Systematic review and meta-analysis of open surgical and endovascular management of thoracic outlet vascular injuries

Abstract

Background: Junctional vascular trauma such as that at the thoracic outlet poses particular challenges in surgical management. The use of endovascular techniques for such injuries is attractive as repair may be facilitated without the need for thoracotomy; however, the utility of such techniques is currently based on opinion, small retrospective series, and literature reviews of narrative and not systematic quality. The objective of this study is to provide a complete and systematic analysis of the literature pertaining to open surgery (OS) and endovascular management (EM) of thoracic outlet vascular injuries.

Methods: An electronic search using the MEDLINE, Embase, Cochrane Library, Science Citation Index, and LILACS databases was performed for articles published from 1947 to November 2011. The review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement standards. Prospective studies and retrospective cohorts of more than 10 patients were included. The primary outcome was all-cause mortality.

Results: One prospective noncomparative study and 73 retrospective series met the inclusion criteria. There were no randomized studies. All studies were at high risk of bias. Fifteen studies described outcomes for both OS and EM (549 patients). The majority of these studies described EM for traumatic arteriovenous fistulas or false aneurysms in stable patients. Direct comparison between OS and EM was possible in only three studies (comprising 23 OS and 25 EM patients), which showed no difference in all-cause mortality (odds ratio, 0.67; 95% confidence interval [CI], 0.11-4.05), but a shorter operating time with EM (mean difference = 58.34 minutes; 95% CI, 17.82-98.85). These three series included successful EM of unstable patients and those with vessel transection. There were 55 studies describing only OS (2057 patients) with a pooled mortality rate of 12.4% (95% CI, 9.9%-15.2%). Four studies described only EM (101 patients) with a pooled mortality rate of 26% (95% CI, 8%-51%), but these represented a distinct subgroup of cases (mainly iatrogenic injuries in older patients).

Conclusions: The current evidence is weak and fails to show superiority of one modality over the other. EM is currently used primarily in highly selected cases, but there are reports of a broader applicability in trauma. High-quality randomized studies or large-scale registry data are needed to further comment on the relative merits or disadvantages of EM in comparison to OS.