Open surgical repair for chronic type B aortic dissection: a systematic review

Abstract

Background: The treatment of chronic type B aortic dissection (CBAD) remains complicated. Thoracic endovascular aortic repair (TEVAR) has supplanted open surgical repair (OSR) as the preferred surgical treatment for CBAD. Despite TEVAR's superior short-term results, much less is understood about its long-term outcomes. As much of the understanding of OSR originates from historical report, contemporary series, with modern surgical techniques and technologies, may present an alternative to TEVAR. The present systematic review will assess the short- and long-term outcomes of historic and contemporary series of OSR for CBAD.

Methods: Electronic searches were performed using six databases from their inception to March 2014. Relevant studies with OSRs for chronic type B dissection were identified. Data were extracted by two independent reviewers and analyzed according to predefined clinical endpoints. Studies were sub-classified into the pre-endovascular (historic series) and endovascular era (contemporary series) depending on whether the majority of cases were performed after 1999.

Results: Nineteen studies were identified for inclusion for quantitative analysis. Pooled short-term mortality was 11.1% overall, and 7.5% in the nine contemporary studies. Stroke, spinal cord ischemia, renal dysfunction, and reoperation for bleeding were 5.9%, 4.9%, 8.1%, and 8.1%, respectively, for the contemporary series. Absolute late reintervention was identified in 13.3% of patients overall, and in 11.3% of patients in the contemporary series. Aggregated survival at 1-, 3-, 5-, and 10-years of all patients were 82.1%, 74.1%, 66.3%, and 50.8%, respectively.

Conclusions: OSR for chronic type B dissection in the contemporary era offers acceptable results. Management approaches should be considered carefully, taking into account both short-term and long-term complications. More research is required to clarify specific indications for OSR and TEVAR in chronic type B dissections.

Keywords: Open surgical repair (OSR); chronic type B dissection; descending aorta; thoracic endovascular aortic repair (TEVAR).

Figure 1

Overall survival based on reconstructed individual patient data. Data of 458 patients from seven studies were reconstructed and presented. Dotted lines represents Kaplan-Meier curves of individual studies, while the solid line represents aggregate reconstructed survival data of the entire cohort.

Figure S1

Search strategy of systematic review on open surgical repair for chronic type B aortic dissection. CBAD, chronic type B aortic dissection.

Figure S2

Funnel plot for systematic review of open surgical repair for chronic type B dissection in all 19 included studies. The logit event rate for mortality (horizontal axis) is presented against the standard error (SE) of the log of logit event rate (vertical axis). The SE inversely corresponds to the study size. Asymmetry of the plot can indicate publication bias. Open circles indicate included studies, while the filed circles represent imputed studies identified through Trim and Fill analysis.