Yan Yan, Xu Li, Zhang Hao, Xu Zhi-Yun, Ding Xue-Yan, Wang Shu-Wei, Xue Xiang, Tan Meng-Wei
Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
Eur J Cardiothorac Surg. 2016 May;49(5):1392-401. doi: 10.1093/ejcts/ezv351. Epub 2015 Oct 13.
The optimal surgical strategy for acute type A aortic dissection (ATAAD) is still controversial because of the inconsistent or even conflicting results of proximal aortic repair (PR) versus extensive aortic repair (ER) on early and late prognostic outcomes. This meta-analysis pooled data from all available studies of PR versus ER to get a summarized conclusion.
Studies were identified by searching the Medline, EMBASE and Cochrane databases. Early and late prognostic outcomes of interest were evaluated with meta-analysis. Fixed- or random-effect models were used according to the significance of heterogeneity. Robustness of pooled estimates and the source of heterogeneity were assessed via sensitivity analyses and meta-regression, respectively. Publication bias was evaluated by the funnel plot and Egger's test.
Nine studies with a total of 1872 patients were included for the meta-analysis. Pooled results indicated that, when compared with the ER procedure, PR was associated with lower early mortality [risk ratio (RR) = 0.69, 95% confidence interval (CI) 0.54-0.90, P = 0.005] but higher incidence of postoperative aortic events including reoperation of the distal aorta (RR = 3.14, 95% CI 1.74-5.67, P < 0.001). PR and ER demonstrated analogous prognosis on long-term mortality (HR = 1.02, 95% CI 0.51-2.06, P = 0.96) and the incidences of early postoperative renal failure (RR = 0.75, 95% CI 0.49-1.14, P = 0.17) and stroke (RR = 0.73, 95% CI 0.30-1.78, P = 0.50). All the pooled results were robust to sensitivity analysis. Heterogeneity was insignificant except for the meta-analysis of late mortality.
Performing a less aggressive initial surgical procedure of PR in ATAAD patients would have lower early mortality but elevated incidence rates of late aortic reintervention, when compared with ER. Other prognostic results of the two surgical strategies including long-term mortality were similar for both.
由于近端主动脉修复术（PR）与广泛主动脉修复术（ER）在早期和晚期预后结果上存在不一致甚至相互矛盾的结果，急性A型主动脉夹层（ATAAD）的最佳手术策略仍存在争议。本荟萃分析汇总了所有关于PR与ER的现有研究数据，以得出总结性结论。
通过检索Medline、EMBASE和Cochrane数据库来识别研究。采用荟萃分析评估感兴趣的早期和晚期预后结果。根据异质性的显著性使用固定效应或随机效应模型。分别通过敏感性分析和荟萃回归评估汇总估计的稳健性和异质性来源。通过漏斗图和Egger检验评估发表偏倚。
纳入9项研究，共1872例患者进行荟萃分析。汇总结果表明，与ER手术相比，PR与较低的早期死亡率相关[风险比（RR）=0.69，95%置信区间（CI）0.54 - 0.90，P = 0.005]，但术后主动脉事件的发生率较高，包括远端主动脉再次手术（RR = 3.14，95% CI 1.74 - 5.67，P < 0.001）。PR和ER在长期死亡率（HR = 1.02，95% CI 0.51 - 2.06，P = 0.96）以及术后早期肾衰竭（RR = 0.75，95% CI 0.49 - 1.14，P = 0.17）和中风（RR = 0.73，95% CI 0.30 - 1.78，P = 0.50）的发生率方面显示出相似的预后。所有汇总结果对敏感性分析均具有稳健性。除晚期死亡率的荟萃分析外，异质性不显著。
与ER相比，对ATAAD患者实施侵袭性较小的初始手术PR，早期死亡率较低，但晚期主动脉再次干预的发生率较高。两种手术策略的其他预后结果，包括长期死亡率，两者相似。
