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

doi:10.19723/j.issn.1671-167X.2022.02.018

Abstract

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

CLC Number:

R744.1

YUAN Chang-wei,WANG Ying-jin,ZHANG Shu-jie,SHEN Sheng-li,DUAN Hong-zhou. Clinical outcomes following microsurgery and endovascular embolization in the management of spinal dural arteriovenous fistula: A meta-analysis study[J].Journal of Peking University (Health Sciences), 2022, 54(2): 304-314.

Figures/Tables 8

Table 1

Study characteristics of included studies"

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

Table 1

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

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