Proximal aortic repair versus extensive aortic repair in the treatment of acute type A aortic dissection: a meta-analysis.

OBJECTIVES The optimal surgical strategy for acute type A aortic dissection (ATAAD) is still controversial because of the inconsistent or even conflicting results of proximal aortic repair (PR) versus extensive aortic repair (ER) on early and late prognostic outcomes. This meta-analysis pooled data from all available studies of PR versus ER to get a summarized conclusion. METHODS Studies were identified by searching the Medline, EMBASE and Cochrane databases. Early and late prognostic outcomes of interest were evaluated with meta-analysis. Fixed- or random-effect models were used according to the significance of heterogeneity. Robustness of pooled estimates and the source of heterogeneity were assessed via sensitivity analyses and meta-regression, respectively. Publication bias was evaluated by the funnel plot and Egger's test. RESULTS Nine studies with a total of 1872 patients were included for the meta-analysis. Pooled results indicated that, when compared with the ER procedure, PR was associated with lower early mortality [risk ratio (RR) = 0.69, 95% confidence interval (CI) 0.54-0.90, P = 0.005] but higher incidence of postoperative aortic events including reoperation of the distal aorta (RR = 3.14, 95% CI 1.74-5.67, P < 0.001). PR and ER demonstrated analogous prognosis on long-term mortality (HR = 1.02, 95% CI 0.51-2.06, P = 0.96) and the incidences of early postoperative renal failure (RR = 0.75, 95% CI 0.49-1.14, P = 0.17) and stroke (RR = 0.73, 95% CI 0.30-1.78, P = 0.50). All the pooled results were robust to sensitivity analysis. Heterogeneity was insignificant except for the meta-analysis of late mortality. CONCLUSIONS Performing a less aggressive initial surgical procedure of PR in ATAAD patients would have lower early mortality but elevated incidence rates of late aortic reintervention, when compared with ER. Other prognostic results of the two surgical strategies including long-term mortality were similar for both.

[1]  E. Shi,et al.  Early and midterm outcomes of hemiarch replacement combined with stented elephant trunk in the management of acute DeBakey type I aortic dissection: comparison with total arch replacement. , 2014, The Journal of thoracic and cardiovascular surgery.

[2]  P. Blanke,et al.  Acute type A aortic dissection extending beyond ascending aorta: Limited or extensive distal repair. , 2014, The Journal of thoracic and cardiovascular surgery.

[3]  H. Zhang,et al.  Acute type A dissection without intimal tear in arch: proximal or extensive repair? , 2014, The Journal of thoracic and cardiovascular surgery.

[4]  A. Dell'aquila,et al.  Fate of the preserved aortic root after treatment of acute type A aortic dissection: 23-year follow-up. , 2013, The Journal of thoracic and cardiovascular surgery.

[5]  P. Blanke,et al.  Supracoronary ascending aortic replacement in patients with acute aortic dissection type A: what happens to the aortic root in the long run? , 2013, The Journal of thoracic and cardiovascular surgery.

[6]  O. Dapunt,et al.  Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection: analysis of the German Registry for Acute Aortic Dissection Type A. , 2012, The Journal of thoracic and cardiovascular surgery.

[7]  A. Montalto,et al.  Reoperation after surgical correction of acute type A aortic dissection: risk factor analysis. , 2012, The Annals of thoracic surgery.

[8]  S. Choo,et al.  Total arch repair versus hemiarch repair in the management of acute DeBakey type I aortic dissection. , 2011, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[9]  M. Suedkamp,et al.  Outcome after surgery for acute aortic dissection type A in patients over 70 years: data analysis from the German Registry for Acute Aortic Dissection Type A (GERAADA). , 2011, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[10]  Li-Zhong Sun,et al.  Total Arch Replacement Combined With Stented Elephant Trunk Implantation: A New “Standard” Therapy for Type A Dissection Involving Repair of the Aortic Arch? , 2011, Circulation.

[11]  S. Lemaire,et al.  Epidemiology of thoracic aortic dissection , 2011, Nature Reviews Cardiology.

[12]  A. Stang.  Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses , 2010, European Journal of Epidemiology.

[13]  N. Shimada,et al.  Operative strategy for acute type a aortic dissection: ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk. , 2009, The Annals of thoracic surgery.

[14]  N. Kouchoukos,et al.  Aortic enlargement and late reoperation after repair of acute type A aortic dissection. , 2007, The Annals of thoracic surgery.

[15]  M. Shiono,et al.  Validity of a limited ascending and hemiarch replacement for acute type A aortic dissection. , 2006, The Annals of thoracic surgery.

[16]  Min-Chi Chen,et al.  Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection. , 2003, Chest.

[17]  K. Furukawa,et al.  Surgical results of hemiarch replacement for acute type A dissection. , 2002, The Annals of thoracic surgery.

[18]  S. Westaby,et al.  Acute type A dissection: conservative methods provide consistently low mortality. , 2002, The Annals of thoracic surgery.

[19]  D. Loisance,et al.  Risk factor analysis for proximal and distal reoperations after surgery for acute type A aortic dissection. , 2002, The Journal of thoracic and cardiovascular surgery.

[20]  M. Parmar,et al.  Extracting summary statistics to perform meta-analyses of the published literature for survival endpoints. , 1998, Statistics in medicine.

[21]  J. Higgins,et al.  Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0. The Cochrane Collaboration , 2013 .

[22]  C. Etz,et al.  The fate of the distal aorta after repair of acute type A aortic dissection. , 2007, The Journal of thoracic and cardiovascular surgery.