A systematic review and meta-analysis comparing single- versus multi-staged approach for endovascular repair of extensive thoracoabdominal aortic aneurysms.

Objective: We aimed to perform a systematic review and meta-analysis comparing the outcomes of single- versus multi-staged fenestrated-branched endovascular aortic repair (FB-EVAR) for extensive thoracoabdominal aortic aneurysms (TAAAs).

Methods: MEDLINE, Embase, and Cochrane databases were searched from inception to March 2024. This study was registered in PROSPERO (CRD42024567099) and followed PRISMA guidelines. Inclusion was restricted to original studies comparing single- versus multi-staged FB-EVAR for reported patients evaluated as extensive TAAAs (Crawford/Safi Extent I-III and V). A multi-staged approach consisted of aneurysm exclusion besides FB-EVAR using one or more staging strategies, including temporary aneurysm sac perfusion, first stage thoracic endovascular aortic repair (TEVAR), unintentional open surgical or endovascular proximal thoracic aortic repair, and minimally invasive staged segmental artery coil embolization (MISSACE). Endpoints evaluated included permanent and any spinal cord injury (SCI), 30-day or in-hospital mortality, acute kidney injury, cardiac, cerebrovascular, and bowel complications. A random-effects meta-analysis was performed using pooled odds ratios (OR) with 95% confidence intervals (CI).

Results: Four cohort studies involving 1,949 patients treated by elective FB-EVAR were included, including 1,097 (56.28%) patients treated by the multi-staged approach. The most frequently utilized staging strategy was TEVAR in 404 patients (37%). Multi-staged repairs significantly reduced permanent SCI events (OR 0.37; 95% CI: 0.23-0.58; p < 0.0001), any SCI events (OR 0.51; 95% CI: 0.29-0.93; p = 0.03) and 30-day or in-hospital mortality (OR 0.57; 95% CI: 0.38-0.85; p = 0.006). Additionally, the multi-staged approach was associated with lower risk of acute kidney injury (OR 0.67; 95% CI: 0.51-0.89; p = 0.005), while there were no significant differences observed for cardiac, cerebrovascular, and bowel complications.

Conclusions: Multi-staged FB-EVAR for elective extensive TAAA repair significantly reduces the risks of permanent and any SCI events, 30-day or in-hospital mortality, and acute kidney injury.