Risk Factor Analysis of Post-TEVAR Distal Aortic Expansion: A Systematic Review and Meta-Analysis

Abstract

Background:

Distal aortic expansion (DAE) after thoracic endovascular aortic repair (TEVAR) remains a critical long-term outcome-related determinant. The aim of this study was to identify risk factors for postoperative DAE through a meta-analysis and meta-regression.

Methods:

In this systematic review and meta-analysis, the PubMed, Embase, and the Cochrane Library databases were searched from database inception to April 1, 2025. The primary outcome was the incidence of distal aortic expansion (DAE) after TEVAR. Pooled effect estimates were calculated using random-effects models, and heterogeneity was assessed with Cochran’s Q test and the I² statistic. Meta-regression was performed to explore potential predictors of DAE. Publication bias was evaluated using Egger’s test and funnel plots.

Results:

Twenty-four studies were included, with a pooled DAE incidence of 27% (95% CI: 21%–35%). Meta-regression indicated that male sex (RR = 3.00, p=0.020), myocardial infarction (RR = 5.98, p<0.001), peripheral vascular disease (RR = 3.39, p=0.007), malperfusion (RR = 1.52, p=0.050), and postoperative false lumen expansion (RR = 1.18, p=0.046) were associated with increased DAE risk. Older age, prior cardiac surgery, congestive heart failure, residual dissection, and post-false lumen (FL) complete thrombosis (distal) were protective factors.

Conclusions:

DAE after TEVAR is determined by a combination of patient comorbidities and aortic remodeling features. Identifying high-risk profiles—such as male sex, cardiovascular comorbidities, and persistent false lumen—may help optimize surveillance and reduce late aortic complications.

Clinical Impact

Distal aortic expansion (DAE) remains a major determinant of late failure after TEVAR for type B aortic dissection. This study provides a comprehensive quantitative synthesis of clinical and remodeling-related predictors of DAE, highlighting high-risk profiles such as male sex, hypertension, prior myocardial infarction, peripheral vascular disease, and persistent false lumen patency. By integrating demographic, comorbidity, and morphological factors, the findings support a risk-adapted surveillance strategy rather than uniform follow-up protocols. Importantly, the study underscores the prognostic significance of false lumen dynamics, reinforcing the role of adjunctive techniques aimed at promoting distal thrombosis. These insights may facilitate individualized monitoring, earlier intervention, and improved long-term durability after TEVAR.