Endotension following endovascular aortic repair: systematic review and meta-analysis on occurrence rate, treatment approaches and outcomes.

Introduction: Endotension is still a poorly understood phenomenon in terms of occurrence rate, treatment indications and outcomes. The aim of this study was to report incidence, different treatment approaches and outcomes of patients affected by endotension after EVAR.

Evidence aquisition: A systematic review of the literature (database searched: PubMed, Web of Science, Scopus, Cochrane Library) was undertaken until June 2024. Articles reporting data about occurrence rate, strategy of treatment and outcomes of patients affected by endotension, including at least five cases of endotension were included. Meta-analyses of proportions were performed using a random-effects model.

Evidence synthesis: Thirteen non-randomized studies published between 2005 and 2024 were examined, with a total of 22,118 patients undergoing EVAR due to abdominal aortic aneurysm. Among them, 209 patients developed endotension during follow-up, resulting in an estimated occurrence rate of 1.6% (95% CI 0.9-2.3). Four approaches to treat endotension were reported in literature. Estimated rates were: open surgical conversion (OSC) in 37.3% (95% CI 10.5-64.0), conservative approach in 25.9% (95% CI -4.4-56.2), endovascular relining in 23.3% (95% CI 11.4-35.2) and semi-conversions in 19.5% (95% CI 4.9-34.2). The technical success (TS) in OSC, relining and semi-conversion subgroups were respectively: 93.4% (95% CI 85.7-101), 80.7% (95% CI 60.5-101) and 94.5% (95% CI 85.2-103.8).

Conclusions: OSC is the most used method, achieving high TS rate. OSC and semi-conversion presented a high CS during follow-up, while relining had lower "durability" compared to surgical treatments. Data about conservative treatment are scarce but in can be considered for selected cases.