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Eur J Cardiothorac Surg 2004;25:236-242
© 2004 Elsevier Science NL

Review

Can the principles of evidence-based medicine be applied to the treatment of aortic dissections?

^a Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA
^b Department of Cardiothoracic and Vascular Surgery, University Hospital Northern Norway, 9038 Tromsø, Norway

Received 4 May 2003; received in revised form 17 November 2003; accepted 19 November 2003.

^* Corresponding author. Address: Department of Cardiothoracic and Vascular Surgery, University Hospital Northern Norway, 9038 Tromsø, Norway. Tel.: +47-776-26612; fax: +47-772-28298
e-mail: truls.myrmel{at}unn.no

Surgical treatment of patients with acute type A aortic dissections has improved early survival from 10–20 to approximately 80%. Data supporting several other treatment recommendations in patients with aortic dissection, however, are less convincing. We hypothesized that applying strict principles of evidence-based medicine would invalidate most of the recommendations in these published papers. We conducted a literature search asking three questions: (1) Is the use of routine circulatory arrest and an ‘open distal’ anastomosis technique better than traditional aortic cross clamping? (2) Does a persistent false lumen in the distal aorta wall have an adverse influence on long-term event-free survival? and (3) Is primary surgical or medical treatment of patients with Stanford acute type B dissections preferable in terms of long-term event-free survival? We searched Entrez Pubmed (National Library of Medicine) for all papers on these topics from 1980 to January 2003. Screening 3164 papers identified using the search terms ‘aortic dissection’ and ‘treatment’ yielded 15 papers fulfilling a set of a priori inclusion criteria. No study had a design that allowed unequivocal conclusions; moreover, the heterogeneity in study design and patient populations precluded formal meta-analysis. The difficulties inherent in conducting stringent clinical studies addressing various treatment strategies for patients with aortic dissection hamper their quality and weaken their recommendations for different treatment options. Specifically, no conclusive evidence exists favoring use of an open distal anastomosis in patients with acute type A dissections or complete elimination of flow in the distal aortic false lumen; similarly, medical therapy of patients with acute type B aortic dissections has no proven advantage over surgical treatment.

Key Words: Aortic dissection • Literature-review • Distal aortic anastomosis • Aortic false lumen

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