Long-term Cardiovascular and All-Cause Mortality following Elective Infrarenal Repair of the Abdominal Aortic Aneurysm: A Systematic Review and Meta-analysis

Background: Patients with abdominal aortic aneurysms (AAAs) have poor survival rates after aneurysm repair compared with the general population, potentially due to increased cardiovascular risk. This systematic review and meta-analysis aimed to assess the long-term incidence of all-cause and cardiovascular mortality after elective, infrarenal AAA repair. Method: The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines were followed (PROSPERO ID: CRD42022344547). Studies published in PubMed, Web of Science, and COCHRANE databases between January 2013 and May 2023 with a mean follow-up time of >= 5 years were included. A weighted linear regression analysis was performed to determine the annual incidence of all-cause and cardiovascular mortality five years after AAA repair. A random effects model calculated the overall incidence rates per 1000 person-years (PY). Endovascular aneurysm repair (EVAR) and open surgical repair (OSR) were compared. Results: Nineteen studies with 84 212 patients (mean follow-up: 68.9 [+/- 13.3] months) were included. Common preoperative cardiovascular comorbidities included hypertension (74.4%), dyslipidemia (43.6%), and coronary artery disease (27.6%). At five years, the mean all-cause mortality was 29.78%, and cardiovascular mortality was 11.98%, with an annual increase of 6.59% and 2.46%, respectively (R2=0.809, p<0.001 and R2=0.824, p<0.001). The random effects model showed an all-cause mortality rate of 62.99 events (95% CI=57.53-68.96; I2=93%) per 1000 PY and a cardiovascular mortality rate of 24.19 events per 1000 PY (95% CI=21.69-26.98; I2=66%). Patients undergoing an EVAR had a significant higher incidence of all-cause and cardiovascular mortality than patients undergoing an OSR (B-coefficient 4.10 and 2.39, both p<0.001, respectively). Conclusion: The long-term all-cause and cardiovascular mortality remain high following elective, infrarenal AAA repair. These findings highlight a much needed optimization and emphasis of cardiovascular risk management, to minimize the long-term incidence of cardiovascular mortality in patients with AAA following surgical intervention. Clinical Impact This study evaluated the long-term outcomes of cardiovascular and all-cause mortality rates following elective repair of the infrarenal abdominal aortic aneurysm. The results of this systematic review and meta-analysis emphasizes the suboptimal cardiovascular risk profile observed in this patient population. Futhermore, it highlights the importance of optimization and emphasis of cardiovascular risk management, including in the long-term after surgical intervention.