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EXPEDITED PUBLICATION

Endovascular Aortic Repair Versus Open Surgical Repair for Descending Thoracic Aortic Disease

A Systematic Review and Meta-Analysis of Comparative Studies

Davy Cheng, MD^_*,_*, Janet Martin, PharmD, MSc (HTA&M)^_*, Hani Shennib, MBBS, Joel Dunning, PhD, Claudio Muneretto, MD, Stephan Schueler, PhD, MD^||, Ludwig Von Segesser, MD^¶, Paul Sergeant, MD, PhD^# and Marko Turina, MD^{_{* *}}

^_* Department of Anesthesia & Perioperative Medicine, Evidence-Based Perioperative Clinical Outcomes Research Group London Health Sciences Centre, The University of Western Ontario, London, Ontario, Canada
Vascular, Heart & Lung Associates, Phoenix, Arizona
Department Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, United Kingdom
Department of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy
^|| Department for Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
^¶ Cardiovascular Surgery, University Hospital CHUV, Lausanne, Switzerland
^# Cardiac Surgery Department, Gasthuisberg University Hospital, Leuven, Belgium
^_** Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland. Support for the meta-analysis was provided by an unrestricted research grant from the European Association of Cardiothoracic Surgery (EACTS) and the Evidence-Based Perioperative Clinical Outcomes Research Group, University of Western Ontario. Dr. Shennib receives consulting fees from W. L. Gore. Part of this study was presented at the the 2009 ACC i2 Late-Breaking Clinical Trials Summit on March 30, 2009, in Orlando, Florida

Manuscript received September 28, 2009; revised manuscript received November 12, 2009, accepted November 19, 2009.

^_* Reprint requests and correspondence: Dr. Davy Cheng, LHSC-University Hospital, 339 Windermere Road, C3-172, London, Ontario N6A 5A5, Canada. (Email: davy.cheng{at}lhsc.on.ca).

Objectives: The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease.

Background: The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials.

Methods: Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies.

Results: Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results.

Conclusions: Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.

Key Words: endovascular • descending aorta • TEVAR • meta-analysis • metaregression • survival

Abbreviations and Acronyms   CI = confidence interval   OR = odds ratio   TEVAR = thoracic endovascular aortic repair   WMD = weighted mean difference

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