Open, closed or a bit of both: a systematic review and meta-analysis of staged thoraco-abdominal aortic aneurysm repair.

Abstract

Staged procedures are one strategy found to be beneficial for medium- to high-risk Crawford extent I-III thoraco-abdominal aortic aneurysm (TAAA) repair patients and may be performed through a variety of techniques. This review sought to compare the primary outcomes of spinal cord ischemia (SCI) and long-term mortality between three cohorts grouped by approach: open, endovascular, and hybrid. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a total of 919 references were extracted from a search of three online databases (Embase, PubMed, Scopus). Following application of inclusion/exclusion criteria and data extraction, quantitative meta-analysis was undertaken utilizing a random effects model. Kaplan-Meier (KM) curves were digitized and aggregated to graph estimated survival. A total of 20 studies representing 924 patients were included. SCI was highest in the endovascular group, at 9.8% of weighted means, followed by hybrid, and open groups at 3.2% and 1.4%, respectively. However, 30-day mortality was highest in the open group at 6.0%, followed by the hybrid group at 3.8%, and endovascular at 3.6%. Aggregated long-term survival estimations are shown graphically, extending to 5 years for open and endovascular cohorts, and 3 years for the smaller hybrid cohort. While all cases incorporated spinal drainage, monitoring and staging for spinal protection, there is innate difference in approach when examining for cord ischemia. This systematic review and meta-analysis of staged TAAA repair describes the first comparison between cohorts of open and endovascular approach, revealing the increased risk of SCI and long-term mortality in endovascular repair.