Comparison of efficiency and safety of open surgery, hybrid surgery and endovascular repair for the treatment of thoracoabdominal aneurysms: a systemic review and network meta-analysis

Objective The objective of this study was to perform a network meta-analysis (NMA) to assess the efficacy and safety of three different surgical interventions- open surgical repair (OSR), hybrid surgical repair (HSR), and endovascular repair (EVAR)- for the treatment of thoracoabdominal aortic aneurysms (TAAAs). Methods Electronic repositories like PubMed, Embase, Web of Science, Scopus, ScienceDirect, the Cochrane library, Clinical trial, and China National Knowledge Infrastructure (CNKI) were systematically searched to identify studies that compared the efficacy of OSR, HSR, and EVAR with endografts for the treatment of TAAAs until December 24th, 2022. Random-effects and fixed-effects models were employed to analyze the data gathered in a network meta-analysis. The study's primary outcomes of interest encompassed in-hospital mortality, long-term survival rate, and postoperative complications. Results Eleven comparative studies meet inclusion criterias. There were 2,222 patients in OSR, 1,574 patients in EVAR and 537 patients in HSR. EVAR has lower one-month mortality than OSR (RR: 0.31; 95% CI: 0.17–0.70) and HSR (RR: 0.37; 95% CI: 0.22–0.71), and lower incident rate of renal complications than HSR (RR: 0.20; 95% CI: 0.08–0.43) and OSR (RR: 0.34; 95% CI: 0.16–0.65). Nonetheless, there was no noteworthy discrepancy identified in the long-term survival rates of these procedures. Conclusions As compared with OSR, HSR, and EVAR, EVER has lower one-month mortality, and lower incident rates of complications. Systematic review registration PROSPERO (CRD42022313829).


S2
Describe the statistical methods used to evaluate the agreement of direct and indirect evidence in the treatment network(s) studied.Describe efforts taken to address its presence when found.

Risk of bias across studies 15
Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).

7-8
Additional analyses 16 Describe methods of additional analyses if done, indicating which were pre-specified.This may include, but not be limited to, the following: • Sensitivity or subgroup analyses; • Meta-regression analyses; • Alternative formulations of the treatment network; and

Web of Science
The database was searched on December 24th, 2022, n=884.

Cochrane Library
The database was searched on December 24th, 2022, n=99.

Clinical Trail
The database was searched on December 24th, 2022, n=47.

Search Strategy:
Condition or disease: Thoracoabdominal Aortic Aneurysm: Other terms : repair

Table S4 -Final GRADE Assessment for perioperative mortality comparison between the 3 treatment options
Each comparison in the network is graded in turn on a scale of "Very low" -> "Low" -> "Moderate" -> "High" certainty.As per the GRADE guidelines, the starting rating for all comparisons is "Low" due to the non-randomised nature of the included studies:

Figure S2
Figure S2 Literature summary network plots for comparative survival rate network meta-analysis at 6month, 1-year, 3-year and 5-year rate (4222 patients across 11 studies) in studies providing comparative outcomes between methods of Thoracoabdominal aortic aneurysms (TAAA) repair.The size of each red node corresponds to the number of study arms included for a treatment across all comparisons.The width of each grey line corresponds to the number of studies comparing the two interventions directly.OSR = Open Surgical Repair; HSR = Hybrid Surgery Repair; EVAR = Endovascular Repair.

Figure S9
Figure S9 Density plot showing the posterior value of 1-month mortality during OSR, HSR, EVAR, which is used to diagnose the convergence range of the model.(OSR = Open Surgical Repair; HSR = Hybrid Surgery Repair; EVAR = Endovascular Repair).

Figure S10
Figure S10 Contribution plot for all-cause 1-month mortality (4222 patients across 11 studies) in studies providing comparative outcomes between methods of Thoracoabdominal aortic aneurysms (TAAA) repair.The size of each square is proportional to the weight attached to each direct summary effect (horizontal axis) for the estimation of each network summary effects (vertical axis).The numbers reexpress the weights as percentages.(A:OSR = Open Surgical Repair; B:HSR = Hybrid Surgery Repair; C:EVAR = Endovascular Repair).

Figure S11
Figure S11Contribution plot for comparative survival rate network meta-analysis at 6-month, 1-year, 3-year and 5-year rate (4222 patients across 11 studies) in studies providing comparative outcomes between methods of Thoracoabdominal aortic aneurysms (TAAA) repair.The size of each square is proportional to the weight attached to each direct summary effect (horizontal axis) for the estimation of each network summary effects (vertical axis).The numbers re-express the weights as percentages.(A:OSR = Open Surgical Repair; B:HSR = Hybrid Surgery Repair; C:EVAR = Endovascular Repair).

Table S1 -PRISMA NMA Checklist PRISMA NMA Checklist of Items to Include When Reporting A Systematic Review Involving a Network Meta-analysis
• Selection of variance structure; • Selection of prior distributions in Bayesian analyses; and • Assessment of model fit.
Provide a brief overview of characteristics of the treatment network.This may include commentary on the abundance of trials and randomized patients for the different interventions and pairwise comparisons in the network, gaps of evidence in the treatment network, and potential biases reflected by the network structure.and/orwhether some of the authors are content experts with professional conflicts of interest that could affect use of treatments in the network.PICOS = population, intervention, comparators, outcomes, study design.*Text in italics indicateS wording specific to reporting of network meta-analyses that has been added to guidance from the PRISMA statement.†Authors may wish to plan for use of appendices to present all relevant information in full detail for items in this section.
• Use of alternative prior distributions for Bayesian analyses (if applicable)./RESULTS†Studyselection17Givenumbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.9Presentation of network structureS3Provide a network graph of the included studies to enable visualization of the geometry of the treatment network.FUNDINGFunding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.This should also include information regarding whether funding has been received from manufacturers of treatments in 1 the network

Table S3 -Quality assessment of all included studies. Note: a
Representativeness of the exposed cohort; b Selection of the non-exposed cohort; c Demonstration that outcome of interest was not present at start of study; d Comparability of cohorts on the basis of the design or analysis; e Was follow-up long enough for outcomes to occur.

Rating the network estimate (RR 0.37 95%CI 0.22-0.71): Moderate Highest
Obvious confounding would relate to physiological risk: open surgery is generally performed in fitter patients.Therefore, to adjust for this would only increase the effect noted (that open surgery has worse perioperative mortality than EVAR).This therefore upgrades the rating one position for this outcome measure.
B) Rating the indirect estimate: Very LowThe most dominant first order loop is EVAR -> HSR -> OPEN: EVAR vs HSR rating (direct): Very Low OPEN vs HSR rating (direct): Very Low Transitivity: low concern C) between direct/indirect ratings: Moderate Incoherence: No concerns Imprecision: No concerns