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; Michal J Kawczynski; Jean H T Daemen; Ehsan Natour; Roberto Lorusso; Simon Schalla; Jos G Maessen; Joachim E Wildberger; Michael J Jacobs; Bartosz Rylski; Elham Bidar

doi:10.1016/j.ejvs.2021.12.045

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, Michal J Kawczynski, Jean H T Daemen, Ehsan Natour, Roberto Lorusso, Simon Schalla, Jos G Maessen, Joachim E Wildberger, Michael J Jacobs, Bartosz Rylski, Elham Bidar

^*Corresponding author for this work

Research output: Contribution to journal › (Systematic) Review article › peer-review

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.

Original language	English
Pages (from-to)	674-687
Number of pages	14
Journal	European Journal of Vascular and Endovascular Surgery
Volume	63
Issue number	5
Early online date	1 Apr 2022
DOIs	https://doi.org/10.1016/j.ejvs.2021.12.045
Publication status	Published - May 2022

Keywords

Aortic dissection
Aortic replacement
FALSE LUMEN
HEMIARCH REPLACEMENT
INTERNATIONAL REGISTRY
MANAGEMENT
OPERATIVE STRATEGY
REPAIR
RISK-FACTOR
SURGERY
TEAR
Total arch replacement
Type A dissection

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Heuts, S., Adriaans, B. P., Kawczynski, M. J., Daemen, J. H. T., Natour, E., Lorusso, R., Schalla, S., Maessen, J. G., Wildberger, J. E., Jacobs, M. J., Rylski, B., & Bidar, E. (2022). 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. European Journal of Vascular and Endovascular Surgery, 63(5), 674-687. https://doi.org/10.1016/j.ejvs.2021.12.045

@article{632b0e5db6f347b3b8fc1a2fba8f05eb,

title = "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",

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.",

keywords = "Aortic dissection, Aortic replacement, FALSE LUMEN, HEMIARCH REPLACEMENT, INTERNATIONAL REGISTRY, MANAGEMENT, OPERATIVE STRATEGY, REPAIR, RISK-FACTOR, SURGERY, TEAR, Total arch replacement, Type A dissection",

author = "Samuel Heuts and Adriaans, {Bouke P} and Kawczynski, {Michal J} and Daemen, {Jean H T} and Ehsan Natour and Roberto Lorusso and Simon Schalla and Maessen, {Jos G} and Wildberger, {Joachim E} and Jacobs, {Michael J} and Bartosz Rylski and Elham Bidar",

year = "2022",

month = may,

doi = "10.1016/j.ejvs.2021.12.045",

language = "English",

volume = "63",

pages = "674--687",

journal = "European Journal of Vascular and Endovascular Surgery",

issn = "1078-5884",

publisher = "Elsevier Saunders",

number = "5",

}

Heuts, S, Adriaans, BP, Kawczynski, MJ, Daemen, JHT, Natour, E , Lorusso, R , Schalla, S , Maessen, JG , Wildberger, JE, Jacobs, MJ, Rylski, B & Bidar, E 2022, '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', European Journal of Vascular and Endovascular Surgery, vol. 63, no. 5, pp. 674-687. https://doi.org/10.1016/j.ejvs.2021.12.045

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. / Heuts, Samuel; Adriaans, Bouke P; Kawczynski, Michal J et al.
In: European Journal of Vascular and Endovascular Surgery, Vol. 63, No. 5, 05.2022, p. 674-687.

Research output: Contribution to journal › (Systematic) Review article › peer-review

TY - JOUR

T1 - Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection

T2 - A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival

AU - Heuts, Samuel

AU - Adriaans, Bouke P

AU - Kawczynski, Michal J

AU - Daemen, Jean H T

AU - Natour, Ehsan

AU - Lorusso, Roberto

AU - Schalla, Simon

AU - Maessen, Jos G

AU - Wildberger, Joachim E

AU - Jacobs, Michael J

AU - Rylski, Bartosz

AU - Bidar, Elham

PY - 2022/5

Y1 - 2022/5

N2 - 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.

AB - 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.

KW - Aortic dissection

KW - Aortic replacement

KW - FALSE LUMEN

KW - HEMIARCH REPLACEMENT

KW - INTERNATIONAL REGISTRY

KW - MANAGEMENT

KW - OPERATIVE STRATEGY

KW - REPAIR

KW - RISK-FACTOR

KW - SURGERY

KW - TEAR

KW - Total arch replacement

KW - Type A dissection

U2 - 10.1016/j.ejvs.2021.12.045

DO - 10.1016/j.ejvs.2021.12.045

M3 - (Systematic) Review article

C2 - 35379543

SN - 1078-5884

VL - 63

SP - 674

EP - 687

JO - European Journal of Vascular and Endovascular Surgery

JF - European Journal of Vascular and Endovascular Surgery

IS - 5

ER -

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

Abstract

Keywords

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