Elsevier

Annals of Vascular Surgery

Volume 54, January 2019, Pages 304-315.e5
Annals of Vascular Surgery

General Review
Open versus Endovascular Repair of Descending Thoracic Aortic Aneurysm Disease: A Systematic Review and Meta-analysis

This abstract has been presented as a poster (presentation on demand) at AATS aortic symposium, April 26–27, 2018, New York, USA.
https://doi.org/10.1016/j.avsg.2018.05.043Get rights and content

Background

The purpose of this study was to determine whether thoracic endovascular aortic repair reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease.

Methods

A comprehensive search was undertaken among the 4 major databases (PubMed, Embase, Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing open versus endovascular repair in thoracic aortic aneurysm. Databases where evaluated and assessed to July 2017. Odds ratios, weighted mean differences, or standardized mean differences and their 95% confidence intervals were analyzed.

Results

A total of 14,580 patients were analyzed in total of 13 articles, which were included in the synthesis of the meta-analysis. A total of 10,672 patients had open repair, and 3,908 patients had endovascular repair. Patients undergoing open repair were younger (mean of 65.1 years vs. 70.0 years, P = 0.0009), and there was higher elective rate in open repair patient (83.4% vs. 81%, P = 0.36). Duration of intensive care and total hospital stay was much shorter in endovascular patients (4.5 vs. 8.5 days, P = 0.002 and 5.7 vs. 9.5 days, P = 0.0004). Postoperative stroke was similar in both groups (P = 0.58); however, higher rate of paraplegia noted in open repair group (P = 0.007). The rate of renal failure (P = 0.01) and cardiac complications (P < 0.0001) was higher in the open repair group. The rate of vascular complications was much higher in the endovascular group of patients (5.29% vs. 1.17%, P = 0.002). Operative mortality was higher in endovascular procedures (4.4% vs. 3.2%, P = 0.005); however, 1- and 5-year mortality showed no statistical difference between the endovascular and open repair groups (22.19%, vs. 24.04%, P = 0.59, and 44.26% vs. 37.37%, P = 0.49).

Conclusions

The present meta-analysis shows that endovascular repair of thoracic aortic aneurysm gives better perioperative outcomes during inhospital stay although the 1- and 5-year mortality remains the same in both groups; but the long-term outcome is yet to be established. A long-term data and studies are required to give a better understanding of comparing these 2 techniques beyond 5 years of follow-up.

Introduction

The prevalence of thoracic aortic diseases, comprising mainly of aneurysm, dissection, and eventually rupture if not recognized and treated appropriately, are increasing among our population. To date, thoracic aortic aneurysm is estimated to affect more than 10 of every 100,000 population,1, 2 of which 30–40% are of the descending thoracic aneurysm (DTA) type.1, 3 Such increase in recording is mainly contributable to the early recognition of asymptomatic aneurysm with improved imaging technology, including computerized tomography, magnetic resonance imaging, and cardiac ultrasound.2, 3

Treatment of such diseases were mainly focused to open surgical repair as gold standard method for the last 50 years ever since the successful open repair of thoracic aortic aneurysm with prosthetic graft by De Bakey and Cooley,4 especially in the acute aortic dissection and rupture cases.5, 6 Such open repair carries high risks of morbidity in terms of spinal cord ischemia and eventually paraplegia and related mortality.7, 8 To minimize such risks of morbidity and perhaps reduce mortality, in mid-1990s, endovascular repair was first used for repairing thoracic aneurysm, as practiced by Dake et al.9 Such alternate method of thoracic endovascular aortic repair (TEVAR) was sought to provide better clinical outcomes in patients who deemed high risk for open repair or typically called nonsurgical candidates.

Since then, there has been a continuous debate for the use, efficacy, and complication rates of TEVAR compared with open repair. The key figures that are leading this comparison are mortality, paraplegia rates, and other complications.10, 11 Despite growing studies comparing the management strategies, there have been many limitations to current evidences, most of which are retrospective studies from single centers.

TEAVR was not deployed extensively until the recent decade.12, 13 Technology has been improving rapidly, such that a more stable and consistent performance has become available. Existing meta-analyses were limited and conducted considerably a long time ago, thus insufficient to take into account the most up-to-date studies and as such there are no long-term results in such studies.14 Therefore, they are suboptimal in evaluating the efficacy of endovascular repair in relation to open surgical repair.

Contrastingly, in recent years, open surgical repair has seen improvements in operative strategies to aid in improving morbidities and mortality rate. This came through advanced organ preservation and the use of neuroprotective methods15 that dramatically reduced complication rates.16 Our study aims at delivering up-to-date longitudinal evidence from comparative trials on whether TEVAR reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease management.

Section snippets

Search Strategy

The primary aim of this systematic review and meta-analysis was to compare the outcomes of open versus endovascular repair in patients with descending thoracic aortic aneurysm. A literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and recommended guidelines.17, 18 Electronic search was performed utilizing 4 major databases, PubMed, Ovid, SCOPUS, and Embase from inception to July 2017. To obtain maximum relevant output from

Included Studies and Patients

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement flowchart describes the process of the literature screening, study selection, and reasons for exclusion (Fig. 1). The initial search result showed 2621 articles, of which 135 were retrieved to assess in full-text. Eventually, results from 13 studies were eligible and were included in both qualitative and quantitative meta-analysis.

Study Characteristics

The study characteristics are summarized in Supplementary Table I.20, 21, 22, 23, 24,

Discussion

This meta-analysis of studies comparing the outcomes of TEVAR and open surgical repair in descending aortic disease provided a comprehensive summary and analysis of the up-to-date evidences that compared the outcome of the 2 methods. A total of 14,580 patients demonstrated that patients receiving open surgery were of a younger age (mean age 65.1 versus 70 years, P = 0.009). The patients receiving TEVAR had generally higher burden of comorbidities, including a higher rate of ischemic heart

References (37)

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