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北京大学学报（医学版） ›› 2022, Vol. 54 ›› Issue (2): 304-314. doi: 10.19723/j.issn.1671-167X.2022.02.018

• 论著 • 上一篇    下一篇

显微外科手术与血管内栓塞治疗硬脊膜动静脉瘘临床疗效比较的meta分析

袁昌巍,王盈进,张书杰,沈胜利,段鸿洲()   

  1. 北京大学第一医院神经外科,北京 100034
  • 收稿日期:2020-02-12 出版日期:2022-04-18 发布日期:2022-04-13
  • 通讯作者: 段鸿洲 E-mail:duanhongzhou@126.com
  • 基金资助:
    国家自然科学基金(81541119);北京大学第一医院交叉临床研究专项资助项目;北京大学第一医院青年临床研究专项基金(2019CR02)

Clinical outcomes following microsurgery and endovascular embolization in the management of spinal dural arteriovenous fistula: A meta-analysis study

YUAN Chang-wei,WANG Ying-jin,ZHANG Shu-jie,SHEN Sheng-li,DUAN Hong-zhou()   

  1. Department of Neurosurgery, Peking University First Hospital, Beijing 100034, China
  • Received:2020-02-12 Online:2022-04-18 Published:2022-04-13
  • Contact: Hong-zhou DUAN E-mail:duanhongzhou@126.com
  • Supported by:
    National Natural Science Foundation of China(81541119);Peking University First Hospital Cross Clinical Study Foundation;Youth Clinical Research Project of Peking University First Hospital(2019CR02)

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摘要：

目的: 通过meta分析比较显微外科手术与血管内栓塞治疗硬脊膜动静脉瘘的临床疗效。方法: 计算机检索PubMed、Embase、Web of Science、Cochrane临床试验数据库、中国知网、万方数据库、中国生物医学文献数据库(Chinese BioMedical Literature Database,CBM),检索时间从数据库建库至2019年12月,纳入采用显微外科手术和血管内栓塞治疗硬脊膜动静脉瘘的所有中英文文献。使用RevMan 5.3软件进行统计学分析,评估术后早期失败率、远期复发、神经功能恢复程度、并发症情况,比较两种治疗方式对硬脊膜动静脉瘘的临床疗效,并对血管内栓塞治疗进行亚组分析。结果: 纳入文献46篇,共1 958例硬脊膜动静脉瘘患者,其中935例采用显微外科手术治疗,1 023例采用血管内栓塞治疗,漏斗图显示未见明显发表偏倚。经meta分析结果显示,显微外科手术早期治疗失败的发生率低于血管内栓塞治疗(OR=0.20, 95%CI: 0.13~0.30, P<0.05),远期复发率也低于血管内栓塞治疗(OR=0.36, 95%CI: 0.22~0.58, P<0.05),显微外科手术治疗后患者神经功能改善情况优于血管内栓塞治疗的患者(OR=2.86, 95%CI: 1.36~5.99, P<0.05),两种治疗方式患者并发症的发生率差异无统计学意义(OR=1.52, 95%CI: 0.88~2.64, P=0.14)。血管内栓塞治疗的患者中,使用Onyx胶进行栓塞比使用α-氰基丙烯酸正丁酯(n-butyl 2-cyanoacrylate,NBCA胶)有更高的治疗失败或复发风险,差异有统计学意义(OR=4.70, 95%CI: 1.55~14.28, P<0.05)。结论: 虽然血管内栓塞治疗硬脊膜动静脉瘘的应用日趋广泛,但显微外科手术所获得的临床疗效仍明显优于血管内栓塞治疗。

关键词: 硬膜, 动静脉瘘, 显微外科手术, 栓塞, 治疗性, Meta分析

Abstract:

