Endovascular stenting versus open surgery for thoracic aortic disease: Systematic review and meta-analysis of perioperative results

Background: Endovascular stenting has emerged as an alternative to open repair in patients requiring surgery for thoracic aortic pathology. A number of comparative series have been published but, to date, there has been no meta-analysis comparing outcomes following stenting as opposed to open surgery. Methods: Electronic abstract databases and conference proceedings were searched to identify relevant series. Pooled odds ratios were calculated using random effects models for perioperative mortality, neurological injury, and major reintervention. Results: The search identified 17 eligible series, totaling 1109 patients (538 stenting). Stenting was associated with a significant reduction in mortality (pooled odds ratio 0.36; 95% CI 0.228-0.578; P < .0001) and major neurological injury (pooled odds ratio 0.39; 95% CI 0.25-0.62; P = .0001). There was no difference in the major reintervention rate (pooled odds ratio 0.91; 95% CI 0.610-1.619). There was a reduction in hospital and critical care stay although there was evidence of heterogeneity and bias with respect to these outcomes. Subgroup analyses suggested that endovascular repair reduced mortality (pooled odds ratio 0.25; 95% CI 0.09-0.66) and neurological morbidity (pooled odds ratio 0.28; 95% CI 0.13-0.61) in stable patients undergoing repair of thoracic aortic aneurysms. There was no effect on mortality in patients with thoracic aortic trauma but neurological injury was reduced (pooled odds ratio 0.17; 95% CI 0.03-1.03). Endovascular repair did not confer any apparent benefit over open surgery in patients with thoracic aortic rupture. Conclusion: Endovascular thoracic aortic repair reduces perioperative mortality and neurological morbidity in patients with descending thoracic aortic aneurysms. There may be less benefit in other thoracic aortic conditions.