Contemporary Management Strategies for Chronic Type B Aortic Dissections

A Systematic Review

Arnoud V Kamman, Hector W L de Beaufort, Guido H W Van Bogerijen, Foeke J H Nauta, Robin H. Heijmen, Frans L. Moll, Joost A. Van Herwaarden, Santi Trimarchi

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.

METHODS: EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.

RESULTS: Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7-2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%-9.4%), cardiac complications (0.0%-5.9%) and rupture (0.5%-5.0%). Most common long-term complications after TEVAR were rupture (0.5%-7.1%), endoleaks (0.0%-15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.

CONCLUSION: We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.

Original languageEnglish
Pages (from-to)e0154930
JournalPLoS One
Volume11
Issue number5
DOIs
Publication statusPublished - 2016

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Dissection
systematic review
chest
Repair
Thorax
Survival
Endoleak
endpoints
Rupture
Spinal Cord Ischemia
Therapeutics
aneurysm
Aortic Rupture
postoperative complications
Mortality
renal failure
ischemia

Keywords

  • Journal Article

Cite this

Kamman, A. V., de Beaufort, H. W. L., Van Bogerijen, G. H. W., Nauta, F. J. H., Heijmen, R. H., Moll, F. L., ... Trimarchi, S. (2016). Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review. PLoS One, 11(5), e0154930. https://doi.org/10.1371/journal.pone.0154930

Contemporary Management Strategies for Chronic Type B Aortic Dissections : A Systematic Review. / Kamman, Arnoud V; de Beaufort, Hector W L; Van Bogerijen, Guido H W; Nauta, Foeke J H; Heijmen, Robin H.; Moll, Frans L.; Van Herwaarden, Joost A.; Trimarchi, Santi.

In: PLoS One, Vol. 11, No. 5, 2016, p. e0154930.

Research output: Contribution to journalArticle

Kamman, AV, de Beaufort, HWL, Van Bogerijen, GHW, Nauta, FJH, Heijmen, RH, Moll, FL, Van Herwaarden, JA & Trimarchi, S 2016, 'Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review', PLoS One, vol. 11, no. 5, pp. e0154930. https://doi.org/10.1371/journal.pone.0154930
Kamman AV, de Beaufort HWL, Van Bogerijen GHW, Nauta FJH, Heijmen RH, Moll FL et al. Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review. PLoS One. 2016;11(5):e0154930. https://doi.org/10.1371/journal.pone.0154930
Kamman, Arnoud V ; de Beaufort, Hector W L ; Van Bogerijen, Guido H W ; Nauta, Foeke J H ; Heijmen, Robin H. ; Moll, Frans L. ; Van Herwaarden, Joost A. ; Trimarchi, Santi. / Contemporary Management Strategies for Chronic Type B Aortic Dissections : A Systematic Review. In: PLoS One. 2016 ; Vol. 11, No. 5. pp. e0154930.
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title = "Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review",
abstract = "BACKGROUND: Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.METHODS: EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.RESULTS: Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6{\%} to 21.0{\%} for OSR, 0.0{\%} to 13.7{\%} for TEVAR, and 0.0{\%} to 9.7{\%} for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0{\%}-92.0{\%} and 53.0{\%}-86.7{\%}, respectively. For TEVAR, one-year survival was 82.9{\%}-100.0{\%} and five-year survival 70.0{\%}-88.9{\%}. For B/FEVAR only one-year survival was available, ranging between 76.4{\%} and 100.0{\%}. Most common postoperative complications included stroke (OSR 0.0{\%}-13.3{\%}, TEVAR 0.0{\%}-11.8{\%}), spinal cord ischemia (OSR 0.0{\%}-16.4{\%}, TEVAR 0.0{\%}-12.5{\%}, B/FEVAR 0.0{\%}-12.9{\%}) and acute renal failure (OSR 0.0{\%}-33.3{\%}, TEVAR 0.0{\%}-34.4{\%}, B/FEVAR 0.0{\%}-3.2{\%}). Most common long-term complications after OSR included aneurysm formation (5.8{\%}-20.0{\%}) and new type A dissection (1.7-2.2{\%}). Early complications after TEVAR included retrograde dissection (0.0{\%}-7.1{\%}), malperfusion (1.3{\%}-9.4{\%}), cardiac complications (0.0{\%}-5.9{\%}) and rupture (0.5{\%}-5.0{\%}). Most common long-term complications after TEVAR were rupture (0.5{\%}-7.1{\%}), endoleaks (0.0{\%}-15.8{\%}) and cardiac complications (5.9{\%}-7.1{\%}). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5{\%}) and endoleaks (0.0{\%}-66.7{\%}). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8{\%}-29.0{\%}, 4.3{\%}-47.4{\%} and 0.0{\%}-53.3{\%}, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.CONCLUSION: We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.",
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T1 - Contemporary Management Strategies for Chronic Type B Aortic Dissections

T2 - A Systematic Review

AU - Kamman, Arnoud V

AU - de Beaufort, Hector W L

AU - Van Bogerijen, Guido H W

AU - Nauta, Foeke J H

AU - Heijmen, Robin H.

AU - Moll, Frans L.

AU - Van Herwaarden, Joost A.

AU - Trimarchi, Santi

PY - 2016

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N2 - BACKGROUND: Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.METHODS: EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.RESULTS: Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7-2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%-9.4%), cardiac complications (0.0%-5.9%) and rupture (0.5%-5.0%). Most common long-term complications after TEVAR were rupture (0.5%-7.1%), endoleaks (0.0%-15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.CONCLUSION: We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.

AB - BACKGROUND: Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.METHODS: EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.RESULTS: Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7-2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%-9.4%), cardiac complications (0.0%-5.9%) and rupture (0.5%-5.0%). Most common long-term complications after TEVAR were rupture (0.5%-7.1%), endoleaks (0.0%-15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.CONCLUSION: We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.

KW - Journal Article

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DO - 10.1371/journal.pone.0154930

M3 - Article

VL - 11

SP - e0154930

JO - PLoS One

JF - PLoS One

SN - 1932-6203

IS - 5

ER -