Alsawas Mouaz, Zaiem Feras, Larrea-Mantilla Laura, Almasri Jehad, Erwin Patricia J, Upchurch Gilbert R, Murad M Hassan
Evidence-based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn.
Mayo Clinic Libraries, Mayo Clinic, Rochester, Minn.
J Vasc Surg. 2017 Oct;66(4):1258-1268.e8. doi: 10.1016/j.jvs.2017.05.082. Epub 2017 Jul 26.
A systematic review and meta-analysis was conducted to evaluate the effectiveness of thoracic endovascular aortic repair (TEVAR) and open repair in patients with descending thoracic aortic aneurysms (TAAs).
PubMed, Ovid MEDLINE, Ovid Embase, EBSCO Cumulative Index to Nursing and Allied Health Literature, and Scopus were searched from each database's inception to January 29, 2016. We selected studies that compared the two approaches in adults with TAAs and reported 30-day mortality or procedure complications. Two reviewers independently extracted data, and conflicts were resolved by consensus. Random-effects meta-analysis was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). The main outcomes and measures were all-cause 30-day mortality, 30-day paraplegia or spinal cord ischemia, stroke, pulmonary complications, and length of hospital and intensive care unit (ICU) stay.
Twenty-seven studies of moderate methodologic quality were included. TEVAR was associated with lower 30-day mortality in ruptured (OR, 0.58; 95% CI, 0.38-0.88) and intact (OR, 0.6; 95% CI, 0.36-0.99) aneurysms. Paraplegia or spinal cord ischemia (OR, 0.35; 95% CI, 0.2-0.61) and pulmonary complications (OR, 0.41; 95% CI, 0.37-0.46) were reduced in patients undergoing TEVAR, whereas a reduction in stroke risk was not statistically significant (OR, 0.89; 95% CI, 0.76-1.03). Pooled mean difference in length of hospital and ICU stay was lower for TEVAR by -5.17 days (95% CI, -7.77 to -2.57) and -5.89 days (95% CI, -9.65 to -2.12), respectively. Three studies showed that compared with open repair, a hybrid approach reduced hospital stay (pooled mean difference, -8.83 days; 95% CI, -14.37 to -3.29) and ICU stay (pooled mean difference, -3.17 days (95% CI, -5.54 to -0.97), with minimal evidence on other outcomes studied.
Observational evidence at high risk of confounding suggests that compared with open repair for TAA, TEVAR reduced risk of mortality, paraplegia, spinal cord ischemia, and pulmonary complications within 30 days of intervention. Patients undergoing TEVAR also had shorter length of hospital and ICU stay compared with patients undergoing open repair.
进行一项系统评价和荟萃分析，以评估胸主动脉腔内修复术（TEVAR）与开放修复术治疗降主动脉瘤（TAA）患者的有效性。
检索了PubMed、Ovid MEDLINE、Ovid Embase、EBSCO护理及相关健康文献累积索引以及Scopus数据库，检索时间从各数据库建库至2016年1月29日。我们选择了比较这两种方法治疗成人TAA并报告30天死亡率或手术并发症的研究。两名审阅者独立提取数据，通过协商解决分歧。采用随机效应荟萃分析来估计比值比（OR）和95%置信区间（CI）。主要结局指标包括全因30天死亡率、30天截瘫或脊髓缺血、中风、肺部并发症以及住院时间和重症监护病房（ICU）住院时间。
纳入了27项方法学质量中等的研究。TEVAR与破裂动脉瘤（OR，0.58；95%CI，0.38 - 0.88）和未破裂动脉瘤（OR，0.6；95%CI，0.36 - 0.99）的30天死亡率较低相关。接受TEVAR的患者截瘫或脊髓缺血（OR，0.35；95%CI，0.2 - 0.61）和肺部并发症（OR，0.41；95%CI，0.37 - 0.46）减少，而中风风险降低无统计学意义（OR，0.89；95%CI，0.76 - 1.03）。TEVAR组的住院时间和ICU住院时间的合并平均差异分别缩短了 -5.17天（95%CI，-7.77至 -2.57）和 -5.89天（95%CI，-9.65至 -2.12）。三项研究表明，与开放修复术相比，杂交手术缩短了住院时间（合并平均差异，-8.83天；95%CI，-14.37至 -3.29）和ICU住院时间（合并平均差异，-3.17天（95%CI，-5.54至 -0.97），而其他研究结局的证据较少。
存在高度混杂风险的观察性证据表明，与TAA开放修复术相比，TEVAR降低了干预后30天内的死亡、截瘫、脊髓缺血和肺部并发症风险。与接受开放修复术的患者相比，接受TEVAR的患者住院时间和ICU住院时间也更短。
