Editor's Choice – Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection: A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival
Samuel Heuts, Bouke P. Adriaans, Michał Kawczyński, Jean H. T. Daemen, Ehsan Natour, Roberto Lorusso, Simon Schalla, Jos G. Maessen, Joachim E. Wildberger, Michael J. Jacobs, Bartosz Rylski, Elham Bidar
Abstract
OBJECTIVE: The extent of aortic replacement during surgery for acute type A aortic dissection (ATAAD) is an important matter of debate. This meta-analysis aimed to evaluate the short and long term outcomes of a proximal aortic repair (PAR) vs. total arch replacement (TAR) in the treatment of ATAAD. DATA SOURCES: A systematic search of PubMed and Embase was performed. Studies comparing PAR to TAR for ATAAD were included. REVIEW METHODS: The primary outcomes were early death and long term actuarial survival at one, five, and 10 years. Random effects models in conjunction with relative risks (RRs) were used for meta-analyses. RESULTS: Nineteen studies were included, comprising 5 744 patients (proximal: n = 4 208; total arch: n = 1 536). PAR was associated with reduced early mortality (10.8% [95% confidence interval (CI) 8.4 - 13.7] vs. 14.0% [95% CI 10.4 - 18.7]; RR 0.73 [95% CI 0.63 - 0.85]) and reduced post-operative renal failure (10.4% [95% CI 7.2 - 14.8] vs. 11.1% [95% CI 6.7 - 17.5]; RR 0.77 [95% CI 0.66 - 0.90]), but there was no difference in stroke (8.0% [95% CI 5.9 - 10.7] vs. 7.3% [95% CI 4.6 - 11.3]; RR 0.87 [95% CI 0.69 - 1.10]). No statistically significant difference was found for survival after one year (83.2% [95% CI 77.5 - 87.7] vs. 78.6% [95% CI 69.7 - 85.5]; RR 1.05 [95% CI 0.99 - 1.11]), which persisted after five years (75.4% [95% CI 71.2 - 79.2] vs. 74.5% [95% CI 64.7 - 82.3]; RR 1.02 [95% CI 0.91 - 1.14]). After 10 years, there was a significant survival benefit for patients who underwent TAR (64.7% [95% CI 61.1 - 68.1] vs. 72.4% [95% CI 67.5 - 76.7]; RR 0.91 [95% CI 0.84 - 0.99]). CONCLUSION: PAR appears to lead to an improved early mortality rate and a reduced complication rate. In the current meta-analysis, the suggestion of an improved 10 year survival benefit of TAR was found, which should be interpreted in the context of potential confounders such as age at presentation, comorbidities, and haemodynamic stability. In any case, PAR seems to be intuitive in older patients with limited dissections, and in those presenting in less stable conditions.