Abstract

BACKGROUND: The respective place of endovascular versus open surgery in thoracic dissecting aneurysm treatment remains debatable. This comprehensive review seeks to analyse the outcomes of endovascular repair (ER) compared to open surgery (OS) in chronic type B aortic dissection treatment. METHODS: Embase and Medline searches (2000 - 2017)were performed following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Outcomes data extracted comprised firstly early mortality and major complications: stroke, spinal cord ischemia (SCI), dialysis, respiratory complications; secondly, late survival and reinterventions. Reintervention causes were divided into proximal, adjacent, distal. Comparative studies provided comparative meta-analyses. Non-comparative studies were analysed in pooled proportion meta-analyses for each group. RESULTS: 39 studies were identified: 10 OS, 25 ER, 4 comparative. Comparative studies meta-analyses revealed lower early mortality for ER (OR: 4.13, 95% CI: 1.10 - 15.4), stroke (OR: 4.33, 95% CI: 1.02-18.35), SCI (OR: 3.3, 95% CI: 0.97 - 11.25) and respiratory complications (OR: 6.88, 95% CI:1.52- 31.02), but higher reintervention rate (OR: 0.34, 95% CI: 0.16 - 0.69). Mid-term survival was similar (OR: 1.19, 95% CI:0.42 - 3.32). Non-comparative studies analyses showed distal causes as the principal reintervention indication in both groups: OS 73%; ER 59%. Reintervention procedures were mainly surgical for OS (85%), mainly endovascular for ER (75%). Rupture rates were: OS 1.2% , ER 3%. CONCLUSIONS: This recent non -randomised data shows early ER benefit, unsustained at mid-term. Reintervention is higher after ER, necessitating improved technique. However, OS is exempt neither from reintervention nor rupture. Both techniques have their place, but patient selection is key.