). Most frequent indications were endoleak (44.4%; 95% confidence interval, 41.4-47.3) and rupture (12.7%; 95% confidence interval, 10.4-15.1). The most common procedures were infrarenal aortic replacement (85.2%; 95% confidence interval, 82.6-87.7) with high use of supravisceral clamping (suprarenal, 25% [95% confidence interval, 21.9-28.1] and supraceliac, 20.7% [95% confidence interval, 17.8-23.6]), and axillobifemoral bypass with stent explant (6.9%; 95% confidence interval, 5.1-8.7). Operative mortality (in-hospital or 30-day) was 10.9% (95% confidence interval, 8.7-13.5). The most frequent morbidities were respiratory (11.4%; 95% confidence interval, 8.1-15.9) and renal (9.5%; 95% confidence interval, 8.1-15.9). Risk factors for mortality were supravisceral clamping (Z = 3.007; Q = 9.044; P = .003) and nonelective status (Z = 3.382; Q = 11.440; P = .001).

Conclusions: Endoleak is the main indication for SOAP, which mostly consists of infrarenal aortic replacement. Risk factors for operative mortality are nonelective status and supravisceral clamping.