Godeiro Fernandez Miguel, Pimentel-Junior Dilson, Dias-Neto Marina, Ruiter Kanamori Lucas, Baumgardt Barbosa Lima Guilherme, Florêncio de Mesquita Cynthia, Monteiro Mastra Fontoura Milena, Prajiante Bertolino Enrico, Katsargyris Athanasios, Brito Queiroz André, De Luccia Nelson, C Mendes Bernardo, S Oderich Gustavo, Carvajal Mulatti Grace
Department of Medicine, Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil.
Department of Medicine, Universidade Federal Fluminense, Niterói, Brazil.
J Vasc Surg. 2025 Jul;82(1):275-285.e2. doi: 10.1016/j.jvs.2025.01.234. Epub 2025 Mar 5.
We aimed to perform a systematic review and meta-analysis comparing the outcomes of single-stage vs multistaged fenestrated-branched endovascular aortic repair (FB-EVAR) for extensive thoracoabdominal aortic aneurysms (TAAAs).
MEDLINE, Embase, and Cochrane databases were searched from inception to March 2024. This study was registered in PROSPERO (CRD42024567099) and followed the PRISMA guidelines. Inclusion was restricted to original studies comparing single-stage vs multistaged FB-EVAR for reported patients evaluated as extensive TAAAs (Crawford/Safi extent I-III and V). A multistaged approach consisted of aneurysm exclusion besides FB-EVAR using one or more staging strategies, including temporary aneurysm sac perfusion, first stage thoracic endovascular aortic repair, unintentional open surgical or endovascular proximal thoracic aortic repair, and minimally invasive staged segmental artery coil embolization. Endpoints evaluated included permanent and any spinal cord injury (SCI), 30-day or in-hospital mortality, acute kidney injury, cardiac, cerebrovascular, and bowel complications. A random effects meta-analysis was performed using pooled odds ratios (ORs) with 95% confidence intervals (CIs).
Four cohort studies involving 1949 patients treated by elective FB-EVAR were included, including 1097 patients (56.28%) treated by the multistaged approach. The most frequently used staging strategy was thoracic endovascular aortic repair in 404 patients (37%). Multistaged repairs significantly reduced permanent SCI events (OR, 0.37; 95% CI, 0.23-0.58; P < .0001), any SCI events (OR, 0.51; 95% CI, 0.29-0.93; P = .03), and 30-day or in-hospital mortality (OR, 0.57; 95% CI, 0.38-0.85; P = .006). Additionally, the multistaged approach was associated with lower risk of acute kidney injury (OR, 0.67; 95% CI, 0.51-0.89; P = .005), although there were no significant differences observed for cardiac, cerebrovascular, or bowel complications.
Multistaged FB-EVAR for elective extensive TAAA repair significantly reduces the risks of permanent and any SCI events, 30-day or in-hospital mortality, and acute kidney injury.
我们旨在进行一项系统评价和荟萃分析，比较单阶段与多阶段开窗分支型血管腔内主动脉修复术（FB-EVAR）治疗广泛胸腹主动脉瘤（TAAA）的疗效。
检索MEDLINE、Embase和Cochrane数据库，检索时间从建库至2024年3月。本研究已在PROSPERO（CRD42024567099）注册，并遵循PRISMA指南。纳入标准仅限于比较单阶段与多阶段FB-EVAR治疗被评估为广泛TAAA（Crawford/Safi I-III和V型）患者的原始研究。多阶段方法除FB-EVAR外，还包括采用一种或多种分期策略进行动脉瘤排除，这些策略包括临时动脉瘤囊灌注、第一阶段胸段血管腔内主动脉修复、意外开放手术或血管腔内近端胸主动脉修复，以及微创分期节段动脉线圈栓塞。评估的终点包括永久性和任何脊髓损伤（SCI）、30天或住院死亡率、急性肾损伤、心脏、脑血管和肠道并发症。使用合并比值比（OR）和95%置信区间（CI）进行随机效应荟萃分析。
纳入四项队列研究，共1949例接受择期FB-EVAR治疗的患者，其中1097例（56.28%）采用多阶段方法治疗。最常用的分期策略是胸段血管腔内主动脉修复，共404例（37%）。多阶段修复显著降低了永久性SCI事件（OR，0.37；95%CI，0.23-0.58；P<.0001）、任何SCI事件（OR，0.51；95%CI，0.29-0.93；P=.03）以及30天或住院死亡率（OR，0.57；95%CI，0.38-0.85；P=.006）。此外，多阶段方法与急性肾损伤风险较低相关（OR，0.67；95%CI，0.51-0.89；P=.005），尽管在心脏、脑血管或肠道并发症方面未观察到显著差异。
对于择期广泛TAAA修复，多阶段FB-EVAR可显著降低永久性和任何SCI事件、30天或住院死亡率以及急性肾损伤的风险。
