■全弓置换(TAR)和脱支加胸主动脉腔内修复(TEVAR)是主动脉弓病变的重要治疗选择。目前尚不清楚这些方法中的一种是否应该被认为是可取的。我们的研究旨在比较这两种方法的长期结果。
■我们对从2023年12月发表的研究中提取的事件发生时间数据进行了汇总荟萃分析。合格标准包括患有任何主动脉弓病变的人群,他们接受了脱支加TEVAR或TAR,倾向评分匹配(PSM)研究(前瞻性/回顾性;单中心/多中心),结局包括随访总生存期/死亡率和/或再干预.
■11项PSM研究符合我们的资格标准,包括总共1142名患者(571对配对)。我们没有观察到两组之间全因死亡风险的任何统计学差异(风险比[HR]=1.20,95%置信区间[CI]=0.91-1.56,p=0.202),但与接受脱支+TEVAR的患者相比,接受TAR的患者晚期主动脉再干预的风险显著降低(HR=0.38,95%CI=0.23~0.64,p<0.001).我们对全因死亡率的荟萃回归分析确定了年龄(系数=-0.047;p=0.012)和A型主动脉夹层(系数=0.012;p=0.010)的统计学差异。
脱支加TEVAR和TAR在主动脉弓病变患者的生存率方面无统计学差异,但随着时间的推移,TAR与晚期主动脉再介入的风险较低相关.尽管老年患者可能从脱支加TEVAR而不是TAR中受益更多,患者可能从TAR获益更多。
结论:尽管两种策略在生存方面似乎同样有价值,在有和无主动脉夹层的患者中,随着时间的推移,全主动脉弓置换术(与治疗主动脉弓病变患者的脱支+TEVAR相比)与晚期主动脉再介入治疗减少相关.然而,我们应该考虑在老年患者中进行脱支+TEVAR,因为它与该人群的死亡风险较低相关.我们研究的新颖之处在于,而不是比较研究水平的效果估计,我们使用重建的事件发生时间数据分析结局.这为我们提供了使用考虑事件和时间的数学上适当的模型进行分析的机会;但是,这些发现可能受到治疗分配偏差的影响.
UNASSIGNED: Total arch replacement (TAR) and debranching plus thoracic endovascular aortic repair (TEVAR) serve as significant therapeutic options for aortic arch pathologies. It remains unclear whether one of these approaches should be considered preferable. Our study aimed to compare the long-term outcomes of these 2 approaches.
UNASSIGNED: We carried out a pooled meta-analysis of time-to-event data extracted from studies published by December 2023. Eligibility criteria included populations with any aortic arch pathology who underwent debranching plus TEVAR or TAR, propensity score-matched (PSM) studies (prospective/retrospective; single-center/multicentric), and the outcomes included follow-up for overall survival/mortality and/or reinterventions.
UNASSIGNED: Eleven PSM studies met our eligibility criteria, including a total of 1142 patients (571 matched pairs). We did not observe any statistically significant difference in the risk of all-cause death between the groups (hazard ratio [HR]=1.20, 95% confidence interval [CI]=0.91-1.56, p=0.202), but patients who underwent TAR had a significantly lower risk of late aortic reinterventions compared with patients who underwent debranching plus TEVAR (HR=0.38, 95% CI=0.23-0.64, p<0.001). Our meta-regression analyses for all-cause mortality identified statistically significant coefficients for age (coefficient=-0.047; p=0.012) and type A aortic dissections (coefficient=0.012; p=0.010).
UNASSIGNED: Debranching plus TEVAR and TAR demonstrate no statistically significant differences in terms of survival in patients with aortic arch pathologies, but TAR is associated with lower risk of late aortic reinterventions over time. Although older patients may benefit more from debranching plus TEVAR rather than from TAR, patients with dissections may benefit more from TAR.
CONCLUSIONS: Although the 2 strategies seem to be equally valuable in terms of survival, total aortic arch replacement (when compared with debranching plus TEVAR to treat patients with aortic arch pathologies) is associated with reduction of late aortic reinterventions over time in patients with and without aortic dissections. However, we should consider debranching plus TEVAR in older patients as it is associated with lower risk of death in this population. The novelty of our study lies in the fact that, instead of comparing study-level effect estimates, we analyzed the outcomes with reconstructed time-to-event data. This offered us the opportunity of performing our analyses with a mathematically appropriate model which consider events and time; however, these findings might be under the influence of treatment allocation bias.