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Frontiers in Cardiovascular Medicine 2022Despite the rapid development of thoracic endovascular aortic repair (TEVAR), it is still a challenge to maintain the blood flow of the branch arteries above the aortic...
OBJECTIVE
Despite the rapid development of thoracic endovascular aortic repair (TEVAR), it is still a challenge to maintain the blood flow of the branch arteries above the aortic arch in Stanford type B aortic dissection involving the left subclavian artery (LSA). The Castor stent graft is an integrated, customized, single-branch stent that enables reconstruction of the LSA. The purpose of this systematic review and meta-analysis was to assess the efficacy of the Castor stent graft for type B aortic dissection.
MATERIALS AND METHODS
An extensive electronic literature search (PROSPERO registration number: CRD42022322146) was undertaken to identify all articles published up to August 2022 that described thoracic aortic repair with branch stents in the treatment of type B aortic dissection involving the LSA. The quality of the included studies was analyzed using the MINORS criteria. The primary outcome measures were the technical success rate, early mortality rate, endoleak rate, and 1-year survival rate. The secondary outcome measures were the stroke rate, left upper extremity ischemia rate, and target vessel patency rate.
RESULTS
Eleven studies involving 415 patients were eligible for this meta-analysis. The LSA was successfully preserved in all procedures. The technical success rate was 97.5% (95% CI: 0.953-0.991); the intraoperative endoleak rate was 0.1% (95% CI: 0.000-0.012); the intraoperative LSA patency rate was 99.52%; the intraoperative LSA stent deformation and stenosis rate was 0.15% (95% CI: 0.000-0.051); the early type I endoleak rate was 1.6% (95% CI: 0.003-0.035); the 30-day mortality rate was 0.96%; the early reintervention rate was 0.9% (95% CI: 0.000-0.040); and the perioperative stroke rate was 0% (95% CI: 0.000-0.005). The 1-year survival rate was 99.7% (95% CI: 0.976-1.000). The half-year LSA patency rate was 99.3%, the 1-year LSA patency rate was 97.58%, and the 2-year LSA patency rate was 95.23%. During the follow-up period, the leakage rate was 0.3% (95% CI: 0.000-0.017), the incidence of left upper extremity ischemia rate was 0.5% (95% CI: 0.000-0.035), and the deformation and stenosis rate of the LSA stent was 2.2% (95% CI: 0.06-0.046).
CONCLUSION
This meta-analysis shows that endovascular repair of type B aortic dissection using the Castor stent-graft may be technically feasible and effective. However, this conclusion needs to be interpreted with caution, as the quality of evidence for all outcomes is between low and very low.
SYSTEMATIC REVIEW REGISTRATION
[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022322146].
PubMed: 36523362
DOI: 10.3389/fcvm.2022.1052094 -
Annals of Cardiothoracic Surgery May 2014The management of acute type B dissection represents a clinical challenge. We undertook a systematic review of the available literature regarding medical, surgical and... (Review)
Review
BACKGROUND
The management of acute type B dissection represents a clinical challenge. We undertook a systematic review of the available literature regarding medical, surgical and endovascular treatments of acute type B aortic dissection and combined the eligible studies into a meta-analysis.
METHODS
An extensive electronic health database search was performed on all articles published from January 2006 up to November 2013 describing the management of acute type B aortic dissection. Studies including less than 15 patients were excluded.
RESULTS
ACUTE COMPLICATED TYPE B DISSECTION: overall, 2,531 patients were treated with endovascular repair (TEVAR) and the pooled rate for 30-day/in-hospital mortality was 7.3%. The pooled estimates for cerebrovascular events, spinal cord ischemia (SCI) and total neurologic events were 3.9%, 3.1% and 7.3%, respectively. A total of 1,276 patients underwent open surgical repair and the pooled rate for 30-day/in-hospital mortality was 19.0%. The pooled rate for cerebrovascular events was 6.8%, for SCI 3.3% and for total neurologic complications 9.8%. Acute uncomplicated type B dissection: outcome of 2,347 patients who underwent conservative medical management were analyzed. The pooled 30-day/in-hospital mortality rate was 2.4%. The pooled rate for cerebrovascular events was 1%, for SCI 0.8% and for overall neurologic complications 2%.
