Endovascular repair of diseases originating in the ascending thoracic aorta: A systematic review and meta-analysis

Objective
This report provides a concise overview of the published literature and clinical outcomes on ascending thoracic endovascular aortic repair (aTEVAR) for diseases originating in, but not restricted to, the ascending aorta.

Methods
PubMed, Scopus, and Web of Science were systematically searched for aTEVAR procedures for diseases originating in the ascending aorta. Nonadult patients or studies with fewer than 5 patients were excluded. This review was registered in the International Prospective Register of Systematic Reviews and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements. The Risk of Bias in Non-randomized Studies - of Interventions tool was used to assess quality. A Grading of Recommendations, Assessment, Development, and Evaluation evidence certainty analysis was performed.

Results
One prospective and 22 retrospective studies included a total of 356 patients (weighted mean age 68.6 ± 10.9 years; 59.3% male). The weighted mean follow-up was 21.2 ± 20.3 months, and prevalent comorbidities were hypertension (72.8%) and coronary artery disease (24.2%). Indications included type A dissections (acute 36.0%; chronic 19.9%), penetrating aortic ulcer (11.5%), and pseudoaneurysm (16.9%). Rapid ventricular pacing (33.4%) was most frequently adopted strategy to reduce cardiac output, and femoral/iliac artery access was used in 84.3%. Tubular stent grafts were used in 229 cases (64.3%), whereas physician-modified stent grafts were necessary in 110 cases (30.9%). In-hospital and follow-up mortality rates were 10.7% (95% CI, 6.3-13.1) and 20.5% (95% CI, 16.4-25.1). Subgroup analyses showed in-hospital and follow-up mortality rates for (acute and chronic) type A dissections of 9.8% (95% CI, 5.9-15.0) and 18.0% (95% CI, 12.7-24.3) subsequently; for penetrating aortic ulcer 9.0% (95% CI, 1.9-24.3) and 15.2% (95% CI, 5.1-31.9); and for pseudoaneurysm 2.8% (95% CI, 1.0-13.9) and 13.3% (95% CI, 5.9-24.6). Intra- and postoperative complications were reported in 43 and 192 cases, with endoleaks occurring in 14 (3.9%) and 37 (10.4%) cases, respectively.

Conclusions
This systematic review assessed current strategies and outcomes for aTEVAR. The findings suggest that aTEVAR holds promise as a treatment option and highlight the potential for further integration of aTEVAR into clinical practice.