Elsevier

Journal of Vascular Surgery

Volume 53, Issue 1, January 2011, Pages 193-199.e21
Journal of Vascular Surgery

Society for Vascular Surgery® document
Comparative effectiveness of the treatments for thoracic aortic transaction

Presented at the 2010 Vascular Annual Meeting of the Society for Vascular Surgery, June 10-13, 2010, Boston, Mass.
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Objectives

To synthesize the available evidence regarding the outcomes associated with nonoperative management, open repair, and endovascular repair of thoracic aortic transection.

Methods

We searched electronic databases (MEDLINE, EMBASE Cochrane, Web of Science, and Scopus) for studies that enrolled patients with aortic transection and measured the outcomes of interest. Two reviewers determined study eligibility and extracted data. We estimated the event rate associated with the different approaches from case series and the relative risk from comparative studies. Estimates from each study were pooled using the random effects model.

Results

We found 139 studies that fulfilled the inclusion criteria, the majority of which were noncomparative surgical case series, retrospective, and none were randomized. Studies included 7768 patients, the majority of which were males. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair and nonoperative management (9%, 19%, and 46%, respectively, P < .01). No significant difference in event rate across the three groups was noted for the outcomes of anterior stroke, posterior stroke, or any stroke. The risk of spinal cord ischemia and end-stage renal disease were higher in open repair compared with the other 2 groups (9% vs 3% and 3%, P = .01 for spinal cord ischemia and 8% vs 5% and 3%, P = .01 for end-stage renal disease). Compared with endovascular repair, open repair was associated with an increased risk of graft infection and systemic infections. Meta-analyses of comparative studies demonstrated that compared with open repair, endovascular repair is associated with reduced mortality and spinal cord ischemia (relative risk, 0.61; 95% confidence interval, 0.46-0.80; and relative risk, 0.34; 95% confidence interval, 0.16-0.74; respectively). Inferences are limited by methodological quality, survival, and publication biases.

Conclusions

Very low-quality evidence suggests that, compared with open repair or nonoperative management, endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, and graft and systemic infections. Nonoperative management is associated with the least favorable outcomes.

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Supported by the Society for Vascular Surgery.

Competition on interest: Dr Lee received research support and consultation fees from Cook, Medtronic, and Bolton Medical. Dr Fairman received research support from Abbott, Medtronic, Cook, Aptus, and Boston Scientific.

Additional material for this article may be found online at www.jvascsurg.org.

Independent peer-review and oversight has been provided by members of the SVS Document Oversight Committee (K. Wayne Johnston, MD (chair), Enrico Ascher, MD, Jack L. Cronenwett, MD, R. Clement Darling, MD, Vivian Gahtan, MD, Peter Gloviczki, MD, Thomas F. Lindsay, MD, Gregorio A. Sicard, MD).