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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.
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”

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Murad MH, et al. 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
Mousa AY, et al. 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
Hoffer EK, et al. 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)
Karifajan K, et al. 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.

Comment(s)

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.

Clinical 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

1. 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. J Vasc Surg 2011 Jan; 53(1):193-199.
2. Mousa AY, Dombrovskiy VY, Haser PB, Graham AM, Vogel TR. Thoracic aortic trauma: outcomes and hospital resource utilization after endovascular and open repair. Vascular. 2010 Sep-Oct; 18(5):250-255.
3. Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular stent-graft or open surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc Interv Radiol 2008 Aug; 19(8):1153-1164.
4. Kasirajan K, Heffernan D, Langsfeld M. Acute thoracic aortic trauma: a comparison of endoluminal stent grafts with open repair and nonoperative management. Ann Vasc Surg 2003 Nov; 17(6):589-595.