title: Endovascular vs. open repair of complicated acute type B aortic dissections.
abstract: Purpose : To assess the comparative effectiveness of thoracic endovascular aortic repair (TEVAR) vs. open surgical repair (OSR) of complicated acute type B aortic dissections (cABAD) using decision analysis. Methods : A decision analysis comparing TEVAR and OSR for cABAD included variables extracted from the best-available evidence. Main outcomes were quality-adjusted life years (QALYs), presented with the 95% credibility intervals (CI), and number of reinterventions over the remaining lifetime. Different clinical scenarios, including age, gender, and risk profile were analyzed. Parameter uncertainty was analyzed using probabilistic sensitivity analysis. Results : In the reference case, a cohort of 55-year-old men, TEVAR was preferred over OSR: 7.07 QALYs (95% CI 6.77 to 7.38) vs. 6.34 QALYs (95% CI 6.04 to 6.66) for OSR. The difference of 0.73 QALYs (95% CI 0.29 to 1.17) is equal to 8.5 months in perfect health. TEVAR was more effective in all analyzed cases and age groups. Perioperative mortality was the most important variable affecting the difference between OSR and TEVAR, followed by the relative risk and percentage of aortic-related complications. Total expected reinterventions were 0.43/patient (TEVAR) and 0.35/patient (OSR). Conclusion : The results of this decision model for the treatment of cABAD suggest that TEVAR is preferred over OSR. Although a higher number of reinterventions is expected, the total effectiveness of TEVAR is higher for all age groups. OSR should be reserved for patients whose aortic anatomy is unsuitable for endovascular repair.
authors.affiliation: 1 Section of Vascular Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
authors.forename: Wouter
authors.initials: W
authors.lastname: Hogendoorn
authors.forename: M G Myriam
authors.initials: MG
authors.lastname: Hunink
authors.forename: Felix J V
authors.initials: FJ
authors.lastname: Schlösser
authors.forename: Frans L
authors.initials: FL
authors.lastname: Moll
authors.forename: Bauer E
authors.initials: BE
authors.lastname: Sumpio
authors.forename: Bart E
authors.initials: BE
authors.lastname: Muhs
mesh_terms: D000208:Acute Disease; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D057186:Comparative Effectiveness Research; D003198:Computer Simulation; D003661:Decision Support Techniques; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D019317:Evidence-Based Medicine; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D019057:Quality-Adjusted Life Years; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality
keywords: acute type B dissection; decision model; open surgical repair; thoracic endovascular aortic repair; treatment