Treating blunt aortic injuries with endografts: pros and cons of a meta-analysis.
Modern management of blunt aortic injury (BAI) is based on evidence from mostly well-conducted meta-analyses as surrogates for prospective randomized controlled trials. There are several obvious pros and cons to this strategy. The advantages rest on the fact that it is unlikely that a prospective randomized trial comparing open surgical repair with endovascular repair will ever be conducted based on ethical grounds and the apparent survival advantage and reduced paraplegia rates associated with an endovascular approach; pooled data from high-volume studies provides for higher statistical power; and a well-conducted meta-analysis provides the ability to control for inter-study variation. The disadvantages of this approach are that meta-analyses are statistical examinations of scientific studies and not scientific studies in and of themselves; sources of bias cannot be controlled by the method of the analysis; and a heavy reliance on published studies can create exaggerated outcomes. Nonetheless, the studies reviewed in this article offer the best glimpse yet at the truth. The evidence grade to support endovascular over open repair for BAI is Level II (intermediate), which suggests that the described effect is plausible but is not quantified precisely or may be vulnerable to bias. The recommendation grade is B (provisional recommendation), which suggests that on balance of the evidence, endovascular repair for BAI is recommended with caution.
Starnes
Benjamin W
BW
Division of Vascular Surgery, University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359796, Seattle, WA 98104, USA. starnes@u.washington.edu
D000959:Antihypertensive Agents / Q000627:therapeutic use; D001011:Aorta / Q000293:injuries / Q000601:surgery*; D015982:Bias; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation*; D019317:Evidence-Based Medicine; D006801:Humans; D015201:Meta-Analysis as Topic; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011474:Prosthesis Design; D012107:Research Design; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000601:surgery*
D000959:Antihypertensive Agents