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Objective: High risk, inoperable patients with ascending aortic disease are increasingly managed with thoracic endovascular aortic repair (TEVAR). The aim of this study was to assess the available literature on TEVAR confined to the ascending aorta (a-TEVAR), describing study and patient characteristics, procedural and stent graft details, and outcomes.

Data sources: This was a systematic review and meta-analysis. MEDLINE, Web of Science, and Scopus were systematically searched for eligible studies reporting on outcomes after a-TEVAR (PROSPERO ID: CRD42023440826). Eligible studies reported outcomes after a-TEVAR without adjunctive supra-aortic vessel treatment.

Review Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed. The ROBINS-I and Joanna Briggs Institute Critical Appraisal Checklist were used as quality assessment tools. A Grading of Recommendations Assessment, Development, and Evaluation (GRADE) evidence certainty analysis was performed for the main outcomes. The main outcome was death. A proportional meta-analysis was performed with a mean and 95% confidence interval (CI) for the main outcomes. All articles were included up to 1 January 2024.

Results: Ninety four studies were included (19 cohort studies, 75 case reports or series), reporting on 259 patients (57.8% male). The mean age was 69.1 (95% CI 65.0 – 73.1) years and mean follow up 19.6 (95% CI 14.5 – 24.6) months. The most common comorbidity was prior cardiac or thoracic surgery (n = 191). The most frequent indications for a-TEVAR (52.1% urgent a-TEVAR) were type A aortic dissection (43.6%) and pseudoaneurysm (38.6%). The most commonly deployed stent grafts were Gore (44.5%), Cook (23.5%), and Medtronic (17.0%). The in hospital mortality rate was 7.3% (95% CI 4.7 – 11.2%), 30 day mortality rate 7.7% (95% CI 5.1 – 11.6%), and overall mortality rate 17.0% (95% CI 12.9 – 22.0%) during follow up. GRADE showed very low evidence certainty for all outcomes. Eighty eight complications were reported and there was a re-operation rate of 13.1% (95% CI 9.5 – 17.8%). In hospital and 30 day mortality rates for type A dissection were 12.4% (95% CI 7.5 – 19.7%) (n = 14) and 13.3% (95% CI 8.2 – 20.8%) (n = 15), respectively, and for pseudoaneurysm 4.0% (95% CI 1.6 – 9.8%) (n = 4) and 4.0% (95% CI 1.6 – 9.8) (n = 4), respectively.

Conclusion: Despite heterogeneous literature and very low GRADE evidence certainty, a-TEVAR seems technically feasible in high risk patients. In addition, there is need for a consensus on when and how to use a-TEVAR and a need for a specific endograft for use in the ascending aorta.