Williams Michael L, de Boer Madeleine, Hwang Bridget, Wilson Bruce, Brookes John, McNamara Nicholas, Tian David H, Shiraev Timothy, Preventza Ourania
Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.
The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
Ann Cardiothorac Surg. 2022 Jan;11(1):1-15. doi: 10.21037/acs-2021-taes-25.
At present, the optimal management strategy for chronic type B aortic dissection (CTBAD) remains unknown, as equipoise remains regarding medical management versus endovascular treatment versus open surgery. However, the results over recent years of thoracic endovascular aortic repair (TEVAR) in CTBAD appear promising. The aim of this systematic review was to provide a comprehensive analysis of the available data reporting outcomes and survival rates for TEVAR in CTBAD.
Electronic searches of six databases were performed from inception to April 2021. All studies reporting outcomes, specifically 30-day mortality rates, for endovascular repair of CTBAD were identified. Relevant data were extracted, and a random-effects meta-analysis of proportions or means was performed to aggregate the data. Survival data were pooled using data derived from original Kaplan-Meier curves, which allows reconstruction of individual patient data.
Forty-eight studies with 2,641 patients were identified. Early (<30 days) all-cause and aortic-related mortality rates were low at 1.6% and 0.5%, respectively. Incidence of retrograde type A dissection in the post-operative period was only 1.4%. There were also low rates of cerebrovascular accidents and spinal cord injury (1.1% and 0.9%, respectively). Late follow-up all-cause mortality was 8.0%, however, late aortic-related mortality was only 2.4%. Reintervention rates were 10.1% for endovascular and 6.7% for surgical reintervention. Pooled rates of overall survival at 1-, 3-, 5- and 10-year were 91.5%, 84.7%, 77.7% and 56.3%, respectively.
The significant heterogeneity in the available evidence and absence of consensus reporting standards are important considerations and concern when interpreting the data. Evaluation of the evidence suggests that TEVAR for CTBAD is a safe procedure with low rates of complications. However, the optimal treatment strategy for CTBAD remains debatable and requires further research. Evidence from high-quality registries and clinical trials are required to address these challenges.
目前，慢性B型主动脉夹层（CTBAD）的最佳管理策略仍不明确，因为在药物治疗、血管腔内治疗与开放手术之间仍存在平衡。然而，近年来胸主动脉腔内修复术（TEVAR）治疗CTBAD的结果似乎很有前景。本系统评价的目的是对报告CTBAD患者接受TEVAR治疗的结局和生存率的现有数据进行全面分析。
从数据库建立至2021年4月进行了六个数据库的电子检索。确定了所有报告CTBAD血管腔内修复术结局，特别是30天死亡率的研究。提取相关数据，并对比例或均值进行随机效应荟萃分析以汇总数据。生存数据使用源自原始Kaplan-Meier曲线的数据进行汇总，这使得能够重建个体患者数据。
共纳入48项研究，涉及2641例患者。早期（<30天）全因死亡率和主动脉相关死亡率较低，分别为1.6%和0.5%。术后逆行A型夹层的发生率仅为1.4%。脑血管意外和脊髓损伤的发生率也较低（分别为1.1%和0.9%）。晚期随访全因死亡率为8.0%，然而，晚期主动脉相关死亡率仅为2.4%。血管腔内再次干预率为10.1%，手术再次干预率为6.7%。1年、3年、5年和10年的总生存率合并率分别为91.5%、84.7%、77.7%和56.3%。
现有证据存在显著异质性且缺乏统一的报告标准，这在解释数据时是重要的考虑因素和关注点。对证据的评估表明，TEVAR治疗CTBAD是一种安全的手术，并发症发生率较低。然而，CTBAD的最佳治疗策略仍存在争议，需要进一步研究。需要高质量注册研究和临床试验的证据来应对这些挑战。
