Systematic review and meta-analysis of current evidence in endograft therapy vs medical treatment for uncomplicated type B aortic dissection.

Abstract

Best medical therapy (BMT) should be recommended for treating uncomplicated Stanford type B aortic dissection (uSTBAD), whereas thoracic aortic endovascular repair (TEVAR) has been controversial for uSTBAD. In this paper, a meta-analysis was conducted on all available randomized controlled trials and observational studies that evaluated the relative benefits and harms of TEVAR and BMT for the management of patients suffering from uSTBAD. Primary endpoints consisted of early adverse events, long-term adverse events, and aortic remodeling. In addition, risk differences (RDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. The random-effects model or the fixed-effects model was used in accordance with the 50% heterogeneity threshold. Seven observational studies and two randomized controlled studies from 11 articles that contained 15,066 patients with uSTBAD (1518 TEVARs) met the inclusion criteria. For early outcomes, no significant differences were found between the TEVAR group and the BMT group in aortic rupture, retrograde dissection, paraplegia/paraparesis, reintervention, aorta-related death, and all-cause death. In the long run, the TEVAR group was found to have a significantly lower incidence of adverse events, which included aortic rupture (OR, 0.26; 95% CI, 0.16-0.42; P < .05; heterogeneity: P = .90, I² = 0%), reintervention (OR, 0.45; 95% CI, 0.26-0.75; P < .05; heterogeneity: P = .17, I² = 41%), aorta-related death (OR, 0.27; 95% CI, 0.18-0.42; P < .05; heterogeneity: P = .61, I² = 0%), and all-cause death (OR, 0.52; 95% CI, 0.42-0.66; P < .05; heterogeneity: P = .05, I² = 53%) as compared with the BMT group. Moreover, in compared with BMT, TEVAR was found to significantly contribute to the complete thrombosis of thoracic false lumen (OR, 55.34; 95% CI, 34.32-89.21; P < .05; heterogeneity: P = .97, I² = 0%), and aortic regression (true lumen expansion and false lumen shrinkage). Although early endovascular repair of uSTBAD does not outperform BMT, its implementation is found to be necessary to facilitate the long-term prognosis. Accordingly, if early TEVAR is to be deferred, close follow-up is critical to allow for timely reintervention.