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Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms

Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms
Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms

Objective To review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic aortic aneurysms (TAA). Design Systematic review and meta-analysis Data sources MEDLINE, EMBASE, CENTRAL, WHO International Clinical Trials Routine data collection, current controlled trials, clinical trials and the NIHR portfolio were searched from January 1994 to March 2020. Eligibility criteria for selective studies All identified studies that compared ESG and OSR, including randomised controlled trials (RCTs), quasi-randomised and non-RCTs, comparative cohort studies and case-control studies matched on main outcomes were sought. Participants had to receive elective treatments for arch/descending (TAA). Studies were excluded where other thoracic aortic conditions (eg, rupture or dissection) were reported, unless results for patients receiving elective treatment for arch/descending TAA reported separately. Data extraction and synthesis Data were extracted by one reviewer and checked by another. Risk of Bias was assessed using the ROBINS-I tool. Meta-analysis was conducted using random effects. Where meta-analysis not appropriate, results were reported narratively. Results Five comparative cohort studies met inclusion criteria, reporting 3955 ESG and 21 197 OSR patients. Meta-analysis of unadjusted short-term (30 day) all-cause mortality favoured ESG (OR 0.75; 95% CI 0.55 to 1.03)). Heterogeneity identified between larger and smaller studies. Sensitivity analysis of four studies including only descending TAA showed no statistical significance (OR 0.73, 95% CI 0.45 to 1.18)), moderate heterogeneity. Meta-analysis of adjusted short-term all-cause mortality favoured ESG (OR 0.71, 95% CI 0.51 to 0.98)), no heterogeneity. Longer-term (beyond 30 days) survival from all-cause mortality favoured OSR in larger studies and ESG in smaller studies. Freedom from reintervention in the longer-term favoured OSR. Studies reporting short-term non-fatal complications suggest fewer events following ESG. Conclusions There is limited and increasingly dated evidence on the comparison of ESG and OSR for treatment of arch/descending TAA. PROSPERO registration number CRD42017054565.

aortic aneurysm, arch, descending, repair, stent, surgery
2044-6055
McCarthy, Andrew
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Gray, Joanne
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Sastry, Priya
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Sharples, Linda
e63e6289-2ee1-4ce0-806c-d5957e17a6bc
Vale, Luke
d0be6b50-51db-4d59-9094-17dcb5582bd8
Cook, Andrew
ab9c7bb3-974a-4db9-b3c2-9942988005d5
McMeekin, Peter
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Freeman, Carol
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Catarino, Pedro
7dd3ef9f-27c8-4341-a093-f4b2a8b0292e
Large, Stephen
5552af58-c1f3-4778-88bc-50ff3a0ef103
McCarthy, Andrew
eb6e0de7-cbdb-40a4-9beb-918383ed3da0
Gray, Joanne
45ed7d3c-4c64-46a2-a4d0-e3f862a4ea42
Sastry, Priya
75f84233-62aa-4c4c-820a-37e16fde784a
Sharples, Linda
e63e6289-2ee1-4ce0-806c-d5957e17a6bc
Vale, Luke
d0be6b50-51db-4d59-9094-17dcb5582bd8
Cook, Andrew
ab9c7bb3-974a-4db9-b3c2-9942988005d5
McMeekin, Peter
649b605e-b49c-4cc0-843a-398e0906d939
Freeman, Carol
6fbdc585-53d9-4b68-a368-ac40185be46b
Catarino, Pedro
7dd3ef9f-27c8-4341-a093-f4b2a8b0292e
Large, Stephen
5552af58-c1f3-4778-88bc-50ff3a0ef103

McCarthy, Andrew, Gray, Joanne, Sastry, Priya, Sharples, Linda, Vale, Luke, Cook, Andrew, McMeekin, Peter, Freeman, Carol, Catarino, Pedro and Large, Stephen (2021) Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms. BMJ Open, 11 (3), [e043323]. (doi:10.1136/bmjopen-2020-043323).

Record type: Article

Abstract

Objective To review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic aortic aneurysms (TAA). Design Systematic review and meta-analysis Data sources MEDLINE, EMBASE, CENTRAL, WHO International Clinical Trials Routine data collection, current controlled trials, clinical trials and the NIHR portfolio were searched from January 1994 to March 2020. Eligibility criteria for selective studies All identified studies that compared ESG and OSR, including randomised controlled trials (RCTs), quasi-randomised and non-RCTs, comparative cohort studies and case-control studies matched on main outcomes were sought. Participants had to receive elective treatments for arch/descending (TAA). Studies were excluded where other thoracic aortic conditions (eg, rupture or dissection) were reported, unless results for patients receiving elective treatment for arch/descending TAA reported separately. Data extraction and synthesis Data were extracted by one reviewer and checked by another. Risk of Bias was assessed using the ROBINS-I tool. Meta-analysis was conducted using random effects. Where meta-analysis not appropriate, results were reported narratively. Results Five comparative cohort studies met inclusion criteria, reporting 3955 ESG and 21 197 OSR patients. Meta-analysis of unadjusted short-term (30 day) all-cause mortality favoured ESG (OR 0.75; 95% CI 0.55 to 1.03)). Heterogeneity identified between larger and smaller studies. Sensitivity analysis of four studies including only descending TAA showed no statistical significance (OR 0.73, 95% CI 0.45 to 1.18)), moderate heterogeneity. Meta-analysis of adjusted short-term all-cause mortality favoured ESG (OR 0.71, 95% CI 0.51 to 0.98)), no heterogeneity. Longer-term (beyond 30 days) survival from all-cause mortality favoured OSR in larger studies and ESG in smaller studies. Freedom from reintervention in the longer-term favoured OSR. Studies reporting short-term non-fatal complications suggest fewer events following ESG. Conclusions There is limited and increasingly dated evidence on the comparison of ESG and OSR for treatment of arch/descending TAA. PROSPERO registration number CRD42017054565.

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More information

Accepted/In Press date: 19 February 2021
Published date: 4 March 2021
Additional Information: Funding Information: The authors would like to thank our Funders and the ETTAA Working Group for their support with this study. Publisher Copyright: © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.
Keywords: aortic aneurysm, arch, descending, repair, stent, surgery

Identifiers

Local EPrints ID: 447540
URI: http://eprints.soton.ac.uk/id/eprint/447540
ISSN: 2044-6055
PURE UUID: 24a6cc68-fda4-4870-9fb3-f8475f92024b
ORCID for Andrew Cook: ORCID iD orcid.org/0000-0002-6680-439X

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Date deposited: 15 Mar 2021 17:39
Last modified: 17 Mar 2024 03:06

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Contributors

Author: Andrew McCarthy
Author: Joanne Gray
Author: Priya Sastry
Author: Linda Sharples
Author: Luke Vale
Author: Andrew Cook ORCID iD
Author: Peter McMeekin
Author: Carol Freeman
Author: Pedro Catarino
Author: Stephen Large

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