Dutch Randomized Endovascular Aneurysm Repair - DREAM

Description:

The goal of the trial was to evaluate treatment of abdominal aortic aneurysms by open repair compared with endovascular repair.

Hypothesis:

Endovascular repair of abdominal aortic aneurysms would be more effective in reducing mortality.

Study Design

  • Crossover

Patients Enrolled: 351
Mean Follow Up: Median 6.4 years
Mean Patient Age: 71 years
Female: 7%

Patient Populations:

  • Patients with an abdominal aortic aneurysm at least 5 cm in diameter, suitable for either treatment modality

Exclusions:

  • Need for emergency aortic repair
  • Inflammatory aneurysm
  • Anatomical variation
  • Connective-tissue disease
  • History of organ transplant
  • Limited life expectancy

Primary Endpoints:

  • Rate of all-cause mortality
  • Rate of reintervention

Drug/Procedures Used:

Eligible patients with an abdominal aortic aneurysm were randomized to endovascular repair (n = 173) versus open repair (n = 178).

Principal Findings:

Overall 351 patients were randomized. In the endovascular repair group, the mean age was 71 years, 93% were men, 10% had diabetes, 41% had cardiac disease, mean body mass index was 26 kg/m2, use of antiplatelet agents was 41%, and use of statin was 37%.

At 6 years, the overall survival rate was 68.9% for endovascular repair versus 69.9% for open repair (p = 0.97). After hospital discharge, the number of deaths (endovascular vs. open repair) attributable to cardiovascular causes was 15 versus 17, cancer was 18 versus 18, and miscellaneous causes were 10 versus 4. At 6 years, freedom from reintervention was 70.4% versus 81.9% (p = 0.03), respectively, for endovascular versus open repair. In the endovascular repair group, 14 patients required a second intervention and 7 patients a third intervention (most commonly for thrombo-occlusive disease, endoleak, and graft migration). In the open repair group, 9 patients required a second intervention and 2 patients a third intervention (most commonly for treatment of incisional hernia).

Interpretation:

Among patients with abdominal aortic aneurysm, long-term survival was similar between endovascular and open repair. Patients in the endovascular repair group required significantly more late reinterventions to repair endoleaks or endograft migrations. The findings of this trial are similar to the larger EVAR 1 trial, which also documented inferior long-term durability of endovascular repair. Additional study of endovascular repair of abdominal aortic aneurysm is needed, especially as newer endograft technology becomes available.

References:

De Bruin JL, Baas AF, Buth J, et al., on behalf of the DREAM Study Group. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1881-9.

Clinical Topics: Vascular Medicine, Atherosclerotic Disease (CAD/PAD)

Keywords: Postoperative Complications, Neoplasms, Endoleak, Endovascular Procedures, Body Mass Index, Platelet Aggregation Inhibitors, Survival Rate, Hernia, Aortic Aneurysm, Abdominal, Diabetes Mellitus, Peripheral Vascular Diseases


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