Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA.
Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
Eur J Vasc Endovasc Surg. 2023 Nov;66(5):609-619. doi: 10.1016/j.ejvs.2023.07.004. Epub 2023 Jul 6.
To evaluate outcomes of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in uncomplicated type B aortic dissections (TBAD).
PubMed/MEDLINE, EMBASE, SciELO, LILACS, CENTRAL/CCTR, Google Scholar, and reference lists of relevant articles.
This was a pooled meta-analysis of time to event data extracted from studies published by December 2022 for the following outcomes: all cause mortality, aortic related mortality, and late aortic interventions. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool.
Ten studies met the eligibility criteria (eight observational; two randomised trials), comprising 17 906 patients (2 332 patients in the TEVAR groups and 15 574 patients in the medical therapy group). Compared with patients who received medical therapy, patients who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.79, 95% CI 0.72 - 0.87, p < .001; GRADE certainty: low) and lower risk of aortic related death (HR 0.43, 95% CI 0.30 - 0.62, p < .001; GRADE certainty: low) without statistically significant difference in the risk of late aortic interventions (HR 1.05, 95% CI 0.88 - 1.26, p = .56; GRADE certainty: low). In the subgroup analyses, TEVAR was associated with lower risk of all cause death when randomised controlled trials only were pooled (HR 0.44, 95% CI 0.23 - 0.83, p = .012; GRADE certainty: moderate), younger patients only (HR 0.56, 95% CI 0.47 - 0.67, p < .001; GRADE certainty: low), Western populations only (HR 0.85, 95% CI 0.77 - 0.93, p = .001; GRADE certainty: low) and non-Western populations only (HR 0.47, 95% CI 0.35 - 0.62, p < .001; GRADE certainty: low). For all cause mortality and aortic related mortality, restricted mean survival time was overall 396 days and 398 days longer with TEVAR (p < .001), respectively, which means that TEVAR was associated with lifetime gain.
TEVAR may be associated with better midterm survival and lower risk of aortic related death in the follow up of patients treated for uncomplicated TBAD compared with medical therapy; however, randomised controlled trials with larger sample sizes and longer follow up are still warranted.
评估胸主动脉腔内修复术（TEVAR）与单纯药物治疗在非复杂性 B 型主动脉夹层（TBAD）中的疗效。
PubMed/MEDLINE、EMBASE、SciELO、LILACS、CENTRAL/CCTR、Google Scholar 和相关文章的参考文献列表。
这是一项针对截至 2022 年 12 月发表的研究中时间相关数据的汇总荟萃分析，评估了以下结局：全因死亡率、主动脉相关死亡率和晚期主动脉介入治疗。通过 Grading of Recommendations, Assessment, Development and Evaluations（GRADE）工具评估证据确定性。
符合纳入标准的 10 项研究（8 项观察性研究，2 项随机试验）共纳入 17906 例患者（TEVAR 组 2332 例，药物治疗组 15574 例）。与接受药物治疗的患者相比，接受 TEVAR 的患者全因死亡风险显著降低（HR 0.79，95%CI 0.72-0.87，p<0.001；GRADE 确定性：低），主动脉相关死亡风险显著降低（HR 0.43，95%CI 0.30-0.62，p<0.001；GRADE 确定性：低），但晚期主动脉介入治疗风险无统计学差异（HR 1.05，95%CI 0.88-1.26，p=0.56；GRADE 确定性：低）。亚组分析显示，仅纳入随机对照试验时，TEVAR 与全因死亡风险降低相关（HR 0.44，95%CI 0.23-0.83，p=0.012；GRADE 确定性：中），且仅在年轻患者（HR 0.56，95%CI 0.47-0.67，p<0.001；GRADE 确定性：低）、西方人群（HR 0.85，95%CI 0.77-0.93，p=0.001；GRADE 确定性：低）和非西方人群（HR 0.47，95%CI 0.35-0.62，p<0.001；GRADE 确定性：低）中与全因死亡风险降低相关。对于全因死亡率和主动脉相关死亡率，TEVAR 组的平均生存时间分别延长 396 天和 398 天（p<0.001）。
与单纯药物治疗相比，TEVAR 可能与非复杂性 TBAD 患者的中期生存改善和主动脉相关死亡率降低相关；然而，仍需要更大样本量和更长随访时间的随机对照试验。
