Proximal stent graft combined with distal bare stent vs. conventional thoracic endovascular aortic repair in the treatment of complicated Stanford type B aortic dissection: a systematic review and meta-analysis.

BACKGROUND

The combination of a proximal stent graft (PSG) and a distal bare stent (DBS) has a number of advantages over standard thoracic endovascular aortic repair (TEVAR) in the treatment of complicated Stanford type B aortic dissection (TBAD). However, direct comparisons between these two treatment approaches remain limited. This meta-analysis aimed to compare the efficacy of these techniques in the treatment of complicated Stanford TBAD.

METHODS

The Cochrane Library, Embase, PubMed, and Web of Science databases were searched using the following key terms: "provisional extension to induce complete attachment technique", "petticoat", "restrictive stent", "protective stent", "bare stent", and "aortic dissection". All articles relevant to the topic were included in the meta-analysis. The following variables were compared between the two approaches: aortic-related mortality (ARM), false lumen (FL) thrombosis, and complications, such as endoleak, aortic rupture, paraplegia or paraparesis, stroke, renal failure, retrograde dissection, conversion to open repair, reintervention, and stent graft-induced new entry (SINE).

RESULTS

A total of 15 studies comprising 1,462 patients were included in the meta-analysis. Of the patients, 635 received a bare stent (the BS group) and 827 received a standard TEVAR (the non-BS group). There were no statistically significant differences between the two groups in terms of the 30-day ARM rate [risk ratio (RR): 0.59; 95% confidence interval (CI): 0.26-1.34; P=0.21], endoleak (RR: 0.87; 95% CI: 0.49-1.53; P=0.62), aortic rupture (RR: 0.65; 95% CI: 0.22-1.94; P=0.44), paraplegia or paraparesis (RR: 0.54; 95% CI: 0.22-1.32; P=0.17), stroke (RR: 0.91; 95% CI: 0.38-2.15; P=0.83), renal failure (RR: 2.35; 95% CI: 0.75-7.43; P=0.14), and retrograde dissection (RR: 1.06; 95% CI: 0.33-3.40; P=0.92). However, the >30-day ARM rate (RR: 0.58; 95% CI: 0.34-0.98; P=0.048), overall ARM rate (RR: 0.58; 95% CI: 0.38-0.88; P=0.01), conversion to open repair (RR: 0.28; 95% CI: 0.08-0.99; P=0.052), reintervention (RR: 0.40; 95% CI: 0.26-0.61; P<0.001), and SINE (RR: 0.14; 95% CI: 0.06-0.32; P<0.001) were significantly reduced in the BS group compared to the non-BS group. Additionally, while there was no significant difference between the two groups in terms of complete FL thrombosis at the thoracic level (RR: 1.20; 95% CI: 0.95-1.52; P=0.13), the two groups differed significantly in terms of complete FL thrombosis at the abdominal level (RR: 2.49; 95% CI: 1.37-4.53; P=0.003).

CONCLUSIONS

Compared with standard TEVAR, combining a PSG with a DBS moderately reduces postoperative complications, and enhances remodeling of the aorta, and thus has advantages in the treatment of complicated Stanford TBAD.