Comparison of Postoperative Outcomes Between Endovascular and Surgical Revascularization of the Left Subclavian Artery in Patients Undergoing Thoracic Endovascular Aortic Repair: Systematic Review and Meta-Analysis

Abstract

Background:

This meta-analysis aimed to compare postoperative outcomes between endovascular and surgical revascularization of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR).

Methods:

We performed a comprehensive search of the MEDLINE and EMBASE databases through February 2024. Pooled results were calculated, and subgroup analyses focused on the chimney technique for LSA revascularization. Kaplan–Meier curves for mid-term all-cause mortality were reconstructed by extracting time-to-event data from the included studies.

Results:

Twelve nonrandomized studies, including a total of 4158 patients, were analyzed. Procedural duration was significantly longer in the surgical revascularization cohort (p < 0.01). No statistically significant differences were found in other short-term outcomes between the 2 groups. However, subgroup analysis of studies focusing on the chimney technique showed that surgical revascularization was associated with a significantly lower rate of postoperative endoleak [odds ratio; OR (95% confidence interval; CI) = 0.17 (0.06–0.49), p < 0.01]. For mid-term outcomes, there were no significant differences in mortality [hazards ratio; HR (95% CI) = 1.25 (0.71–2.22), p = 0.44], aortic re-intervention rate [HR (95% CI) = 1.10 (0.49–2.47), p = 0.81], or LSA patency rate [HR (95% CI) = 1.24 (0.40–3.89), p = 0.71] between the 2 strategies. The follow-up endoleak rate tended to be lower in the surgical revascularization group [HR (95% CI) = 0.50 (0.24–1.03), p = 0.06], with a more pronounced trend in the subgroup analysis of studies exclusively employing the chimney technique [HR (95% CI) = 0.33 (0.10–1.02), p = 0.05], though the differences were not statistically significant. Reconstructed Kaplan–Meier curves for all-cause mortality indicated no significant difference in mid-term survival between the groups [HR (95% CI) = 0.94 (0.74–1.19), p = 0.60].

Conclusions:

This meta-analysis reveals comparable postoperative outcomes between surgical and endovascular LSA revascularization in patients undergoing TEVAR. However, the chimney technique was associated with a higher rate of postoperative endoleak.

Clinical Impact

This meta-analysis provides insights into the comparative effectiveness of surgical versus endovascular left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR). While both techniques demonstrated comparable short- and mid-term outcomes, the chimney stent-graft technique showed a higher incidence of postoperative endoleak, suggesting a need for careful patient selection and follow-up. These findings will guide clinicians in optimizing LSA revascularization strategies and balancing procedural risks with postoperative outcomes in patients requiring LSA coverage during TEVAR.