CONCLUSIONS
Endovascular repair provides a superior 30-day/in-hospital survival for acute complicated type B aortic dissection compared to surgical aortic reconstruction. However, open repair still has a significant role as endovascular repair is not applicable in all patients and there remains concerns regarding the durability of this technique. TEVAR seems to have a more favorable outcome regarding aortic remodeling and the aortic-specific survival rate when compared with medical therapy alone. Randomized controlled trials focusing on the prognostic factors of early and late complications in uncomplicated type B dissections are needed.
PubMed: 24967162
DOI: 10.3978/j.issn.2225-319X.2014.05.08 -
BMC Surgery Jul 2023This systematic review and meta-analysis aimed to study the evidence on the efficacy and safety of omitting axillary lymph node dissection (ALND) for patients with... (Meta-Analysis)
Meta-Analysis
Efficacy and safety comparison between axillary lymph node dissection with no axillary surgery in patients with sentinel node-positive breast cancer: a systematic review and meta-analysis.
BACKGROUND
This systematic review and meta-analysis aimed to study the evidence on the efficacy and safety of omitting axillary lymph node dissection (ALND) for patients with clinically node-negative but sentinel lymph node (SLN)-positive breast cancer using all the available evidence.
METHODS
The Embase, Medline, and Cochrane Library databases were searched through February 25, 2023. Original trials that compared only the sentinel lymph node biopsy (SLNB) with ALND as the control group for patients with clinically node-negative but SLN-positive breast cancer were included. The primary outcomes were axillary recurrence rate, total recurrence rate, disease-free survival (DFS), and overall survival (OS). Meta-analyses were performed to compare the odds ratio (OR) in rates and the hazard ratios (HR) in time-to-event outcomes between both interventions. Based on different study designs, tools in the revised Cochrane risk of bias tool were used for randomized trials and the risk of bias in nonrandomized studies of interventions to assess the risk of bias for each included article. Funnel plots and Egger's test were used for the publication's bias assessment.
RESULTS
In total, 30 reports from 26 studies were included in the systematic review (9 reports of RCTs, 21 reports of retrospective cohort studies). According to our analysis, omitting ALND in patients with clinically node-negative but SLN-positive breast cancer had a similar axillary recurrence rate (OR = 0.95, 95% confidence interval (CI): 0.76-1.20), DFS (HR = 1.02, 95% CI: 0.89-1.16), and OS (HR = 0.97, 95% CI: 0.92-1.03), but caused a significantly lower incidence of adverse events and benefited in locoregional recurrence rate (OR = 0.76, 95% CI: 0.59-0.97) compared with ALND.
CONCLUSION
For patients with clinically node-negative but SLN-positive breast cancer (no matter the number of the positive SLN), this review showed that SLNB alone had a similar axillary recurrence rate, DFS, and OS, but caused a significantly lower incidence of adverse events and showed a benefit for the locoregional recurrence compared with ALND. An OS benefit was found in the Macro subset that used SLNB alone versus complete ALND. Therefore, omitting ALND is feasible in this setting.
TRIAL REGISTRATION
CRD 42023397963.
Topics: Humans; Female; Sentinel Lymph Node; Breast Neoplasms; Retrospective Studies; Neoplasm Recurrence, Local; Lymph Node Excision; Sentinel Lymph Node Biopsy; Lymphatic Metastasis; Lymphadenopathy; Axilla; Lymph Nodes
PubMed: 37495945
DOI: 10.1186/s12893-023-02101-8 -
Interactive Cardiovascular and Thoracic... Mar 2022This study aims to systematically review published literature on male-female differences in presentation, management and outcomes in patients diagnosed with acute... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
This study aims to systematically review published literature on male-female differences in presentation, management and outcomes in patients diagnosed with acute thoracic aortic dissection (AD).
METHODS
A systematic literature search was conducted for studies published between 1 January 1999 and 19 October 2020 investigating mortality and morbidity in adult patients diagnosed with AD. Patient and treatment characteristics were compared with odds ratios (ORs) and standardized mean differences and a meta-analysis using a random-effects model was performed for early mortality. Overall survival and reoperation were visualized by pooled Kaplan-Meier curves.
