Abstract
Background
Frozen elephant trunk (FET) surgery offers a new alternative in the management of
complex thoracic aortic aneurysms and dissections. We performed a systematic review
and meta-analysis of comparator observational studies evaluating the efficacy of FET
compared with conventional aortic arch surgery, primarily focusing on mortality and
stroke as well as the secondary outcomes of spinal cord ischemia, major bleeding,
and operative time.
Methods
We searched MEDLINE, EMBASE, PubMed, and the Cochrane Library for trials and studies
comparing the FET technique with conventional surgery in patients with aortic aneurysms
or dissections, or both. The overall quality of evidence was low, as assessed by Grading
of Recommendations, Assessment, Development, and Evaluation, based primarily on the
risk of bias secondary to study design, plausible confounding, and imprecision.
Results
Meta-analysis revealed a significant reduction in mortality (12 studies, 1803 patients:
odds ratio [OR], 0.55; 95% CI, 0.39-0.78) and a nonsignificant reduction in stroke
(12 studies, 1803 patients: OR, 0.78; 95% CI, 0.52-1.15) favouring FET; however, FET
was associated with a significant increase in spinal cord ischemia (9 studies, 1476
patients: OR, 2.20; 95% CI, 1.10-4.37). No significant differences between groups
were observed regarding major bleeding, cardiopulmonary bypass time, or cross-clamp
time.
Conclusions
Current evidence suggests that FET surgery is associated with lower mortality in patients
with thoracic aneurysmal disease and dissections, without a significant increase in
stroke, bleeding, or operative times. However, the risk of spinal cord ischemia is
increased in patients who undergo FET. A well-powered randomized trial is needed to
evaluate this evolving field.
Résumé
Introduction
La technique de la trompe d’éléphant gelée (TEG) offre une nouvelle solution de rechange
dans la prise en charge des anévrismes et des dissections complexes de l’aorte thoracique.
Nous avons réalisé une revue systématique et une méta-analyse d’études observationnelles
qui comparent l’efficacité de la technique de la TEG à l’intervention chirurgicale
traditionnelle de l’arc aortique en se penchant principalement sur la mortalité et
l’accident vasculaire cérébral (AVC) ainsi que sur les résultats secondaires de l’ischémie
de la moelle spinale, des hémorragies majeures et de la durée opératoire.
Méthodes
Nous avons effectué des recherches dans MEDLINE, EMBASE, PubMed et la Bibliothèque
Cochrane pour relever des essais et des études qui comparent la technique de la TEG
à l’intervention chirurgicale traditionnelle chez les patients ayant subi des anévrismes
ou des dissections de l’aorte, ou les deux. En fonction du système GRADE (Grading
of Recommendations, Assessment, Development and Evaluation), qui reposait principalement
sur le risque de biais secondaires au plan de l’étude, aux facteurs de confusion plausibles
et à l’imprécision, les données probantes étaient dans l’ensemble de faible qualité.
Résultats
La méta-analyse a révélé une réduction significative de la mortalité (12 études, 1803
patients : ratio d’incidence approché [RIA], 0,55 ; intervalle de confiance [IC] à
95 %, 0,39-0,78) et une réduction non significative de l’AVC (12 études, 1803 patients
: RIA, 0,78 ; IC à 95 %, 0,52-1,15) qui favorisaient la technique de la TEG. Toutefois,
la technique de la TEG a été associée à une augmentation significative de l’ischémie
de la moelle spinale (9 études, 1476 patients : RIA, 2,20 ; IC à 95 %, 1,10-4,37).
Aucune différence significative entre les groupes n’a été observée concernant les
hémorragies majeures, la durée du pontage cardiopulmonaire ou la durée du clampage.
Conclusions
Les données probantes actuelles montrent que la technique de la TEG est associée à
une mortalité plus faible chez les patients ayant des anévrismes et des dissections
de l’aorte thoracique sans augmentation significative de l’AVC, des hémorragies ou
de la durée des interventions chirurgicales. Toutefois, le risque d’ischémie de la
moelle spinale est accru chez les patients qui subissent la technique de la TEG. Un
essai à répartition aléatoire de bonne puissance statistique est nécessaire pour que
ce domaine en évolution fasse l’objet d’une évaluation.
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Article info
Publication history
Published online: December 26, 2017
Accepted:
December 17,
2017
Received:
October 2,
2017
Footnotes
See page 271 for disclosure information.
Identification
Copyright
© 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
