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. 2012 Nov 14;11(11):CD006512.
doi: 10.1002/14651858.CD006512.pub2.

Endovascular versus conventional medical treatment for uncomplicated chronic type B aortic dissection

Pinar Ulug  1 , James E McCaslin, Gerard Stansby, Janet T Powell
Affiliations

Endovascular versus conventional medical treatment for uncomplicated chronic type B aortic dissection

Pinar Ulug et al. Cochrane Database Syst Rev. .

Abstract

Background: Aortic dissection is a potentially life-threatening condition that occurs when a tear forms in the inner lining of the aorta. It has traditionally been treated by blood pressure control (medical treatment) or open surgery, both with high mortality rates. More recently stent-graft repair has been suggested as an alternative.

Objectives: To identify the best management for uncomplicated (without rupture of the organs or malperfusion of the extremities) subacute or chronic type B aortic dissection.

Search methods: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched May 2012) and CENTRAL (2012, Issue 4). Clinical trials databases were searched for ongoing or unpublished studies.

Selection criteria: All randomised controlled trials designed to compare the outcome of uncomplicated (without rupture of the organs or malperfusion of the extremities) chronic (occurring more than two weeks previously) type B aortic dissection when treated by stenting adjunctive to best medical treatment versus best medical treatment alone were included.

Data collection and analysis: Data on all cause and aorta-related mortality at two years was collected and analysed. In addition, secondary outcome measures were analysed, including morbidity, complications (additional endovascular or open surgery for rupture, expansion or malperfusion) and quality of life.

Main results: A single trial was identified that fulfilled the inclusion criteria (INSTEAD trial). The two-year all cause survival was not statistically significantly different between study groups (95.6% ± 2.5% in the optimised medical therapy (OMT) group and 88.9% ± 3.7% in the thoracic endovascular aneurysm repair (TEVAR) + OMT group; log rank test P = 0.15).

Authors' conclusions: Overall, the data at two years were insufficient to make any practice recommendations. However, the data on the anatomic remodeling of dissected aortas observed after TEVAR + OMT is encouraging and future studies should follow up cases for at least five years to see if early endovascular interventions, even in stable initially uncomplicated type B patients, are of long-term benefit.

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Conflict of interest statement

None known

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 1 Optimal medical treatment + TEVAR versus optimal medical treatment, outcome: 1.1 All cause mortality within 2 years of randomisation.
4
4
Forest plot of comparison: 1 Optimal medical treatment + TEVAR versus optimal medical treatment, outcome: 1.2 Aorta‐related deaths within 2 years of randomisation.
1.1
1.1. Analysis
Comparison 1 Optimal medical treatment + TEVAR versus optimal medical treatment, Outcome 1 All cause mortality within 2 years of randomisation.
1.2
1.2. Analysis
Comparison 1 Optimal medical treatment + TEVAR versus optimal medical treatment, Outcome 2 Aorta‐related deaths within 2 years of randomisation.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD006512

References

References to studies included in this review

INSTEAD trial {published data only}
    1. Dake MD. The significance of INSTEAD. http://bibamed.agcl.com/cx_2007/Sun%201635%20Dake.pdf. 2007.
    1. Nienaber C. More Vascular and Endovascular Controversies, Charing Cross 28th International Symposium; 2006 Apr 8‐11; London. 2006.
    1. Nienaber C. INSTEAD Trial ‐ 3 month data. http://bibamed.agcl.com/cx_2006/Sun1615Nienaber.pdf. 2006.
    1. Nienaber C. Type B aortic dissection ‐ Intervention vs. best medical treatment. Vascular News 2006;Educational Supplement (VN32):2‐3.
    1. Nienaber CA. INSTEAD Trial: INvestigation of STEnt Grafts in Patients With Type B Aortic Dissection. http://clinicaltrials.gov/ct2/show/NCT00525356?term=aortic+dissection&am... 2007.

References to studies excluded from this review

ADSORB trial {published data only}
    1. Anon. A European Study on Medical Management Versus TAG Device + Medical Management for Acute Uncomplicated Type B Dissection (ADSORB). http://clinicaltrials.gov/ct2/show/NCT00742274?term=aortic+dissection&am... 2008.
    1. Brunkwall J, Lammer J, Verhoeven E, Taylor P. ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta. European Journal of Vascular and Endovascular Surgery 2012;44(1):31‐6. - PubMed
Chemelli‐Steingruber 2010 {published data only}
    1. Chemelli‐Steingruber I, Chemelli A, Strasak A, Hugl B, Hiemetzberger R, Jaschke W, et al. Endovascular repair or medical treatment of acute type B aortic dissection? A comparison. European Journal of Radiology 2010;73(1):175‐80. - PubMed
Duda 2002 {published data only}
    1. Duda SH, Pusich B, Raygrotzki S, Uckmann FP, Aebert H, Tepe G, et al. Endovascular implantation of stent‐grafts in the thoracic aorta ‐mid‐term results of a prospective controlled study [Endovaskuläre Implantation von Stent‐Grafts in die Aorta thoracica ‐ Mittelfristige Ergebnisse einer prospektiven kontrollierten Studie]. Rofo 2002;174(4):485‐9. - PubMed

References to ongoing studies

NCT01354119 {unpublished data only}
    1. Jong‐Min Song. Long‐term Benefit of Aortic Stent‐graft in Patients With Distal Aortic Dissection. http://clinicaltrials.gov/ct2/show/NCT01354119?term=stent+and+aneurysm+a... 2011. [Other: NCT01354119].

