Elective Open Repair of Abdominal Aortic Aneurysms (AAA):

A Systematic Review of Risk Factors for Associated Mortality

Dezembro 2007

Turma 5 - 1º ano Mestrado Integrado em Medicina, FMUP

Outline

Topics• Introduction• Research Question and Aims• Participants and Methods

– Type of Study– Study Participants– Study Design– Variables and data collection– Statistical Analysis– Expected Results

• Current Situation• Future Work

INTRODUCTION

Abdominal Aortic Aneurysm (AAA):

Abnormal widening of artery, usually considered when the widening is more than 1.5 times the “normal” diameter of the aorta above

What is an AAA?

INTRODUCTION

What is an AAA?

Risk Factors:

• Smoking

• Family history of AAA

• Chronic obstructive pulmonary disease

• Previous vascular surgery

• Hypertension

• Atherosclerosis

• Age>50 y.o. and male gender

INTRODUCTION

What are the risk factors for AAA development?

INTRODUCTION

Elective Open Repair (EOR):

• Invasive surgery procedure with insertion of a prosthetic tube-like graft

• Two types:– Transperitoneal

– Left retroperitoneal

What is an EOR?

INTRODUCTION

Postoperative Complications:• Haemorrhage• Gastrointestinal ischemia and/or dysfunction• Cardiac events• Pulmonary insufficiency• Renal failure• Erectile dysfunction• Graft infection

What are the common postoperative complications of EOR?

RESEARCH QUESTION AND AIMS

Research Questions:

• Which risk factors and postoperative complications mostly contribute to mortality after EOR?

• Is it possible to improve the prediction of patient’s outcome after EOR?

Aims:• Summarize mortality rates and Identify risk factors and

postoperative complications which are more commonly associated with mortality after EOR.

Research Question and Aims

Type of Study

Systematic Review

Type of Study

PARTICIPANTS AND METHODS

Study Participants (n=203)All published papers on PubMed Database considering a

query with the words:• (("abdominal aortic aneurysm"[Text Word] OR "aortic aneurysm,

abdominal"[MeSH Terms] OR aaa[Text Word])

• AND elective[All Fields]

• AND open[All Fields])

• AND ((("wound healing"[TIAB] NOT Medline[SB]) OR "wound healing“[MeSH Terms] OR repair[Text Word]) OR ("surgery"[Subheading] OR "operative surgical procedures"[Text Word] OR "surgical procedures, operative"[MeSH Terms] OR "surgery"[MeSH Terms] OR surgery[Text Word]))

• AND mortality[Text Word]

Study Participants

PARTICIPANTS AND METHODS

Study Design:1st Triage Phase

PARTICIPANTS AND METHODS

n=80

Study Design

Study Design: 1st Triage Phase

• Inclusion Criteria1. Abdominal aortic aneurysms (AAA)

2. Elective open repair/surgery (EOR)

3. Mortality rates after elective open repair

4. Postoperative complications

5. Patient’s outcome

• Exclusion Criteria1. Other types or “mixed” aortic aneurysms (n=10)

2. Emergency repair of ruptured AAA (n=13)

3. Patients submitted to endovascular repair (EVAR) (n=51)

4. Other papers as reviews, systematic reviews, meta-analysis, letters or editorials (n=20)

5. Papers in other languages rather than English, French, Spanish or Portuguese (n=16)

6. Not related studies (n=26)

PARTICIPANTS AND METHODS

Study Design

Study Design:2nd Triage Phase

PARTICIPANTS AND METHODS

Included papersn=80

Study Design

Study Design: 2nd Triage Phase

PARTICIPANTS AND METHODS

The inclusion criteria will be the availability of information for each of the predefined variable in study.

Study Design

Study Design:Final Phase

PARTICIPANTS AND METHODS

Full papers includedn=??