RESULTS
Nine studies investigating type A dissections (AD-A), 1 investigating type B dissections (AD-B) and 3 investigating both AD-A and AD-B were included encompassing 18 659 patients. Males were younger in both AD-A (P < 0.001) and AD-B (P < 0.001), and in AD-A patients males had more distally extended dissections [OR 0.57, 95% confidence interval (CI) 0.46-0.70; P < 0.001]. Longer operation times were observed for males in AD-A (standardized mean difference 0.29, 95% CI 0.17-0.41; P < 0.001) while male patients were less often treated conservatively in AD-B (OR 0.65, 95% CI 0.58-0.72; P < 0.001). The pooled early mortality risk ratio for males versus females was 0.94 (95% CI 0.84-1.06, P = 0.308) in AD-A and 0.92 (95% CI 0.83-1.03, P = 0.143) in AD-B. Pooled overall mortality in AD-A showed no male-female difference, whereas male patients had more reinterventions during follow-up.
CONCLUSIONS
This systematic review shows male-female differences in AD patient and treatment characteristics, comparable early and overall mortality and inconsistent outcome reporting. As published literature is scarce and heterogeneous, large prospective studies with standardized reporting of male-female characteristics and outcomes are clearly warranted. Improved knowledge of male-female differences in AD will help shape optimal individualized care for both males and females.
CLINICAL REGISTRATION NUMBER
PROSPERO, ID number: CRD42020155926.
Topics: Adult; Aortic Dissection; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Humans; Male; Prospective Studies; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 34664071
DOI: 10.1093/icvts/ivab270 -
Current Problems in Cardiology Mar 2024Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with... (Review)
Review
Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.
Topics: Humans; Cardiac Rehabilitation; Quality of Life; Evidence Gaps; Treatment Outcome; Aortic Dissection; Randomized Controlled Trials as Topic
PubMed: 38246318
DOI: 10.1016/j.cpcardiol.2023.102348 -
International Journal of Stroke :... Apr 2024Cervical artery dissection (CAD) involving the carotid or vertebral arteries is an important cause of stroke in younger patients. The purpose of this systematic review... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND PURPOSE
Cervical artery dissection (CAD) involving the carotid or vertebral arteries is an important cause of stroke in younger patients. The purpose of this systematic review is to assess the risk of recurrent CAD.
METHODS
A systematic review and meta-analysis was conducted on studies in which patients experienced radiographically confirmed dissections involving an extracranial segment of the carotid or vertebral artery and in whom CAD recurrence rates were reported.
RESULTS
Data were extracted from 29 eligible studies (n = 5898 patients). Analysis of outcomes was performed by pooling incidence rates with random effects models weighting by inverse of variance. The incidence of recurrent CAD was 4% overall (95% confidence interval (CI) = 3-7%), 2% at 1 month (95% CI = 1-5%), and 7% at 1 year in studies with sufficient follow-up (95% CI = 4-13%). The incidence of recurrence associated with ischemic events was 2% (95% CI = 1-3%).
CONCLUSIONS
We found low rates of recurrent CAD and even lower rates of recurrence associated with ischemia. Further patient-level data and clinical subgroup analyses would improve the ability to provide patient-level risk stratification.
Topics: Humans; Stroke; Vertebral Artery Dissection; Vertebral Artery; Carotid Arteries; Carotid Artery, Internal, Dissection; Recurrence
PubMed: 37661311
DOI: 10.1177/17474930231201434 -
Journal of Vascular Surgery Oct 2018Spontaneous isolated celiac artery dissection (SICAD) and spontaneous isolated superior mesenteric artery dissection (SISMAD) represent the major types of spontaneous... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Spontaneous isolated celiac artery dissection (SICAD) and spontaneous isolated superior mesenteric artery dissection (SISMAD) represent the major types of spontaneous visceral artery dissection. However, no quantitative meta-analysis of SICAD and SISMAD is available. The aim of our study was to pool current evidence concerning basic profiles, treatment strategies, long-term adverse events, and morphologic changes of lesioned vessels in SICAD and SISMAD patients.
METHODS
We searched the MEDLINE, Embase, Scopus, and Cochrane Databases (January 1, 1946-September 21, 2017) for studies of SICAD and SISMAD. Related cohort studies or case series with sample size larger than 10 were included. Two reviewers independently extracted and summarized the data. A random-effects model was used to calculate pooled estimates.