Objective: To compare the clinical effect of microsurgery and endovascular embolization in the treatment of spinal dural arteriovenous fistula (SDAVF) by meta-analysis. Methods: A systematic review was performed to retrieve all relevant literature about surgical treatment or endovascular embolization of SDAVF up to December 2019 through PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials Results, CNKI, Wanfang Data, and SinoMed. The Chinese and English key words included: “SDAVF”, “spinal dural arteriovenous fistula”, “spinal AVM”, “spinal vascular malformation and treatment”. The included studies were evaluated using the Newcastle-Ottawa scale. The early failure rate, long-term recurrence, neurological recovery, and complications were evaluated and the clinical effects of the two methods in the treatment of SDAVF were compared by using RevMan 5.3 software. And a further subgroup analysis of the therapeutic effect of endovascular embolization with different embolic agents was conducted. Results: A total of 46 studies involving 1 958 cases of SDAVF were included, in which 935 cases were treated by microsurgery and 1 023 cases were treated by endovascular embolization. The funnel plot demonstrated that there was no publication bias. The results of meta-analysis showed that the incidence of early surgical failure was lower than that of endovascular embolization (OR=0.20, 95%CI: 0.13-0.30, P<0.05), and the long-term recurrence was also lower than that of endovascular embolization (OR=0.36, 95%CI: 0.22-0.58, P<0.05). The improvement of neurological function in the surgical patients is significantly higher than that in the patients treated with endovascular embolization (OR=2.86, 95%CI: 1.36-5.99, P<0.05). There was no significant difference in the occurrence of complications in these two groups (OR=1.52, 95%CI: 0.88-2.64, P=0.14). In the cases of endovascular embolization, the risk of treatment failure or recurrence was higher with Onyx glue than with n-butyl 2-cyanoacrylate (NBCA), and the difference was statistically significant (OR=4.70, 95%CI: 1.55-14.28, P<0.05). Conclusion: Although the treatment of dural arteriovenous fistulas by intravascular embolization has been widely used, the clinical effect of microsurgery is still better than that of endovascular embolization. Large scale and high-quality randomized controlled trials are required to validate the efficacy and safety of endovascular treatment in SDAVF patients.

Key words: Dura mater, Arteriovenous fistula, Microsurgery, Embolization, therapeutic, Meta-analysis

中图分类号: 

  • R744.1

表1

纳入文献的一般情况"

