Surgery compared with medical treatment in patients with type A aortic intramural hematoma: a systematic review and meta-analysis.

BACKGROUND: The optimal management strategy for type A aortic intramural hematoma (IMH) remains controversial. In these patients, we conducted a meta-analysis to assess outcomes following early surgery (ES) vs. initial medical treatment (MT). METHODS: A systematic search of PubMed, the Cochrane Library, EMBASE, and ClinicalTrials.gov was performed. Studies that compared ES with initial MT for type A IMH were eligible. RESULTS: Across 22 studies of 1,831 participants, the ES group demonstrated a non-significant lower in-hospital mortality [relative risk (RR): 0.74; 95% confidence interval (CI): 0.50-1.10] and significantly reduced all-cause mortality during follow-up (RR: 0.56; 95% CI: 0.37-0.83) compared with the initial MT group. No significant difference was detected in the risk of aortic-related death between the ES group and the initial MT group. Patients receiving initial MT but converted to timely surgery (CS) later had 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 the ES group. 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)]. CONCLUSIONS: In patients with type A IMH, ES was associated with non-significantly lower in-hospital mortality and remarkably reduced all-cause mortality during follow-up compared with initial MT. Conversion from initial MT to timely surgery yielded non-inferior outcomes compared with ES, suggesting that a "wait-and-see" strategy might also lead to acceptable outcomes in selected patients. Further high-quality prospective studies are required to establish the optimal management approach for this population.