Surgery compared with medical treatment in patients with type A aortic intramural hematoma: a systematic review and meta-analysis
S Lyu, S Wu, Y M Yang, L H ZhengAbstract
Background
The optimal management strategy for type A aortic intramural hematoma (IMH) remains controversial. This meta-analysis aimed to evaluate the outcomes of early surgery (ES) compared with initial medical treatment (MT) in this population.
Methods
PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched to identify studies comparing early surgery with initial medical treatment in patients with type A IMH.
Results
Across twenty-two studies involving 1831 patients, early surgery demonstrated a non-significant lower in-hospital mortality [RR(95%CI): 0.74 (0.50-1.10)] and remarkably reduced all-cause mortality during follow-up [RR(95%CI): 0.56 (0.37-0.83)] compared with initial medical treatment. No significant difference was detected in the risk of aortic-related death between the ES group and the Initial MT group. During index hospitalization and follow-up, a portion of the patients in the Initial MT group were converted to timely surgery. The initial MT group could be divided into three subgroups: patients receiving initial medical treatment but converted to timely surgery later (CS group), patients declining doctor-recommended surgery (DS group), and patients receiving pure medical treatment. In order to evaluate the prognostic differences between different management strategies, we conducted further analysis in different subgroup combinations. Patients receiving initial medical treatment but converted to timely surgery (CS) later have a comparable in-hospital mortality [ES vs.CS: RR(95%CI): 0.85 (0.44-1.64)] and significantly reduced all-cause mortality during follow-up [ES vs.CS: RR(95%CI): 3.80 (1.12-12.84)] compared with early surgery. When excluding patients declining doctor-recommended surgery (DS) from the Initial MT group, the risk of in-hospital death was comparable between the ES group and the Initial MT-DS group [RR(95%CI): 1.04 (0.49-2.17)].
Conclusion
In patients with type A IMH, early surgery is associated with non-significantly lower in-hospital mortality and remarkably reduced all-cause mortality during follow-up compared with initial medical treatment. Conversion from initial medical treatment to timely surgery yields non-inferior outcomes compared to early surgery, supporting a “wait-and-see” strategy in selected patients. Further high-quality prospective studies are needed to provide more evidence for the optimal management strategy of this population.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.