主动脉腔内覆膜支架置入术与开放手术治疗急性B型主动脉夹层的meta分析

Endovascular stent versus open surgery in the acute type B aortic dissection ： a meta-analysis

目的评价主动脉腔内覆膜支架置人术（支架置入术）与开放手术治疗急性B型胸主动脉夹层（ acute type B aortic dissection,ATBAD）的疗效。方法系统检索Cochrane图书馆的临床对照试验中心注册库（Cochrane Central Register of Controlled Trials, CENTRAL）、MEDLINE .EMBASE .CINAHL.Web of Science. OpenSIGLE .National Technical Information Service（NTIS）和中国知网（CNKI）、中国生物文献数据库（CBM）、维普数据库（VIP）、万方数据库（WanFangData）里的主动脉腔内覆膜支架置入术和开放手术治疗急性B型主动脉夹层的临床对照试验。文献检索起止时间均为从建库到2011年1月18日。由研究人员根据Cochrane偏倚评价和GRADE系统推荐分级方法，对证据质量进行严格评价和资料提取，对符合质量标准的临床对照试验进行meta分析。统计学分析采用RevMan5．0软件和GRAED profiler 3．2．2软件。结果5个临床试验共318例患者纳入研究。GRADE评价分析发现30天病死率的证据质量是低级，其他结局均为极低级。急性B型主动脉夹层患者主动脉腔内覆膜支架置入术组与手术组治疗的短期病死率差异有统计学意义，OR0．19、95％CI[0．09，0．39]，P〈0．001，但围术期并发症和远期病死率两组比较差异无统计学意义，OR1．40、95％CI[0．24，8．18]。结论主动脉腔内覆膜支架置入术只能作为治疗急性B型主动脉夹层的一种选择，目前的证据尚不能证明其可完全替代开放手术。

Objective Acute type B aortic dissection （ATBAD） is a life-threatening condition. Open surgical （OS） repair with a prosthetic graft has been a conventional treatment for ATBAD. Thoracic endovascular aortic repair （TEVAR）, as a less invasive and potentially safer technique, has been used increasingly in recent decade. Evidence to support the use of TEVARin these patients is needed. This recta-analysis was to assess the efficacy of TEVAR versus conventional OS in patients with ATBAD. Methods We searched the Cochrane Central Register of Controlled Trials （CENTRAL） in The Cochrane Library （last searched 2010, Issue 4） , MEDLINE , EMBASE, CINAHL, Web of Science,OpenSIGLE,National Technical Information Service（NTIS） ,CNKI,Chinese Biomedicine Database,VIP,WanFang Data for clinical trials and additional sources for published and unpublished trials until 1/18/2011. Controlled trials in which patients with ATBAD were assigrLed to TEVAR or OS repair were included. The authors extracted independently the following information using a specifically designed data collection form for individual trial included： first author and the year of publication, study population, interventions used （TEVAR or OS repair） and outcomes （short-term mortality, short-term complications, long-term complications and long-term mortality rates）. Data were extracted on the relevant methodological domains to minimize the bias in the analysis with use of the Cochrane methods for bias assessment and Grading of Recommendations Assessments Development and Evaluation （GRADE） methods. For each outcome, GRADE criteria and Cochrane Bias evaluation were used to evaluate the quality of the evidence with regard to inconsistency （heterogeneity）, indirectness, imprecision, and other potential sources of bias, such as publication and reporting bias. RevmanS. 0 and GRAED profiler 3.2.2 software were used to analyze the data. Results Five trials （318 participants） were included in the analysis. The five studies were limited by lack of allocation concealment and blindness, and the studies were small. The evidence quality determined with the GRADE approach for 30-day mortality was poor and for other variables was very poor. As compared with ATBAD, TEVAR associated with a significantly reduced short-term mortality , M-H fixed odds ratio 0.19, 95% CI [ 0.09, 0.39 ] , P 〈0. 001. However, TEVAR could not improve the postoperative outcomes such as complications or long-term mortality ,M-H random odds ratio 1.40, 95% CI[ 0.24, 8.18]. Conclusion TEVAR can be weakly recommended as an alternative for the treatment of ATBAD in selected cases and may not he used as a general option in place of surgery based on the current evidences.