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Thoracic endovascular repair of chronic type B aortic dissection: a systematic review
Michael L Williams1,2,3, Madeleine de Boer4, Bridget Hwang2
1Department of Cardiothoracic Surgery, John Hunter Hospital, Newcastle, Australia.
Insights
Thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection (CTBAD) shows promising safety and low complication rates. However, optimal treatment strategies for CTBAD require further investigation with high-quality clinical trials.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Thoracic Surgery
Background:
- The optimal management for chronic type B aortic dissection (CTBAD) is debated, with ongoing equipoise between medical management, endovascular repair, and open surgery.
- Thoracic endovascular aortic repair (TEVAR) has emerged as a potentially promising treatment option for CTBAD.
- This systematic review aims to analyze existing data on outcomes and survival rates associated with TEVAR in CTBAD patients.
Purpose of the Study:
- To conduct a comprehensive analysis of outcomes and survival rates for thoracic endovascular aortic repair (TEVAR) in patients with chronic type B aortic dissection (CTBAD).
- To evaluate the safety and efficacy of TEVAR as a treatment modality for CTBAD.
Main Methods:
- A systematic literature search was conducted across six databases up to April 2021 to identify studies reporting outcomes for endovascular repair of CTBAD.
- Data on early (<30 days) and late mortality, complications (e.g., retrograde type A dissection, stroke, spinal cord injury), and reintervention rates were extracted.
- A random-effects meta-analysis was performed to aggregate data, and survival data were pooled using Kaplan-Meier curve reconstruction.
Main Results:
- The meta-analysis included 48 studies involving 2,641 patients.
- Early mortality rates were low: 1.6% for all-cause and 0.5% for aortic-related mortality.
- Low incidences of retrograde type A dissection (1.4%), cerebrovascular accidents (1.1%), and spinal cord injury (0.9%) were observed. Late aortic-related mortality was 2.4%, with 1-, 3-, 5-, and 10-year survival rates of 91.5%, 84.7%, 77.7%, and 56.3%, respectively. Reintervention rates were 10.1% for endovascular and 6.7% for surgical approaches.
Conclusions:
- TEVAR for CTBAD appears to be a safe procedure with a low complication profile.
- Significant heterogeneity exists in current evidence, and a lack of standardized reporting hinders definitive conclusions.
- Further high-quality research, including registries and clinical trials, is necessary to establish the optimal treatment strategy for CTBAD.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
