Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review

BackgroundCurrently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.MethodsEMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.ResultsThirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7–2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%–9.4%), cardiac complications (0.0%–5.9%) and rupture (0.5%–5.0%). Most common long-term complications after TEVAR were rupture (0.5%–7.1%), endoleaks (0.0%–15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.ConclusionWe found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.研究背景 目前，慢性B型主动脉夹层（chronic type B aortic dissections, CBAD）的最优管理策略仍不明确。为此，本研究对相关文献进行系统综述，以对比开放手术修复（open surgical repair, OSR）、标准胸主动脉腔内修复术（standard thoracic endovascular aortic repair, TEVAR）以及分支型/开窗型胸主动脉腔内修复术（branched and fenestrated TEVAR, BEVAR/FEVAR）用于CBAD的治疗效果。 研究方法 本研究检索了2000年1月至2015年10月间EMBASE与MEDLINE数据库中的符合条件的研究。纳入的研究需针对初始接受药物治疗的CBAD患者，报道OSR、TEVAR、B/FEVAR或上述多种治疗方式的治疗结局。主要结局指标为早期死亡率、1年生存率及5年生存率；次要结局指标包括并发症发生情况。此外，本研究还构建了治疗平衡时间（Time until Treatment Equipoise, TUTE）曲线。 研究结果 本研究共筛选出35篇文献纳入系统综述。最终纳入OSR患者1081例、TEVAR患者1397例以及B/FEVAR患者61例。OSR组的早期死亡率为5.6%~21.0%，TEVAR组为0.0%~13.7%，B/FEVAR组为0.0%~9.7%。OSR组的1年生存率为72.0%~92.0%，5年生存率为53.0%~86.7%；TEVAR组的1年生存率为82.9%~100.0%，5年生存率为70.0%~88.9%；B/FEVAR组仅可获取1年生存率数据，范围为76.4%~100.0%。最常见的术后并发症包括脑卒中（OSR组0.0%~13.3%，TEVAR组0.0%~11.8%）、脊髓缺血（OSR组0.0%~16.4%，TEVAR组0.0%~12.5%，B/FEVAR组0.0%~12.9%）以及急性肾衰竭（OSR组0.0%~33.3%，TEVAR组0.0%~34.4%，B/FEVAR组0.0%~3.2%）。OSR术后最常见的远期并发症为动脉瘤形成（5.8%~20.0%）与新发A型夹层（1.7%~2.2%）。TEVAR术后早期并发症包括逆行夹层（0.0%~7.1%）、灌注不良（1.3%~9.4%）、心脏并发症（0.0%~5.9%）以及主动脉破裂（0.5%~5.0%）；TEVAR术后最常见的远期并发症为主动脉破裂（0.5%~7.1%）、内漏（0.0%~15.8%）与心脏并发症（5.9%~7.1%）。B/FEVAR术后未观察到短期主动脉破裂或灌注不良事件；其远期并发症包括灌注不良（6.5%）与内漏（0.0%~66.7%）。OSR、TEVAR与B/FEVAR组的再次干预率分别为5.8%~29.0%、4.3%~47.4%与0.0%~53.3%。OSR组的TUTE为2.7年，TEVAR组为9.9个月，B/FEVAR组为10.3个月。 研究结论 本研究发现，标准TEVAR用于CBAD的早期生存获益仅略优于OSR。TEVAR术后并发症发生率更高，但OSR术后的并发症通常更为严重。B/FEVAR的初始应用经验证实了其可行性，但仍需长期研究结果以对比其与OSR及标准TEVAR的疗效。综上，CBAD的最优治疗方案仍存在争议，需结合患者个体情况制定决策。TUTE似乎是一种可行且有效的工具，可帮助我们更好地理解CBAD的管理结局。