MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
J Vasc Surg. 2021 Nov;74(5):1721-1731.e4. doi: 10.1016/j.jvs.2021.01.054. Epub 2021 Feb 13.
The standard surgical approach to Stanford type A aortic dissection is open repair. However, up to one in four patients will be declined surgery because of prohibitive risk. Patients who are treated nonoperatively have an unacceptably high mortality. Endovascular repair of the ascending aorta is emerging as an alternative treatment for a select group of patients. The reported rates of technical success, mortality, stroke, and reintervention have varied. The objective of the study was to systematically report outcomes for acute type A dissections repaired using an endovascular approach.
The systematic review and meta-analysis was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. We performed online literature database searches through April 2020. The demographic and procedural characteristics of the individual studies were tabulated. Data on technical success, short-term mortality, stroke, and reintervention were extracted and underwent meta-analysis using a random effects model.
Fourteen studies with 80 cases of aortic dissection (55 acute and 25 subacute) were included in the final analysis. A wide variation was found in technique and device design across the studies. The outcomes rates were estimated at 17% (95% confidence interval [CI], 10%-26%) for mortality, 15% (95% CI, 8%-23%) for technical failure, 11% (95% CI, 6%-19%) for stroke and 18% (95% CI, 9%-31%) for reintervention. The mean Downs and Black quality assessment score was 13.9 ± 3.2.
The technique for endovascular repair of type A aortic dissection is feasible and reproducible. The results of our meta-analysis demonstrate an acceptable safety profile for inoperable patients who otherwise would have an extremely poor prognosis. Data from clinical trials are required before the technique can be introduced into routine clinical practice.
斯坦福 A 型主动脉夹层的标准手术方法是开放修复。然而，多达四分之一的患者因手术风险过高而被拒绝手术。未经手术治疗的患者死亡率极高。升主动脉血管内修复术正在成为一类特定患者的替代治疗方法。报告的技术成功率、死亡率、中风和再次干预率各不相同。本研究的目的是系统地报告采用血管内方法修复急性 A 型夹层的结果。
本系统评价和荟萃分析符合 PRISMA（系统评价和荟萃分析的首选报告项目）指南。我们通过在线文献数据库搜索，截至 2020 年 4 月进行了搜索。将各个研究的人口统计学和程序特征制成表格。提取技术成功率、短期死亡率、中风和再次干预的数据，并使用随机效应模型进行荟萃分析。
最终分析纳入了 14 项研究的 80 例主动脉夹层病例（55 例急性，25 例亚急性）。研究之间的技术和器械设计存在很大差异。死亡率估计为 17%（95%置信区间[CI]，10%-26%），技术失败率为 15%（95% CI，8%-23%），中风发生率为 11%（95% CI，6%-19%），再次干预率为 18%（95% CI，9%-31%）。平均唐斯和布莱克质量评估得分为 13.9±3.2。
血管内修复 A 型主动脉夹层的技术是可行和可重复的。我们的荟萃分析结果表明，对于否则预后极差的手术禁忌患者，该技术具有可接受的安全性。在该技术引入常规临床实践之前，需要来自临床试验的数据。
