The best treatment for partial transection of the thoracic aorta.
Date First Published:
November 28, 2010
Last Updated:
January 27, 2011
Report by:
David R. McGowan, Helen M. Sims,, Medical Students (Brighton and Sussex Medical School)
Three-Part Question:
In [patients presenting with a partial transection of the aorta] is [open surgery better than endovascular repair] in [reducing mortality]?
Clinical Scenario:
An adult patient arrives in the emergency department via ambulance and is unconscious and hypotensive following a car accident in which the patient was wearing a seat-belt. CT with contrast shows a transcection of their thoracic aorta which needs intervention.
Search Strategy:
Medline 1948 - January 2011 was searched using the Ovid interface and the Cochrane Library was searched.
Search Details:
Ovid:
[("aortic transection" OR "aortic trauma" OR (aort* AND transection).ti,ab OR AORTA/su] AND [(open AND surgery).ti,ab OR THORACIC SURGERY/] AND [(endovascular OR intravascular OR catheter OR "minimally invasive").ti,ab OR BLOOD VESSEL PROSTHESIS IMPLANTATION/] LIMIT to English language and Human
Cochrane Library:
“aort*” and “aortic transection”
[("aortic transection" OR "aortic trauma" OR (aort* AND transection).ti,ab OR AORTA/su] AND [(open AND surgery).ti,ab OR THORACIC SURGERY/] AND [(endovascular OR intravascular OR catheter OR "minimally invasive").ti,ab OR BLOOD VESSEL PROSTHESIS IMPLANTATION/] LIMIT to English language and Human
Cochrane Library:
“aort*” and “aortic transection”
Outcome:
117 papers were found, or which 4 were suitable for assessing which of the invasive approaches was the most suitable for acute traumatic aortic transections. There were no suitable responses to searches in the Cochrane Library.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparative effectiveness of the treatments for thoracic aortic transection. Murad MH, Rizvi AZ, Malgor R, Carey J, Alkatib AA, Erwin PJ, Lee WA, Fairman RM. 2011 USA | 139 studies with 7768 patients were analysed, the majority of patients were male. | 3a - Systematic review of case studies | Mortality | Lower in endovascular repair than open (9% vs 19%, p<0.01), Relative risk (0.61 in endovascular repair compared to open) | Majority of studies were noncomparative surgical case series, retrospective, and not one was randomised. |
| Stroke | No significant difference between open and endovascular repair | ||||
| Spinal cord ischaemia and end-stage renal disease | Increased risk in open repair compared with endovascular (9% vs 3%, p=0.01), Relative risk of spinal cord ischaemia (0.34 in endovascular repair compared to open) | ||||
| Infection risk | Increased in open surgery compared with endovascular for both graft and systemic infection | ||||
| Thoracic aortic trauma: outcomes and hospital resource utilization after endovascular and open repair. Mousa AY, Dombrovskiy VY, Haser PB, Graham AM, Vogel TR. 2011 USA | 510 patients were identified as unergoing surgical or endovascular repair for traumatic aortic injury. | 2c - Systematic review and meta-analysis of ‘outcome’ studies. | Mortality | Higher in open repair than endovascular (14.61% vs 7.43%, p=0.009) | Studies were noncomparative surgical case series, retrospective, and none were randomised. |
| Pulmonary complications | Higher in open repair compared with endovascular (37.8% vs 21.65%, p<0.001) | ||||
| Stroke | Higher in endovascular repair than open (2.1% vs 5.8%. p=0.03) | ||||
| Duration of hospital stay and cost | Higher in open repair than endovascular | ||||
| Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review. Hoffer EK, Forauer AR, Silas AM, Gemery JM. 2008 USA | 19 studies with 262 endovascular and 376 open operations were identified. | 2a - Systematic review and meta-analysis of cohort studies. | Mortality | Odds ratio for endovascular versus open repair was 0.43 (95% CI 0.26-0.70; p=0.001) | There were no prospective randomised studies. |
| Paraplegia | Odds ratio for endovascular versus open repair was 0.30 (95% CI 0.12-0.76; p=0.01) | ||||
| Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management. Kasirajan K, Heffernan D, Langsfeld M. 2003 USA | 15 patients who underwent open repair (n=10) or endovascular (n=5) over a 33 month period. | 4 - Case-series. | Mortality | Higher in open surgical treatment than endovascular (50% vs 20%) | Small patient numbers. Case-series with no randomisation of patients. |
| Paraplegia | No paraplegia was noted in either intervention. |
Author Commentary:
3 systematic reviews and 1 case-series were suitable for investigating which of open or endovascular approaches was best for thoracic aortic transection repair. Despite the lack of any form of prospective randomised study investigating outcomes in endovascular and open repairs of thoracic aortic transection, there is much evidence in the literature regarding one of these approaches. The majority of studies are case series papers describing single centre experiences in one of the interventions. However, meta-analyses have taken this data and allowed for a comparison of the techniques.
There is much work around ‘aortic repair’, where all aortic pathologies are included while few studies look exclusively at aortic transections, and only one study by Kasirajan et al. compared these two interventions in aortic transections alone. The majority of studies looked at ‘aortic disease/pathology’ and coupled their results under these umbrella terms, making it impossible to differentiate the results for aortic transections.
Further research is required comparing greater patient numbers than used in the Kasirajan et al. study, or where patients are randomised into either open or endovascular repair groups to enable for direct comparison of outcomes.
There is much work around ‘aortic repair’, where all aortic pathologies are included while few studies look exclusively at aortic transections, and only one study by Kasirajan et al. compared these two interventions in aortic transections alone. The majority of studies looked at ‘aortic disease/pathology’ and coupled their results under these umbrella terms, making it impossible to differentiate the results for aortic transections.
Further research is required comparing greater patient numbers than used in the Kasirajan et al. study, or where patients are randomised into either open or endovascular repair groups to enable for direct comparison of outcomes.
Bottom Line:
It can be deduced from the literature available that the reduced mortality and complication rate of endovascular interventions, and the continuing development of endovascular procedures, make endovascular treatment a safer technique for the repair of thoracic aortic transections compared to open surgery.
References:
- Murad MH, Rizvi AZ, Malgor R, Carey J, Alkatib AA, Erwin PJ, Lee WA, Fairman RM.. Comparative effectiveness of the treatments for thoracic aortic transection.
- Mousa AY, Dombrovskiy VY, Haser PB, Graham AM, Vogel TR.. Thoracic aortic trauma: outcomes and hospital resource utilization after endovascular and open repair.
- Hoffer EK, Forauer AR, Silas AM, Gemery JM.. Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review.
- Kasirajan K, Heffernan D, Langsfeld M.. Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management.