• Mourad Boufi, Benjamin O Patterson, Anderson D Loundou, Laurent Boyer, Matthew J Grima, Ian M Loftus, and Peter J Holt.
• St George's Vascular Institute, St George's Hospital NHS Trust, London, United Kingdom; Department of Vascular Surgery, University Hospital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France; UMR T24, IFSTTAR, Aix-Marseille Université, Marseille, France. Electronic address: mourad.boufi@ap-hm.fr.
• Ann. Thorac. Surg. 2019 May 1; 107 (5): 1559-1570.

BackgroundThe respective place of endovascular repair (ER) versus open surgery (OS) in thoracic dissecting aneurysm treatment remains debatable. This comprehensive review seeks to compare the outcomes of ER versus OS in chronic type B aortic dissection treatment.MethodsEmbase and Medline searches (2000 to 2017) were performed following PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. Outcomes data extracted comprised (1) early mortality and major complications: stroke, spinal cord ischemia (SCI), dialysis, and respiratory complications; and (2) late survival and reinterventions. Reintervention causes were divided into proximal, adjacent, and distal. Comparative studies allowed comparative meta-analysis. Noncomparative studies were analyzed in pooled proportion meta-analyses for each group.ResultsA total of 39 studies were identified after exclusions, of which 4 were comparative. Comparative meta-analysis demonstrated lower early mortality for ER (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.10 to 15.4), stroke (OR, 4.33; 95% CI, 1.02 to 18.35), SCI (OR, 3.3; 95% CI, 0.97 to 11.25), and respiratory complications (OR, 6.88; 95% CI,1.52 to 31.02), but higher reintervention rate (OR, 0.34; 95% CI, 0.16 to 0.69). Midterm survival was similar (OR, 1.19; 95% CI, 0.42 to 3.32). Noncomparative studies demonstrated that most reinterventions were related to the aortic segment distal to primary intervention in both groups (OS 73%, ER 59%). Reintervention procedures were mainly surgical for OS (85%), mainly endovascular for ER (75%). Rupture rates were 1.2% (OS) and 3% (ER).ConclusionsEndovascular repair is associated with significant early benefits, but this is not sustained at midterm. Reintervention is more frequent, but the OS is not exempt from reintervention or late rupture. Both techniques have their place, but patient selection is key.Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

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