Rossi Matthew J, Ilyas Sadia, Abramowitz Steven D, De Freitas Simon, Hockstein Maxwell A, Maloni Krystal C, Shults Christian, Fatima Javairiah
Vascular Surgery Integrated Residency Program, MedStar Health, Washington, DC, USA.
Department of Vascular Surgery, MedStar Washington Hospital Center, Washington, DC, USA.
J Endovasc Ther. 2024 Aug 15:15266028241271679. doi: 10.1177/15266028241271679.
The present standard of care to treat aortic arch pathologies is open surgical repair with cardiopulmonary bypass and deep hypothermic arrest. With approaches for total endovascular and extra-anatomic cervical debranching hybrid arch repair becoming more diverse, understanding what is considered a successful operation is prerequisite for a rigorous comparison of techniques. This review describes the specific outcomes reported, the rates of success, and the definitions of technical and clinical success in total endovascular and extra-anatomic cervical debranching hybrid aortic arch repair.
A comprehensive search of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was performed. Studies with patients undergoing total endovascular or hybrid extra-anatomic cervical debranching repair of the aortic arch were included. Any publications including only patients with Ishimaru zone 2 or distal repairs were excluded from this review. Studies with less than 5 patients were excluded. Data extraction was performed by one author. Data items included were study design, procedure type, procedural details, underlying pathology, type of cervical debranching, type of endograft repair, surgical outcomes, definition of cerebrovascular events, technical success, and the definition of technical success.
Of 1754 studies screened for review, 85 studies with 5521 patients were included. By frequency, the included studies examined the following interventions: fenestrated devices, branched devices, parallel grafting. Most studies were retrospective single-institution studies. There were no randomized controlled trials. Short-term mortality and cerebrovascular events were nearly universally reported, present in 99% and 95% of studies reviewed, respectively. Only 27% of studies provided an explicit definition for cerebrovascular events. While 75% of studies reported a technical success rate, only 45% of those studies provided explicit criteria. Clinical success rates were infrequently reported, present in only 5.9% of studies reviewed.
The definitions of technical success that were provided fell short of analogous defined reporting standards in nearly all studies, inflating technical success rates. Definitions of cerebrovascular events and technical success require stringent criteria to uniformly compare various methods of endovascular aortic arch repair. A societal consensus document for reporting standards of endovascular aortic arch repair would allow for higher-quality outcomes research.
Total endovascular and extra-anatomic cervical debranching hybrid operations are being increasingly utilized for complex aortic arch repair. These techniques, however, can be associated with serious complications. Currently, there is no accepted metric to define technical or report clinical outcomes. Due to the paucity of high-quality data, use of these approaches may be limited in clinical practice. This study emphasizes the need for the development of standards for reporting outcomes in endovascular aortic arch repair. Future studies can then utilize these benchmarks, whcih will allow for improved efficacy and safety in these techniques.
目前治疗主动脉弓病变的标准治疗方法是在体外循环和深低温停循环下进行开放手术修复。随着全腔内和解剖外颈部去分支杂交弓修复方法越来越多样化，了解什么被认为是成功的手术是严格比较技术的先决条件。本综述描述了全腔内和解剖外颈部去分支杂交主动脉弓修复中报告的具体结果、成功率以及技术和临床成功的定义。
对MEDLINE、Embase和Cochrane对照试验中央登记册进行了全面检索。纳入了对接受主动脉弓全腔内或杂交解剖外颈部去分支修复的患者进行的研究。本综述排除了仅包括Ishimaru 2区或远端修复患者的任何出版物。排除患者少于5例的研究。由一位作者进行数据提取。纳入的数据项目包括研究设计、手术类型、手术细节、基础病理、颈部去分支类型、腔内修复类型、手术结果、脑血管事件的定义、技术成功以及技术成功的定义。
在筛选用于综述的1754项研究中，纳入了85项研究，共5521例患者。按频率计算，纳入的研究检查了以下干预措施：开窗装置、分支装置、平行移植。大多数研究是回顾性单机构研究。没有随机对照试验。几乎所有研究都报告了短期死亡率和脑血管事件，分别在99%和95%的综述研究中出现。只有27%的研究为脑血管事件提供了明确的定义。虽然75%的研究报告了技术成功率，但其中只有45%的研究提供了明确的标准。临床成功率很少被报告，仅在5.9%的综述研究中出现。
几乎所有研究中提供的技术成功定义都未达到类似的定义报告标准，从而夸大了技术成功率。脑血管事件和技术成功的定义需要严格的标准，以便统一比较各种腔内主动脉弓修复方法。一份关于腔内主动脉弓修复报告标准的社会共识文件将有助于开展更高质量的结局研究。
全腔内和解剖外颈部去分支杂交手术越来越多地用于复杂主动脉弓修复。然而，这些技术可能会伴有严重并发症。目前，尚无公认的指标来定义技术或报告临床结果。由于高质量数据匮乏，这些方法在临床实践中的应用可能受到限制。本研究强调了制定腔内主动脉弓修复结局报告标准的必要性。未来的研究可以利用这些基准，从而提高这些技术的疗效和安全性。
