Systematic review and meta-analysis of endovascular interventions for Stanford type A aortic dissection

Simon De Freitas; Matthew J Rossi; Steven D Abramowitz; Javairiah Fatima; Misaki M Kiguchi; Raghuveer Vallabhaneni; Stewart R Walsh; Edward Y Woo

doi:10.1016/j.jvs.2021.01.054

Systematic review and meta-analysis of endovascular interventions for Stanford type A aortic dissection

J Vasc Surg. 2021 Nov;74(5):1721-1731.e4. doi: 10.1016/j.jvs.2021.01.054. Epub 2021 Feb 13.

Authors

Simon De Freitas¹, Matthew J Rossi², Steven D Abramowitz², Javairiah Fatima², Misaki M Kiguchi², Raghuveer Vallabhaneni³, Stewart R Walsh⁴, Edward Y Woo²

Affiliations

¹ MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC. Electronic address: simon.p.defreitas@medstar.net.
² MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC.
³ MedStar Heart and Vascular Institute, MedStar Union Memorial Hospital, Baltimore, Md.
⁴ Lambe Institute for Translational Research, National University of Ireland Galway, Galway, Ireland.

PMID: 33592292
DOI: 10.1016/j.jvs.2021.01.054

Abstract

Objective: The standard surgical approach to Stanford type A aortic dissection is open repair. However, up to one in four patients will be declined surgery because of prohibitive risk. Patients who are treated nonoperatively have an unacceptably high mortality. Endovascular repair of the ascending aorta is emerging as an alternative treatment for a select group of patients. The reported rates of technical success, mortality, stroke, and reintervention have varied. The objective of the study was to systematically report outcomes for acute type A dissections repaired using an endovascular approach.

Methods: The systematic review and meta-analysis was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. We performed online literature database searches through April 2020. The demographic and procedural characteristics of the individual studies were tabulated. Data on technical success, short-term mortality, stroke, and reintervention were extracted and underwent meta-analysis using a random effects model.

Results: Fourteen studies with 80 cases of aortic dissection (55 acute and 25 subacute) were included in the final analysis. A wide variation was found in technique and device design across the studies. The outcomes rates were estimated at 17% (95% confidence interval [CI], 10%-26%) for mortality, 15% (95% CI, 8%-23%) for technical failure, 11% (95% CI, 6%-19%) for stroke and 18% (95% CI, 9%-31%) for reintervention. The mean Downs and Black quality assessment score was 13.9 ± 3.2.

Conclusions: The technique for endovascular repair of type A aortic dissection is feasible and reproducible. The results of our meta-analysis demonstrate an acceptable safety profile for inoperable patients who otherwise would have an extremely poor prognosis. Data from clinical trials are required before the technique can be introduced into routine clinical practice.

Keywords: Aortic dissection; Endovascular; Stanford type A.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Adult
Aged
Aged, 80 and over
Aortic Aneurysm / diagnostic imaging
Aortic Aneurysm / mortality
Aortic Aneurysm / surgery*
Aortic Dissection / diagnostic imaging
Aortic Dissection / mortality
Aortic Dissection / surgery*
Blood Vessel Prosthesis Implantation* / adverse effects
Blood Vessel Prosthesis Implantation* / mortality
Clinical Decision-Making
Endovascular Procedures* / adverse effects
Endovascular Procedures* / mortality
Female
Humans
Male
Middle Aged
Patient Safety
Risk Assessment
Risk Factors
Treatment Outcome