A Meta-Analysis of Endovascular Versus Open Repair of Traumatic Thoracic Aortic Injuries

Background: Traumatic thoracic aortic injuries (TTAI) are associated with high mortality and morbidity. These patients often have multiple other injuries and delayed aortic repair is frequently employed. The introduction of endoluminal grafts offers an alternative to open surgical repair. We performed a meta-analysis of comparative studies evaluating endovascular versus open repair of these injuries.
Methods: A systematic search of published studies reporting treatment of TTAI was performed. The following databases were searched: Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. Search terms included thoracic aortic trauma, traumatic thoracic aortic injury, traumatic aortic rupture, stent graft repair, endovascular repair. We used the "related articles" function to broaden the search. Outcomes analyzed were perirocedural mortality and paraplegia rate. We used the random-effects model to calculate the odds ratio and 95% confidence intervals. Publication bias was investigated using funnel plots. Statistical heterogeneity was considered present if P<0.05 .
Results: Seven retrospective cohort studies published from 2003 to2006 were retrieved, all were included in this analysis. All were non-randomized, no prospective randomized trials were found. These studies reported on 192 patients. 107 patients were treated with open repair and they were compared with 85 patients that were treated with thoracic endograft aortic repair(TEVAR). Periprocedural mortality was significantly lower with TEVAR, odds ratio 0.31(95% confidence interval 0.11 to 0.86), P=0.96 for heterogeneity (image1). Data regarding postoperative paraplegia were reported in five of these studies, 73 patients were treated with TEVAR and 90 patients with open repair. The risk of postoperative paraplegia was significantly less with TEVAR, odds ratio 0.20 (95%confidence interval 0.03 to 1.2), P= 0.94 for heterogeneity (image2). The funnel plots for the two examined outcomes are presented in images 3 and 4.
Conclusions: Endovascular treatment of descending thoracic aortic trauma is an alternative to open repair and is associated with lower postoperative mortality and paraplegia rates. The durability of TEVAR in this patient population has not been extensively evaluated and long term follow-up data is necessary to determine whether it will become the preferred method of management for these seriously injured patients.