Background:This network meta-analysis compares outcomes of optimal medical therapy (OMT) and pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection at different phases of chronicity.Methods:MEDLINE and EMBASE were searched through November 2023. Pooled short-term outcomes (short-term mortality, perioperative complications) and long-term outcomes (all-cause mortality, aortic-related mortality, aortic re-intervention rates) were calculated.Results:Systematic review identified 17 studies (2 randomized controlled trials, 3 propensity score matching, and 2 inverse probability weighting). Subacute-phase intervention had lower short-term mortality than the acute-phase (hazard ratio [HR] [95% confidence interval [CI]]=0.60 [0.38-0.94], p=0.027). No significant differences were observed in aortic rupture and paraplegia. Acute-phase TEVAR had a higher stroke incidence than subacute-phase intervention (HR [95% CI]=2.63 [1.36-5.09], p=0.042), chronic (HR [95% CI]=2.5 [1.03-6.2], p=0.043), and OMT (HR [95% CI]=1.57 [1.12-2.18], p=0.008). Acute-phase TEVAR had higher long-term all-cause mortality than subacute-phase intervention (HR [95% CI]=1.34 [1.03-1.74], p=0.03). Optimal medical therapy had elevated long-term all-cause mortality compared with subacute-phase TEVAR (HR [95% CI]=1.67 [1.25-2.33], p<0.001) and increased long-term aortic-related mortality vs acute-phase (HR [95% CI]=2.08 [1.31-3.31], p=0.002) and subacute-phase (HR [95% CI]=2.6 [1.62-4.18], p<0.01) interventions. No significant differences were observed in aortic re-intervention rates.Conclusions:Pre-emptive TEVAR may offer lower all-cause mortality and aortic-related mortality than OMT. Considering lower short-term mortality, perioperative stroke rate, and long-term mortality, our findings support pre-emptive TEVAR during the subacute phase.Clinical ImpactThe optimal timing of pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection remains uncertain. This network meta-analysis suggests that the subacute phase (14-90 days from symptom onset) emerges as the optimal timing for pre-emptive TEVAR. This window is associated with lower rates of short-term complications and higher long-term survival rates compared with alternative strategies.

中文翻译：

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单纯性 B 型主动脉夹层先发性胸腔内主动脉修复术的最佳时机：网络荟萃分析

背景：该网络荟萃分析比较了最佳药物治疗 (OMT) 和先发性胸主动脉腔内修复术 (TEVAR) 对于不同慢性阶段的无并发症 B 型主动脉夹层的结果。方法：检索至 2023 年 11 月的 MEDLINE 和 EMBASE。计算汇总的短期结局（短期死亡率、围手术期并发症）和长期结局（全因死亡率、主动脉相关死亡率、主动脉再干预率）。 结果：系统评价确定了 17 项研究（2 项随机对照研究）试验、3 项倾向得分匹配和 2 项逆概率加权）。亚急性期干预的短期死亡率低于急性期（风险比 [HR] [95% 置信区间 [CI]]=0.60 [0.38-0.94]，p=0.027）。主动脉破裂和截瘫没有观察到显着差异。急性期 TEVAR 的卒中发生率高于亚急性期干预（HR [95% CI]=2.63 [1.36-5.09]，p=0.042）、慢性期（HR [95% CI]=2.5 [1.03-6.2]， p=0.043）和 OMT（HR [95% CI]=1.57 [1.12-2.18]，p=0.008）。急性期 TEVAR 的长期全因死亡率高于亚急性期干预（HR [95% CI]=1.34 [1.03-1.74]，p=0.03）。与亚急性期 TEVAR 相比，最佳药物治疗的长期全因死亡率升高（HR [95% CI]=1.67 [1.25-2.33]，p<0.001），并且与急性期相比，长期主动脉相关死亡率增加（HR [95% CI]=2.08 [1.31-3.31]，p=0.002）和亚急性期（HR [95% CI]=2.6 [1.62-4.18]，p<0.01）干预。主动脉再干预率没有观察到显着差异。 结论：先发性 TEVAR 可能比 OMT 提供更低的全因死亡率和主动脉相关死亡率。考虑到较低的短期死亡率、围手术期卒中发生率和长期死亡率，我们的研究结果支持在亚急性期进行先发性 TEVAR。临床影响先发性胸主动脉腔内修复术 (TEVAR) 治疗无并发症的 B 型主动脉夹层的最佳时机仍不确定。该网络荟萃分析表明，亚急性期（症状出现后 14-90 天）是先发制人 TEVAR 的最佳时机。与其他策略相比，该窗口期与较低的短期并发症发生率和较高的长期生存率相关。