Endovascular Versus Open Surgical Repair for Ruptured Descending Aortic Pathologies: A Systematic Review and Meta-analysis of Observational Studies: A commentary

Abstract

This large meta-analysis of 10,466 patients across 44 studies [1] has concluded significant advantages of thoracic endovascular aortic repair (TEVAR) over open surgical repair (OSR) in the management of ruptured descending thoracic aorta (rDTA) with respect to both early mortality and morbidity. This is consistent with recommendations of both the European Society of Cardiology [2] and European Society of Vascular Surgery [3] where the relevant guidelines are based on Class 1, Level B/C evidence. In the absence of a randomized control trial, such a meta-analysis is pragmatically the best data available despite being retrospective and based on observational cohort studies. Nonetheless, the dataset reported here is compromised by being outdated (all studies except one, were published prior to 2013) and likely to be influenced by positive reporting bias. The inclusion of two different pathologies—blunt aortic injury and thoracic aneurysms, with a very small number of aortic dissections, also makes analysis as a whole cohort difficult. The demographic of these groups is very different (hence the low mean age) and crucially, traumatic injuries involve a one-off insult affecting a focal area of the aorta, whereas aneurysm formation is a chronic degenerative condition typically involving a much more extensive segment. This would suggest that the former group is likely to be more suitable for TEVAR from an anatomical perspective, but their outcome is also dictated by the extent of any other injuries sustained. The latter group is typically older with deranged physiology and this is reflected in the higher incidence of renal failure, ischaemic heart disease and diabetes in patients treated by TEVAR rather than OSR. Nevertheless, it is reassuring to see a low rate of heterogeneity between reported studies, and the advantages of the endovascular approach were seen across all pathologies. This is not surprising as rDTA, regardless of the aetiology, is a rapidly fatal condition if not treated expeditiously. The upfront advantages of a minimally invasive approach (avoiding thoracotomy, aortic crossclamping and blood loss) particularly in such an emergent setting translate into better early mortality rates and fewer early complications. However, for the younger traumatic group, in particular, long-term outcomes are needed before TEVAR can be endorsed as first-line treatment for all. Ten studies (1747 patients) reported results out to a mean of just over 4 years and although there is no information on late re-intervention rates, mortality was not different between TEVAR and OSR groups suggesting that any re-interventions did not lead to death. Over the last decade, practice has, perhaps informed by some of the studies reported here, changed to reflect the better outcomes of an endovascular approach in rDTA. Whilst the role of endovascular repair in the elective infrarenal abdominal aortic setting is increasingly challenged, based on poor durability, TEVAR is now established as first-line treatment in the thoracic segment. In the context of a ruptured aorta (regardless of cause), rapid exclusion takes priority over durability concerns in any case and the data reported by Salsano et al. cements the place of & Michael P. Jenkins [email protected]