[A04] Is a 14 Day Delay Necessary when Treating Uncomplicated Type B Aortic Dissection with Thoracic Endovascular Aneurysm Repair? A Systematic Review and Meta-analysis

Objective The optimal timing of early thoracic endovascular aneurysm repair (TEVAR) for treating uncomplicated type b aortic dissection (UTBAD) is unknown. The INSTEAD trial, comparing TEVAR with best medical therapy, did not recruit patients in the first 14 days. However, this early delay risks uncomplicated TBAD becoming complicated, increasing mortality. A systematic review and meta-analysis of comparative outcomes between TEVAR performed in the acute and subacute phases of TBAD was performed. Methods A systematic search of MEDLINE was conducted according to PRISMA guidelines. Studies comparing peri-operative outcomes between TEVAR performed in the acute and subacute phases of TBAD were included. Subgroup analyses were undertaken for (1) studies reporting uncomplicated TBAD only, and (2) studies permitting comparison of “delayed acute phase” treatment (3 – 14 days) with subacute treatment. Results The search yielded 13 retrospective, observational studies (2 849 patients). Overall, compared with subacute phase treatment, acute phase TEVAR was associated with higher mortality (relative risk [RR] 3.45, 95% confidence interval [CI] 2.06 – 5.79, p < .001) and stroke (RR 2.29, 95% CI 1.31 – 4.00, p = .004), but equivalent rates of retrograde dissection, spinal cord ischaemia, and re-intervention. Across studies reporting on uncomplicated TBAD only, acute phase TEVAR was associated with higher mortality than subacute TEVAR (RR 3.14, 95% CI 1.37 – 7.21, p = .007) but not for other complications. There was no difference in death or complications between TEVAR performed at 3 – 14 days compared with subacute phase TEVAR. Conclusion TEVAR for UTBAD in the acute phase, compared with subacute phase, carries a higher rate of death, but not retrograde dissection, stroke, or spinal cord ischaemia. It may be necessary to wait for only three days and not 14 when planning TEVAR. The optimal timing of early thoracic endovascular aneurysm repair (TEVAR) for treating uncomplicated type b aortic dissection (UTBAD) is unknown. The INSTEAD trial, comparing TEVAR with best medical therapy, did not recruit patients in the first 14 days. However, this early delay risks uncomplicated TBAD becoming complicated, increasing mortality. A systematic review and meta-analysis of comparative outcomes between TEVAR performed in the acute and subacute phases of TBAD was performed. A systematic search of MEDLINE was conducted according to PRISMA guidelines. Studies comparing peri-operative outcomes between TEVAR performed in the acute and subacute phases of TBAD were included. Subgroup analyses were undertaken for (1) studies reporting uncomplicated TBAD only, and (2) studies permitting comparison of “delayed acute phase” treatment (3 – 14 days) with subacute treatment. The search yielded 13 retrospective, observational studies (2 849 patients). Overall, compared with subacute phase treatment, acute phase TEVAR was associated with higher mortality (relative risk [RR] 3.45, 95% confidence interval [CI] 2.06 – 5.79, p < .001) and stroke (RR 2.29, 95% CI 1.31 – 4.00, p = .004), but equivalent rates of retrograde dissection, spinal cord ischaemia, and re-intervention. Across studies reporting on uncomplicated TBAD only, acute phase TEVAR was associated with higher mortality than subacute TEVAR (RR 3.14, 95% CI 1.37 – 7.21, p = .007) but not for other complications. There was no difference in death or complications between TEVAR performed at 3 – 14 days compared with subacute phase TEVAR. TEVAR for UTBAD in the acute phase, compared with subacute phase, carries a higher rate of death, but not retrograde dissection, stroke, or spinal cord ischaemia. It may be necessary to wait for only three days and not 14 when planning TEVAR.