Study Design

Variable description and data collection:Article peer-review to extract information data about :

Study characteristics:• name of first author

• year of publication

• country of origin

• type of study

• sample size

Preoperative clinical variables:• age

• risk factors exposition

• patient’s condition

• aneurysm diameter

Postoperative Clinical variables: venous bleeding gastrointestinal ischemia renal failure myocardial infarction respiratory complications clinical outcome <30 days

PARTICIPANTS AND METHODS

Variables in study

Planed statistical analysis

• Data input on Database using Statistical Package for Social Sciences

(SPSS) or Review Manager (RevMan) software

• Analysis of the frequency of each factor/complication

• Selection of the most common postoperative complications

• Estimation of Relative Risk (RR) of each factor for mortality

• Comparison of mortality rates with clinical and outcome history

PARTICIPANTS AND METHODS

Statistical Analysis

Limits of the study

We are aware that the Query we have applied may not be specific

enough due to:

1. Inexistence of a unique term to define “elective open repair”

2. The number of risk factors and postoperative complications

3. Difficulty to define the outcome<30 days after repair

Limits

RESULTS

Expected Results

• Summarize the mortality rates and Identify the postoperative complications more commonly associated with failure after EOR

• Provide “strong” evidences for prediction of patient’s outcome after EOR based on the clinical evidences and postoperative complications

Expected Results

RESULTS

Current situation

ID Nom e da Tarefa Duration Start Finish Predeces sorsResource Names

1 Phase 1 13 days Wed 10-10-07 Mon 29-10-07

2 Identification of problem 1 day Wed 10-10-07 Wed 10-10-07 Class 5

3 Work planning 5 days Thu 11-10-07 Wed 17-10-07 2 Class 5

4 Literature research about Elective Open Repair AAA 2 days Thu 11-10-07 Fri 12-10-07 2 Henrique Messias[25%];Ana Pinto[25%];Joana Teixeira[25%];Luís Mendes [25%]

5 Definition of MeSH terms to include in the Query 0,5 days Fri 12-10-07 Fri 12-10-07 4SS;2 Class 5

6 Definition of query 0,5 days Fri 12-10-07 Fri 12-10-07 5 Class 5

7 Application of query in PUBMED databas e 0,25 days Mon 15-10-07 Mon 15-10-07 6 Class 5

8 Definition of m ethods 1 day Thu 11-10-07 Thu 11-10-07 7 Sérgio Cardoso;Sílvia Farraposo;Joana Teixeira;Rafaela Parreira

9 Writing of protocol draft 5 days Mon 15-10-07 Fri 19-10-07 8 Hugo Sousa;Sofia Figueiredo;Filipa Figueiredo;Filipa Gomes

10 Elaboration of Powerpoint presentation 2 days Thu 25-10-07 Fri 26-10-07 9 Ana Pinto;Catarina Machado;Miguel Mascarenhas ;Luís Mendes

11 Firs t presentation 0 days Mon 29-10-07 Mon 29-10-07 10 Miguel Mascarenhas [50%];Ana Pinto[50%]

12 Phase 2 37 days Wed 31-10-07 Fri 21-12-07 1

13 Review of Query 0,25 days Wed 31-10-07 Wed 31-10-07 Class 5

14 Re-application of query in PUBMED database 0,25 days Wed 31-10-07 Wed 31-10-07 13 Class 5;Hugo Sousa

15 Definition of inclusion/exclusion criteria 0,5 days Wed 31-10-07 Wed 31-10-07 14 Class 5

16 Review and Selection of Abstracts 23 days Thu 01-11-07 Mon 03-12-07 14

17 Dis tribution of abs tracts for review 0,25 days Thu 01-11-07 Thu 01-11-07 14;15 Hugo Sousa;Luís Mendes

18 Analys is of abstracts with inclusion/exclusion criteria 17 days Thu 01-11-07 Fri 23-11-07 14;15;17 Class 5

19 Definition of variables to extract 1 day Mon 03-12-07 Mon 03-12-07 18 Hugo Sousa[50%];Class 5[50%]

20 Elaboration of Gant Map 5 days Mon 03-12-07 Fri 07-12-07 15 Sílvia Farraposo[70%];Sofia Figueiredo[20%];Hugo Sousa[10%]

21 Elaboration of Workflows 5 days Mon 03-12-07 Fri 07-12-07 8;9;14;20 Rafaela Parreira[25%];Sílvia Farraposo[50%];Filipa Figueiredo[25%]