Additional references

Bernard 2001
    1. Bernard Y, Zimmermann H, Chocron S, Litzler JF, Kastler B, Etievent JP, et al. False lumen patency as a predictor of late outcome in aortic dissection. American Journal of Cardiology 2001;87(12):1378–82. - PubMed
DeBakey 2006
    1. Bakey ME. Aortic Dissection: DeBakey classification. http://www.learningradiology.com/notes/chestnotes/aorticdissection.htm (accessed 26 September 2006).
Eggebrecht 2006
    1. Eggebrecht H, Nienaber CA, Neuhäuser M, Baumgart D, Kische S, Schmermund A, et al. Endovascular stent‐graft placement in aortic dissection: a meta‐analysis. European Heart Journal 2006;27(4):489–98. - PubMed
Erbel 1993
    1. Erbel R, Oelert H, Meyer J, Puth M, Mohr‐Katoly S, Hausmann D, et al. Effect of medical and surgical therapy on aortic dissection evaluated by transesophageal echocardiography. Implications for prognosis and therapy. The European Cooperative Study Group on Echocardiography. Circulation 1993;87(5):1604–15. - PubMed
Higgins 2011
    1. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.
Kwolek 2009
    1. Kwolek CJ, Watkins MT. The INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial: the need for ongoing analysis. Circulation 2009;120(25):2513‐4. - PubMed
Nienaber 1999
    1. Nienaber CA, Fattori R, Lund G, Dieckmann C, Wolf W, Kodolitsch Y, et al. Nonsurgical reconstruction of thoracic aortic dissection by stent‐graft placement. New England Journal of Medicine 1999;340(20):1539‐45. - PubMed
Nienaber 2005
    1. Nienaber CA, Zannetti S, Barbieri B, Kische S, Schareck W, Rehders TC, on behalf of the INSTEAD study collaborators. INvestigation of STEnt grafts in patients with type B Aortic Dissection: design of the INSTEAD trial ‐ a prospective, multicenter, European randomized trial. American Heart Journal 2005;149(4):592‐9. - PubMed
Nienaber 2009
    1. Nienaber CA, Rousseau H, Eggebrecht H, Kische S, Fattori R, Rehders TC, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009;120(25):2519‐28. - PubMed
Nienaber 2011
    1. Nienaber CA. Influence and critique of the INSTEAD Trial (TEVAR versus medical treatment for uncomplicated type B aortic dissection). Seminars in Vascular Surgery 2011;24(3):167‐71. - PubMed
RevMan 2011 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.. Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.
Shu 2011
    1. Shu C, He H, Li QM, Li M, Jiang XH, Luo MY. Endovascular repair of complicated acute type‐B aortic dissection with stent graft: early and mid‐term results. European Journal of Vascular and Endovascular Surgery 2011;42(4):448‐53. - PubMed
Stanford 2006
    1. Stanford W. Aortic Dissection: Stanford classification. http://www.learningradiology.com/notes/chestnotes/aorticdissection.htm (accessed 26 September 2006).
Steuer 2011
    1. Steuer J, Eriksson MO, Nyman R, Björck M, Wanhainen A. Early and long‐term outcome after thoracic endovascular aortic repair (TEVAR) for acute complicated type B aortic dissection. European Journal of Vascular and Endovascular Surgery 2011;41(3):318‐23. - PubMed
Thrumurthy 2011
    1. Thrumurthy SG, Karthikesalingam A, Patterson BO, Holt PJ, Hinchliffe RJ, Loftus IM, et al. A systematic review of mid‐term outcomes of thoracic endovascular repair (TEVAR) of chronic type B aortic dissection [Review]. European Journal of Vascular and Endovascular Surgery 2011;42(5):632‐47. - PubMed
Tsai 2006
    1. Tsai TT, Fattori R, Trimarchi S, Isselbacher E, Myrmel T, Evangelista A, et al. Long‐term survival in patients presenting with type B acute aortic dissection: insights from International Registry of Acute Aortic Dissection. Circulation 2006;114(21):2226‐31. - PubMed
White 2011
    1. White RA, Miller DC, Criado FJ, Dake MD, Diethrich EB, Greenberg RK, et al. Report on the results of thoracic endovascular aortic repair for acute, complicated, type B aortic dissection at 30 days and 1 year from a multidisciplinary subcommittee of the Society for Vascular Surgery Outcomes Committee. Journal of Vascular Surgery 2011;53(4):1082‐90. - PubMed

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