RESULTS
In total, 43 studies were included. An estimated 8% (95% confidence interval [CI], 0.01-0.21) symptomatic SICAD and 12% (95% CI, 0.06-0.19) symptomatic SISMAD patients with initial conservative management required secondary intervention during follow-up, whereas none of the asymptomatic patients treated conservatively required secondary intervention. As for morphologic changes during follow-up, a higher proportion of SICAD patients (64%; 95% CI, 0.47-0.80) achieved complete remodeling compared with SISMAD patients (25%; 95% CI, 0.19-0.32), and an estimated 6% (95% CI, 0.00-0.16) of SICAD and 12% (95% CI, 0.05-0.20) of SISMAD patients had morphologic progression. Overall, the pooled estimate of long-term all-cause mortality was 0% (95% CI, 0.00-0.03) in SICAD and 1% (95% CI, 0.00-0.02) in SISMAD. When stratified by symptoms, symptomatic patients were associated with a significantly increased probability of accomplishing complete remodeling (odds ratio, 3.95; 95% CI, 1.31-11.85) compared with asymptomatic patients.
CONCLUSIONS
Initial conservative treatment is safe for asymptomatic SICAD or SISMAD patients. Symptomatic patients managed conservatively have relatively high occurrence of late secondary intervention, which may require closer surveillance, especially in SISMAD because of a lower rate of remodeling.
Topics: Adult; Aged; Aged, 80 and over; Aortic Dissection; Anticoagulants; Asymptomatic Diseases; Celiac Artery; Clinical Decision-Making; Conservative Treatment; Endovascular Procedures; Female; Fibrinolytic Agents; Humans; Male; Mesenteric Artery, Superior; Middle Aged; Odds Ratio; Platelet Aggregation Inhibitors; Risk Factors; Time Factors; Treatment Outcome; Vascular Remodeling; Vascular Surgical Procedures
PubMed: 30126785
DOI: 10.1016/j.jvs.2018.05.014 -
Frontiers in Cardiovascular Medicine 2023The evolution of the false lumen after the repair of acute aortic dissection has been linked to numerous adverse clinical outcomes, including increased late mortality... (Review)
Review
BACKGROUND AND AIM
The evolution of the false lumen after the repair of acute aortic dissection has been linked to numerous adverse clinical outcomes, including increased late mortality and a higher risk of reoperation. Despite the widespread use of chronic anticoagulation in patients who have undergone repair for acute aortic dissection, the effects of this therapy on false lumen evolution and its subsequent consequences are yet to be fully understood. This meta-analysis aimed to investigate the impact of postoperative anticoagulation on patients with acute aortic dissection.
METHODS
In PubMed, Cochrane Libraries, Embase, and Web of Science, we performed a systematic review of nonrandomized studies, comparing outcomes with postoperative anticoagulation vs. non-anticoagulation on aortic dissection. We investigated the status of false lumen (FL), aorta-related death, aortic reintervention, and perioperative stroke in aortic dissection patients with anticoagulation and non-anticoagulation.
RESULTS
After screening 527 articles, seven non-randomized studies were selected, including a total of 2,122 patients with aortic dissection. Out of these patients, 496 received postoperative anticoagulation while 1,626 served as controls. Meta-analyses of 7 studies revealed significantly higher FL patency in Stanford type A aortic dissection (TAAD) postoperative anticoagulation with an OR of 1.82 (95% CI: 1.22 to 2.71; = 2.95; ²=0%; =0.93). Moreover, there was no statistically significant difference between the two groups in aorta-related death, aortic reintervention, and perioperative stroke with an OR of 1.31 (95% CI: 0.56 to 3.04; = 0.62; ² = 0%; = 0.40), 0.98 (95% CI: 0.66 to 1.47; = 0.09; ² = 23%; = 0.26), 1.73 (95% CI: 0.48 to 6.31; = 0.83; ² = 8%; = 0.35), respectively.
CONCLUSIONS
Postoperative anticoagulation was associated with higher FL patency in Stanford type A aortic dissection patients. However, there was no significant difference between the anticoagulation and non-anticoagulation groups in terms of aorta-related death, aortic reintervention, and perioperative stroke.