22 Writing of protocol 12 days Mon 03-12-07 Tue 18-12-07 16 Hugo Sousa[25%];Sofia Figueiredo[15%];Filipa Gomes[10%];Henrique Mess ias [10%];Miguel Mascarenhas [10%];Joana Teixeira[10%];Catarina Machado[10%];Ana Pinto[10%];Luís Mendes [5%]

23 Elaboration of Powerpoint presentation 4 days Fri 14-12-07 Wed 19-12-07 22SS Sérgio Cardoso;Henrique Mes sias ;Hugo Sous a;Sofia Figueiredo

24 Second presentation 0 days Fri 21-12-07 Fri 21-12-07 23 Henrique Messias[50%];Sérgio Cardoso[50%]

CURRENT SITUATION

Gant Map (Phase 1 and 2)

FUTURE WORK

ID Nom e da Tarefa Duration Start Finish Predeces sorsResource Names

25 Phase 3 30 days Mon 28-01-08 Mon 10-03-08 12

26 Review and Analysis of Papers 25 days Mon 28-01-08 Fri 29-02-08

27 Dis tribution of papers for peer-review 0 days Mon 28-01-08 Mon 28-01-08 Class 5;Hugo Sousa;Luís Mendes

28 Analys is of papers 23 days Mon 28-01-08 Wed 27-02-08 27 Class 5

29 inclusion/exclusion criteria filtering 2 days Thu 28-02-08 Fri 29-02-08 28 Class 5

30 Elaboration of Powerpoint presentation 5 days Mon 03-03-08 Fri 07-03-08 26SS Joana Teixeira;Rafaela Parreira;Catarina Machado;Ana Pinto

31 Third presentation 0 days Mon 10-03-08 Mon 10-03-08 30 Class 5

32 Phase 4 50 days Mon 24-03-08 Mon 02-06-08 25

33 Extraction and Analysis of Data 29 days Mon 24-03-08 Thu 01-05-08

34 Data extraction from included papers 10 days Mon 24-03-08 Fri 04-04-08 29 Hugo Sousa;Sofia Figueiredo;Filipa Figueiredo;Sílvia Farraposo;Ana Pinto;Luís Mendes ;Joana Teixeira

35 Data compilation on SPSS database 5 days Mon 07-04-08 Fri 11-04-08 34 Sérgio Cardoso;Henrique Mes sias ;Luís Mendes;Miguel Mascarenhas

36 Statystical Analys is 10 days Fri 18-04-08 Thu 01-05-08 35 Hugo Sousa;Class 5

37 On-line presentation of res ults 15 days Mon 28-04-08 Fri 16-05-08 41SS Sílvia Farraposo;Luís Mendes ;Joana Teixeira;Rafaela Parreira;Catarina Machado;Henrique Mess ias

38 Elaboration of Powerpoint presentation 5 days Mon 26-05-08 Fri 30-05-08 40SS Hugo Sousa;Luís Mendes;Catarina Machado;Miguel Mascarenhas

39 Final pres entation 0 days Mon 02-06-08 Mon 02-06-08 38 Class 5

40 Complete Writing of Paper 31 days Mon 14-04-08 Mon 26-05-08 22

41 Writing of Results 10 days Mon 14-04-08 Fri 25-04-08 35 Hugo Sousa[50%];Class 5[50%]

42 Writing of Discuss ion 10 days Mon 28-04-08 Fri 09-05-08 41 Hugo Sousa;Class 5

43 Writing of Conclus ion 5 days Mon 12-05-08 Fri 16-05-08 42 Hugo Sousa;Class 5

44 Paper review and corrections 5 days Tue 20-05-08 Mon 26-05-08 43 Class 5;Sílvia Farraposo;Hugo Sous a

FUTURE WORK

Gant Map (Phase 3 and 4)

Elective Open Repair of Abdominal Aortic Aneurysms (AAA):

A Systematic Review of Risk Factors for Associated Mortality

Dezembro 2007

Turma 5 - 1º ano Mestrado Integrado em Medicina, FMUP