Knowledge and Encounter Research Unit, Mayo Clinic, Rochester, MN, USA.
J Vasc Surg. 2011 Jan;53(1):193-199.e1-21. doi: 10.1016/j.jvs.2010.08.028. Epub 2010 Oct 29.
To synthesize the available evidence regarding the outcomes associated with nonoperative management, open repair, and endovascular repair of thoracic aortic transection.
We searched electronic databases (MEDLINE, EMBASE Cochrane, Web of Science, and Scopus) for studies that enrolled patients with aortic transection and measured the outcomes of interest. Two reviewers determined study eligibility and extracted data. We estimated the event rate associated with the different approaches from case series and the relative risk from comparative studies. Estimates from each study were pooled using the random effects model.
We found 139 studies that fulfilled the inclusion criteria, the majority of which were noncomparative surgical case series, retrospective, and none were randomized. Studies included 7768 patients, the majority of which were males. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair and nonoperative management (9%, 19%, and 46%, respectively, P < .01). No significant difference in event rate across the three groups was noted for the outcomes of anterior stroke, posterior stroke, or any stroke. The risk of spinal cord ischemia and end-stage renal disease were higher in open repair compared with the other 2 groups (9% vs 3% and 3%, P = .01 for spinal cord ischemia and 8% vs 5% and 3%, P = .01 for end-stage renal disease). Compared with endovascular repair, open repair was associated with an increased risk of graft infection and systemic infections. Meta-analyses of comparative studies demonstrated that compared with open repair, endovascular repair is associated with reduced mortality and spinal cord ischemia (relative risk, 0.61; 95% confidence interval, 0.46-0.80; and relative risk, 0.34; 95% confidence interval, 0.16-0.74; respectively). Inferences are limited by methodological quality, survival, and publication biases.
Very low-quality evidence suggests that, compared with open repair or nonoperative management, endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, and graft and systemic infections. Nonoperative management is associated with the least favorable outcomes.
综合有关非手术治疗、开放修复和胸主动脉夹层血管内修复的结局的现有证据。
我们检索了电子数据库（MEDLINE、EMBASE、Cochrane、Web of Science 和 Scopus），以纳入主动脉夹层患者，并测量了感兴趣的结局。两名评审员确定了研究的合格性并提取了数据。我们从病例系列中估计了不同方法的事件发生率，并从比较研究中估计了相对风险。使用随机效应模型对每个研究的估计值进行了汇总。
我们找到了 139 项符合纳入标准的研究，其中大多数是非比较性的外科病例系列，回顾性的，没有随机的。研究纳入了 7768 名患者，其中大多数是男性。血管内修复的死亡率明显低于开放修复和非手术治疗（分别为 9%、19%和 46%，P<.01）。在三组之间，前卒中、后卒中或任何卒中的发生率没有显著差异。与其他两组相比，开放修复的脊髓缺血和终末期肾病的风险更高（9%比 3%和 3%，P=.01 对于脊髓缺血和 8%比 5%和 3%，P=.01 对于终末期肾病）。与血管内修复相比，开放修复与移植物感染和全身感染的风险增加相关。比较研究的荟萃分析表明，与开放修复相比，血管内修复与降低死亡率和脊髓缺血相关（相对风险，0.61；95%置信区间，0.46-0.80；和相对风险，0.34；95%置信区间，0.16-0.74；分别）。结论：低质量证据表明，与开放修复或非手术治疗相比，胸主动脉夹层的血管内修复与更好的生存和降低脊髓缺血、肾损伤以及移植物和全身感染的风险相关。非手术治疗的结局最不理想。