No. Author Year Study
type		 S E Follow-up/
months		 Initial failure
(S/E)		 Late recurrence
(S/E)		 Complications: S Complications: E NOS
score
1 Ushikoshi et al[5] 1999 RS 6 6 6 0/2 1/Not reported 1 transient deterioration
of paraparesis;
1 hemorrhage in
the medulla
oblongata		 2 transient deterioration
of paraparesis;
1 transient
L4 radiculopathy		 6
2 Song et al[6] 2001 RS 7 23 10.5 0/7 2/5 Not reported Not reported 6
3 Jellema et al[7] 2005 RS 12 24 1-120 0/0 0/8 Not reported Not reported 5
4 Andres et al[8] 2008 RS 4 17 12 0/4 Not reported/
Not reported		 0 0 5
5 Narvid et al[9] 2008 RS 24 39 49 4/7 0/5 0 0 7
6 Park et al[10] 2008 RS 1 17 12-160 0/2 0/1 0 1 transient aortic
intimal dissection		 5
7 Sherif et al[11] 2008 RS 7 19 24 0/0 0/2 0 0 5
8 Hessler et al[12] 2010 RS 54 102 24 0/21 2/6 Not reported Not reported 5
9 Shinoyama et al[13] 2010 RS 17 3 57 0/0 0/2 Not reported Not reported 6
10 Kaufmann et al[14] 2011 RS 33 1 Not reported 3/0 Not reported/
Not reported		 Not reported Not reported 5
11 Ruiz-Juretschke
et al[15]		 2011 RS 10 9 36 1/2 1/2 1 CSF fistula;
1 septic shock
secondary to
colon perforation		 1 spinal cord
infarction		 6
12 Cenzato et al[16] 2012 RS 55 10 36 0/3 Not reported/
Not reported		 0 0 5
13 Cho et al[17] 2013 RS 5 23 20 0/2 0/2 1 CSF leak 3 temporary
thromboembolic symtoms;
1 temporary
radiculomedullary
artery spasm;
1 asymptomatic
aortic arch dissection		 5
14 Clark et al[18] 2013 RS 8 15 32 0/2 1/6 Not reported 0 6
15 Gemmete et al[19] 2013 RS 4 29 Not reported 0/3 0/2 0 1 transient neurological
worsening due to
penetration of
embolic material
deep into
venous system		 6
16 Inagawa et al[20] 2013 RS 2 12 5-97 0/4 0/1 0 1 transient gait
disturbance;
1 permanent
gait disturbance		 5
17 Kirsch et al[21] 2013 RS 17 61 18 0/14 Not reported/
Not reported		 1 transient
radicular pain;
1 transient paraperesis;
1 CSF leak		 1 spinal cord infarction 5
18 Takai et al[22] 2013 RS 23 4 14 0/0 Not reported/
Not reported		 1 CSF fistula;
1 wrong-level
laminectomy,
1 idiopathic
venous thrombosis		 0 4
No. Author Year Study
type		 S E Follow-up/
months		 Initial failure
(S/E)		 Late recurrence
(S/E)		 Complications: S Complications: E NOS
score
19 Gokhale et al[23] 2014 RS 17 10 24 0/0 0/3 2 wound infections 1 spinal cord infarction 5
20 Qi et al[24] 2014 RS 40 12 Not reported 0/5 0/3 1 wound infection;
1 haematoma		 0 4
21 Rashad et al[25] 2014 RS 9 3 3-24 0/1 0/1 Not reported Not reported 6
22 Yen et al[26] 2014 RS 2 10 6 0/2 Not reported/
Not reported		 0 1 spinal cord
infarction; 1 brainstem
and cerebellar infarction		 4
23 Chibbaro et al[27] 2015 RS 30 120 Not reported 0/2 0/6 0 Not reported 5
24 Özkan et al[28] 2015 RS 25 5 34.8 2/2 0/0 1 epidural haematoma 0 5
25 Shin et al[29] 2015 RS 6 9 27 0/0 Not reported/
Not reported		 0 1 temporary cord
ischaemia		 5
26 Sri et al[30] 2015 RS 2 36 10 0/18 0/1 Not reported Not reported 5
27 Zogopoulos et al[31] 2016 RS 3 11 25.5 0/3 0/1 1 CSF leak 1 transient lower
extremity weakness		 6
28 Lee et al[32] 2016 RS 5 32 >24 0/12 Not reported/
Not reported		 1 pseudomeningocele 0 5
29 Sasamori et al[33] 2016 RS 19 31 81.2 1/6 0/3 1 wound infection;
1 epidural haematoma;
1 subdural haematoma		 1 spinal cord infarct;
1 aortic dissection;
two extravascular
dislocations of a
guide wire		 6
30 Adrianto et al[34] 2017 RS 5 4 37 2/1 Not reported/
Not reported		 Not reported Not reported 6
31 Durnford et al[35] 2017 RS 11 22 63 0/10 0/2 1 wound infection;
1 pseudomeningocele		 2 intercostal artery
rupture with
retroperitoneal
haematoma; 1 DVT		 6
32 Gross et al[36] 2017 RS 43 28 16 0/14 Not reported/
Not reported		 1 epidural haematoma;
2 wound infections;
3 CSF leaks		 2 radicular artery
ruptures; 1 transient
worsened numbness;
1 lower extremity
weakness		 7
33 Koch et al[37] 2017 RS 14 20 9 0/7 0/0 1 symptomatic
pseudomeningocele;
1 wound seroma		 2 microcatheter
ruptures		 6
34 Ma et al[38] 2018 PS 81 13 12 0/3 0/1 1 surgical site infection 0 8
35 Bretonnier et al[39] 2019 RS 23 40 S: 21.7;
E: 34.3		 1/12 6/3 2 epidural haematoma;
1 CSF leak;
1 wound infection		 1 spinal cord infarction 6
36 Huang et al[40] 2003 RS 8 7 2-24 0/0 0/2 Not reported Not reported 5
37 Li et al[41] 2003 RS 98 12 3-120 0/0 Not reported/3 Not reported Not reported 5
38 Pan et al[42] 2005 RS 11 38 12-48 0/0 Not reported/0 Not reported Not reported 6
39 Yu et al[43] 2008 RS 16 5 2-120 1/1 Not reported/
Not reported		 Not reported Not reported 4
40 Yu et al [44] 2012 RS 9 2 6-24 0/0 0/0 Not reported Not reported 5
41 Li et al[45] 2013 RS 14 9 6-30 0/2 0/2 Not reported Not reported 5
42 Qi XQ et al[46] 2014 RS 40 12 6-72 5/2 Not reported/2 1 wound infections;
1 epidural haematoma		 Not reported 5
43 Zhao[47] 2014 RS 29 21 6-12 0/0 0/0 Not reported Not reported 4
44 Cai et al[48] 2018 RS 11 2 6 0/0 Not reported/
Not reported		 Not reported Not reported 4
45 Zhang et al[49] 2018 RS 10 34 9 0/0 0/6 0 Not reported 5
46 Hu[50] 2019 RS 28 13 10-65 0/0 0/2 Not reported Not reported 5

图1

文献筛选流程图"

图2

显微外科手术与血管内栓塞治疗早期失败率的比较"

图3

显微外科手术与血管内栓塞治疗远期复发率的比较"

图4

显微外科手术与血管内栓塞治疗患者神经功能改善情况的比较"

图5

显微外科手术与血管内栓塞治疗并发症的比较"

图6

Onyx胶与NBCA治疗失败的比较"

图7

早期失败(A)、远期复发(B)、神经功能改善(C)、并发症(D)的漏斗图分析"

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