| Description: |
Objective: To evaluate the impact of proximal vs infrarenal aortic cross-clamping on perioperative outcomes during open abdominal aortic aneurysm repair. Methods: Article screening was conducted using the MEDLINE, Embase, and the Cochrane Library databases. The primary outcome was 30-day mortality; secondary outcomes included cardiac, renal, pulmonary, gastrointestinal, cerebrovascular, and wound complications; reintervention; dialysis; and hospital length of stay. End points were compared using the risk ratio (RR) for binary outcomes and the mean difference for continuous outcomes. For all outcomes, 95% confidence intervals (CIs) were calculated. Subgroup analysis was conducted for supraceliac and suprarenal clamp groups. A trial sequential analysis was conducted for the primary outcome. Meta-regression was conducted for all covariates with at least 10 observations. Heterogeneity was assessed through the I2 statistic. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment of the findings was performed. Results: Fifteen studies comprising 13,140 patients were included. Infrarenal clamping was associated with significantly lower 30-day mortality (RR, 2.26; 95% CI, 1.32-3.89; P = .003), reduced renal complications (RR, 2.57; 95% CI, 2.03-3.26; P < .0001), permanent dialysis, myocardial infarction, arrhythmia, pulmonary complications, reintervention, and shorter hospital stay. No differences were found for cerebrovascular, gastrointestinal, or wound complications. Subgroup analysis indicated that excess mortality was primarily driven by supraceliac clamping. Conclusions: Infrarenal aortic clamping during open abdominal aortic aneurysm repair confers superior perioperative outcomes compared with proximal clamping. When technically feasible, the lowest possible clamp level should be chosen to minimize renal and cardiac morbidity and improve early postoperative survival. |