A network meta-analysis comparing the efficacy and safety of thoracic endovascular aortic repair with open surgical repair and optimal medical therapy for type B aortic dissection

Abstract

Objective

Acute type B aortic dissection (TBAD) is a critical medical condition associated with increasing incidence and mortality. This meta-analysis aims to comprehensively compare the outcomes of three treatment modalities for TBAD: open surgical repair (OSR), thoracic endovascular aortic repair (TEVAR), and optimal medical therapy (OMT).

Methods

A literature search of databases was conducted to retrieve studies comparing TEVAR, OMT, and OSR in patients with TBAD from inception till January 7, 2023. Several baseline characteristics, along with relevant outcomes, were extracted. Overall survival, 30-day in-hospital mortality, and incidence of reintervention were regarded as primary outcomes, whereas secondary outcomes included incidence of complications. Complications assessed in this review include cardiac complications, myocardial infarction, paraplegia or paraparesis, stroke, pulmonary complications, renal failure, retrograde type A aortic dissection, and rupture of TBAD. The analysis analyzed Kaplan-Meier survival curves using Engauge Digitizer V4.1 (Markmitch) for overall survival assessment. Subsequently, Tierney’s method was employed to calculate the hazard ratio (HR). Additional outcomes were examined using RStudio Version 1.4.1717, utilizing the “pcnetmeta” package to compute odds ratios (ORs). These measures were then used to generate contrast plots. Absolute plots were constructed by calculating the absolute risk (AR), enabling a comprehensive simultaneous comparison of all treatment groups. Furthermore, risk difference (RD) facilitated rank probability computation, culminating in the creation of rank graphs presented in grayscale.

Results

Analysis revealed comparable overall survival rates between TEVAR and OSR and between TEVAR and OMT. In contrast, OMT demonstrated a significantly superior overall survival rate to open surgery (HR, 1.68; P = .04). TEVAR exhibited the lowest mean absolute risk for in-hospital mortality (0.080 ± 0.014), cardiac complications (0.104 ± 0.039), myocardial infarction (0.027 ± 0.016), and renal failure (0.119 ± 0.022). Conversely, OSR displayed the lowest mean values for reintervention incidence (0.072 ± 0.027), retrograde type A aortic dissection (0.044 ± 0.023), and TBAD rupture (0.069 ± 0.056). OMT yielded the lowest mean values for paraplegia or paraparesis incidence (0.024 ± 0.016), stroke (0.031 ± 0.017), and pulmonary complications (0.300 ± 0.135). The overall analysis aligned with the subgroup analysis for acute and chronic cases in most outcomes. However, for acute TBAD, TEVAR proved to have a lower risk of pulmonary complications. For rupture of TBAD, although OSR showed the lowest risk for chronic TBAD, TEVAR was analyzed to have a lower risk for acute cases.

Conclusions

In terms of overall survival, medical treatment emerged superior to OSR and showcased the lowest risks for paraplegia, stroke, and pulmonary complications. TEVAR, on the other hand, demonstrated the lowest risk for in-hospital mortality, cardiac complications, myocardial infarction, and renal complications. Meanwhile, OSR showed the lowest risk for reintervention, retrograde type A aortic dissection, and TBAD rupture.