PubMed: 37234372
DOI: 10.3389/fcvm.2023.1173945 -
Annals of Saudi Medicine 2023Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are surgical methods used for rectal neuroendocrine tumors (NETs) with diameters of ≤ 10... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are surgical methods used for rectal neuroendocrine tumors (NETs) with diameters of ≤ 10 mm. However, which method has a higher performance remains uncertain.
OBJECTIVES
Evaluate which of the two methods shows a higher performance.
DESIGN
Systematic review and meta-analysis METHODS: Data from PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to 12 April 2022. Outcomes, including complete resection, en bloc resection, recurrence, perforation, bleeding, and procedure time, were pooled by 95% confidence intervals (95% CI) using a fixed- or random-effects model.
MAIN OUTCOME MEASURES
Complete resection, en bloc resection, and recurrence.
SAMPLE SIZE
18 studies, including 1168 patients were included in the study.
RESULTS
Eighteen retrospective cohort studies were included in this meta-analysis. There were no statistical differences in the rates of complete resection, en bloc resection, recurrence, perforation, and bleeding rates between EMR and ESD. However, a statistical difference was detected in the procedure time; EMR had a significantly shorter time (MD=-17.47, 95% CI=-22.31 - -12.62, <.00001).
CONCLUSIONS
EMR and ESD had similar efficacies and safety profiles in resectioning rectal NETs ≤ 10 mm. Even so, the advantages of EMR included a shorter operation time and expenditure. Thus, with respect to health economics, EMR outperformed ESD.
LIMITATION
Most of these studies are retrospective cohort studies instead of RCTs.
CONFLICT OF INTEREST
None.
Topics: Humans; Neuroendocrine Tumors; Endoscopic Mucosal Resection; Retrospective Studies; Treatment Outcome; Rectal Neoplasms; Intestinal Mucosa; Neoplasm Recurrence, Local
PubMed: 37270677
DOI: 10.5144/0256-4947.2023.179 -
Surgical Endoscopy Feb 2014For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal dissection (ESD), flexible endoscopy has aimed at en bloc R0 resection of superficial lesions of the digestive tract. This systematic review and meta-analysis compared the safety and effectiveness of ESD and full-thickness rectal wall excision by TEM in the treatment of large nonpedunculated rectal lesions preoperatively assessed as noninvasive.
METHODS
A systematic review of the literature published between 1984 and 2010 was conducted (Registration no. CRD42012001882). Data were integrated with those from the original databases requested from the study authors when needed. Pooled estimates of the proportions of patients with en bloc R0 resection, complications, recurrence, and need for further treatment in the ESD and TEM series were compared using random-effects single-arm meta-analysis.
RESULTS
This review included 11 ESD and 10 TEM series (2,077 patients). The en bloc resection rate was 87.8 % (95 % confidence interval [CI] 84.3-90.6) for the ESD patients versus 98.7 % (95 % CI 97.4-99.3 %) for the TEM patients (P < 0.001). The R0 resection rate was 74.6 % (95 % CI 70.4-78.4 %) for the ESD patients versus 88.5 % (95 % CI 85.9-90.6 %) for the TEM patients (P < 0.001). The postoperative complications rate was 8.0 % (95 %, CI 5.4-11.8 %) for the ESD patients versus 8.4 % (95 % CI 5.2-13.4 %) for the TEM patients (P = 0.874). The recurrence rate was 2.6 % (95 % CI 1.3-5.2 %) for the ESD patients versus 5.2 % (95 % CI 4.0-6.9 %) for the TEM patients (P < 0.001). Nevertheless, the rate for the overall need of further abdominal treatment, defined as any type of surgery performed through an abdominal access, including both complications and pathology indications, was 8.4 % (95 % CI 4.9-13.9 %) for the ESD patients versus 1.8 % (95 % CI 0.8-3.7 %) for the TEM patients (P < 0.001).
CONCLUSIONS
The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.
Topics: Dissection; Humans; Intestinal Mucosa; Microsurgery; Neoplasm Recurrence, Local; Neoplasm Staging; Rectal Neoplasms; Rectum
PubMed: 24149849
DOI: 10.1007/s00464-013-3238-3