General ReviewOpen versus Endovascular Repair of Descending Thoracic Aortic Aneurysm Disease: A Systematic Review and Meta-analysis
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
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2023, Current Problems in SurgeryCitation Excerpt :Contemporary studies and meta-analyses showed that TEVAR patients tend to have a higher rate of comorbidities, including chronic obstructive pulmonary disease, chronic kidney disease, and peripheral artery disease. The most significant comorbidity seen in these patients is ischemic heart disease, with recent meta-analysis showing a prevalence of 91.3% in TEVAR patients Vs 3.99% of patients undergoing OSR, likely because these patients are particularly unable to tolerate cross-clamping.47 Reports on in-hospital mortality rates have been inconsistent.