杂交主动脉弓置换术的系统评价和荟萃分析。
A systematic review and meta-analysis of hybrid aortic arch replacement.
机构信息
Department of Vascular Surgery, Athens University Medical School, Attikon University Hospital, Athens, Greece; ; The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia;
出版信息
Ann Cardiothorac Surg. 2013 May;2(3):247-60. doi: 10.3978/j.issn.2225-319X.2013.05.06.
BACKGROUND
Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies.
METHODS
Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality.
RESULTS
Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort.
CONCLUSIONS
Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.
背景
腔内时代的发展改变了主动脉弓病变的治疗方式。有几项研究描述了使用腔内和开放手术联合治疗弓部疾病。杂交修复主动脉弓部病变被认为是一种侵袭性较小的方法，因此对于不适合开放修复的高危患者来说是一种很有吸引力的选择。本荟萃分析的目的是评估杂交技术在主动脉弓部病变患者中的疗效。
方法
进行了广泛的电子文献检索，以确定截至 2012 年 12 月所有描述杂交主动脉弓修复术伴胸内超主动脉分支血运重建和随后支架移植物置入的文章。符合条件的研究分为两组：第 I 组包括主动脉弓离断术的研究，第 II 组包括报道象鼻技术（冷冻或支架）的研究。分别进行荟萃分析以评估技术成功率、卒中、脊髓缺血（SCI）、需要透析的肾衰竭、心脏和肺部并发症发生率以及 30 天/住院死亡率。
结果
共有 46 项研究符合本荟萃分析的纳入标准：26 项研究共 956 例患者报道了主动脉弓离断术，20 项研究共 1316 例患者行冷冻或支架象鼻技术。主动脉弓离断组 30 天/住院死亡率的合并估计值为 11.9%，象鼻组为 9.5%。任何严重程度的脑血管事件术后的合并发生率为 7.6%和 6.2%，而不可逆的脊髓损伤症状在主动脉弓离断组和象鼻组的合并估计值分别为 3.6%和 5.0%。需要透析的肾衰竭发生率在两组分别为 5.7%和 3.8%，而心脏并发症发生率在主动脉弓离断组为 6.0%，在象鼻组为 19.7%。
结论
杂交弓技术为开放修复提供了一种安全的替代方法，具有可接受的短期和中期结果。然而，卒中发生率和死亡率仍然值得关注。未来需要前瞻性试验比较开放常规技术与杂交方法或完全腔内方法。
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