Management of complicated and uncomplicated acute type B dissection. A systematic review and meta-analysis

Abstract

Background: The management of acute type B dissection represents a clinical challenge. We undertook a systematic review of the available literature regarding medical, surgical and endovascular treatments of acute type B aortic dissection and combined the eligible studies into a meta-analysis.

Methods: An extensive electronic health database search was performed on all articles published from January 2006 up to November 2013 describing the management of acute type B aortic dissection. Studies including less than 15 patients were excluded.

Results: ACUTE COMPLICATED TYPE B DISSECTION: overall, 2,531 patients were treated with endovascular repair (TEVAR) and the pooled rate for 30-day/in-hospital mortality was 7.3%. The pooled estimates for cerebrovascular events, spinal cord ischemia (SCI) and total neurologic events were 3.9%, 3.1% and 7.3%, respectively. A total of 1,276 patients underwent open surgical repair and the pooled rate for 30-day/in-hospital mortality was 19.0%. The pooled rate for cerebrovascular events was 6.8%, for SCI 3.3% and for total neurologic complications 9.8%. Acute uncomplicated type B dissection: outcome of 2,347 patients who underwent conservative medical management were analyzed. The pooled 30-day/in-hospital mortality rate was 2.4%. The pooled rate for cerebrovascular events was 1%, for SCI 0.8% and for overall neurologic complications 2%.

Conclusions: Endovascular repair provides a superior 30-day/in-hospital survival for acute complicated type B aortic dissection compared to surgical aortic reconstruction. However, open repair still has a significant role as endovascular repair is not applicable in all patients and there remains concerns regarding the durability of this technique. TEVAR seems to have a more favorable outcome regarding aortic remodeling and the aortic-specific survival rate when compared with medical therapy alone. Randomized controlled trials focusing on the prognostic factors of early and late complications in uncomplicated type B dissections are needed.

Keywords: Type B aortic dissection; acute; endovascular; medical treatment.

Figure 1

Study flow chart. TEVAR, treated with thoracic endovascular aortic repair; BMT, best medical treatment.

Figure 2

(A) Proportion meta-analysis plot (random effects) of 30-day/in-hospital mortality in endovascular treatment for acute complicated type B dissection. [Pooled proportion, 0.073 (95% CI, 0.053 to 0.096), I², 69.3% (95% CI, 53.4% to 78.1%)]; (B) Forest plot of cerebrovascular events in endovascular treatment for acute complicated type B dissection. Data were available from 25 studies [pooled proportion, 0.039, (95% CI, 0.032 to 0.048), I², 30% (95% CI, 0% to 56.4%)]; (C) Proportion meta-analysis plot (random effects) of spinal cord ischemia in endovascular treatment for acute complicated type B dissection. Data were available from 27 studies [pooled proportion, 0.031, (95% CI, 0.02 to 0.044), I², 46.3% (95% CI, 6.1% to 64.9%)]; (D) Proportion meta-analysis plot (random effects) of total neurological events in endovascular treatment for acute complicated type B dissection. Data were available from 25 studies [pooled proportion, 0.073, (95% CI, 0.052 to 0.097), I², 65.8% (95% CI, 44.1% to 76.6%)].

Figure 3

(A) Proportion meta-analysis plot (fixed effects) of 30-day/in-hospital mortality after open surgery for complicated acute type B dissection. [Pooled proportion, 0.19 (95% CI, 0.168 to 0.211), I², 43.6% (95% CI, 0% to 72.4%)]; (B) Proportion meta-analysis plot (fixed effects) of cerebrovascular events after open surgery for complicated acute type B dissection. [Available data in nine studies, pooled proportion, 0.068 (95% CI, 0.054 to 0.082), I², 52% (95% CI, 0% to 77.7%)]; (C) Proportion meta-analysis plot (fixed effects) of spinal cord ischemia after open surgery for complicated acute type B dissection. [Available data in nine studies, pooled proportion, 0.033 (95% CI, 0.024 to 0.044), I², 39.7% (95% CI, 0% to 73.3%)]; (D) Proportion meta-analysis plot (fixed effects) of total neurologic events after open surgery for complicated acute type B dissection. Available data in nine studies, [pooled proportion, 0.098 (95% CI, 0.082 to 0.115), I², 39.4% (95% CI, 0% to 74.8%)].

Figure 4

(A) Proportion meta-analysis plot (random effects) of 30-day/in-hospital mortality after best medical management for uncomplicated acute type B dissection. [Pooled proportion, 0.024 (95% CI, 0.009 to 0.046), I², 85.9% (95% CI, 78.3% to 90%)]; (B) Proportion meta-analysis plot (fixed effects) of cerebrovascular events after best medical management for uncomplicated acute type B dissection. [Available data in eight studies, pooled proportion, 0.01 (95% CI, 0.006 to 0.016), I², 0% (95% CI, 0% to 56.3%)]; (C) Proportion meta-analysis plot (fixed effects) of spinal cord ischemia after best medical management for uncomplicated acute type B dissection. [Available data in nine studies, pooled proportion, 0.008 (95% CI, 0.005 to 0.013), I², 0% (95% CI, 0% to 54.4%)]; (D) Proportion meta-analysis plot (random effects) of total neurological events after best medical management for uncomplicated acute type B dissection. [Available data in nine studies, pooled proportion, 0.02 (95% CI, 0.006 to 0.041), I², 79.1% (95% CI, 56.2% to 87.5%)].