目的:本系统综述和荟萃分析旨在探讨左锁骨下动脉血运重建术与非血运重建术在胸主动脉腔内修复术中的有效性。并总结其适应症的当前证据。
方法:在多个数据库中进行了计算机化搜索,包括MEDLINE,Scopus,科克伦图书馆,和WebofScience,截至2023年11月发表的研究。研究选择,数据抽象,和质量评估(使用纽卡斯尔-渥太华量表)由两名审阅者独立进行,与第三作者解决差异。使用随机效应模型计算具有95%置信区间(CIs)的合并比值比(ORs),并使用漏斗图评估发表偏倚。
结果:在76项纳入的研究中,左锁骨下动脉血运重建与卒中风险降低相关(OR,0.67;95%CI,0.45-0.98;n=15331),脊髓缺血(OR,0.75;95%CI,0.56-0.99;n=11995),和手臂缺血(OR,0.09;95%CI,0.01-0.59;n=8438)。截瘫无明显减少(OR,0.56;95%CI,0.21-1.47;n=1802)或死亡率(OR,0.77;95%CI,0.53-1.12;n=11831)。此外,内漏的风险在两组中是相当的(OR,1.25;95%CI,0.55-2.84;p=0.60;n=793),而血运重建组的再干预风险显著较高(OR,1.98;95%CI,1.03-3.83;p=0.04;n=272)。两组都有相似的主要风险(OR,0.45;95%CI,0.19-1.09;p=0.08;n=1113),未成年人(或,0.21;95%CI,0.01-3.45;p=0.27;n=183),肾(或,0.61;95%CI,0.12-3.06;p=0.55;n=310),和肺(或,0.59;95%CI,0.16-2.15;p=0.42;n=8083)并发症。左锁骨下动脉血运重建的最常见适应症是脊髓缺血的一级预防。增加着陆区,和一级预防中风。
结论:胸主动脉腔内修复术中左锁骨下动脉血运重建与减少神经系统并发症相关,但未发现对死亡率有影响。该研究强调了血运重建的重要指征以及并发症的重要预测因素。为临床决策和未来研究提供依据。
OBJECTIVE: This systematic
review and meta-analysis aims to investigate the effectiveness of left subclavian artery revascularization compared with non-revascularization in thoracic endovascular aortic repair, and to summarize the current evidence on its indications.
METHODS: A computerized search was conducted across multiple databases, including MEDLINE, SCOPUS, Cochrane Library, and Web of Science, for studies published up to November 2023. Study selection, data abstraction, and quality assessment (using the Newcastle-Ottawa Scale) were independently conducted by two reviewers, with a third author resolving discrepancies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models and publication bias was assessed using funnel plots.
RESULTS: In the 76 included studies, left subclavian artery revascularization was associated with reduced risks of stroke (OR, 0.67; 95% CI, 0.45-0.98; n = 15,331), spinal cord ischemia (OR, 0.75; 95% CI, 0.56-0.99; n = 11,995), and arm ischemia (OR, 0.09; 95% CI, 0.01-0.59; n = 8438). No significant reduction in paraplegia (OR, 0.56; 95% CI, 0.21-1.47; n = 1802) or mortality (OR, 0.77; 95% CI, 0.53-1.12; n = 11,831) was observed. Moreover, the risk of endoleak was comparable in both groups (OR, 1.25; 95% CI, 0.55-2.84; P = .60; n = 793), whereas the risk of reintervention was significantly higher in the revascularization group (OR, 1.98; 95% CI, 1.03-3.83; P = .04; n = 272). Both groups had similar risks of major (OR, 0.45; 95% CI, 0.19-1.09; P = .08; n = 1113), minor (OR, 0.21; 95% CI, 0.01-3.45; P = .27; n = 183), renal (OR, 0.61; 95% CI, 0.12-3.06; P = .55; n = 310), and pulmonary (OR, 0.59; 95% CI, 0.16-2.15; P = .42; n = 8083) complications. The most frequent indications for left subclavian artery revascularization were primary prevention of spinal cord ischemia, augmentation of the landing zone, and primary stroke prevention.
CONCLUSIONS: Left subclavian artery revascularization in thoracic endovascular aortic repair was associated with reduced neurological complications but was not found to impact mortality. The study highlights important indications for revascularization as well as significant predictors of complications, providing a basis for clinical decision-making and future research.