Systematic review and meta-analysis on endovascular repair of nonelective thoracoabdominal aortic aneurysms and aneurysms involving visceral arteries

Introduction: Thoracoabdominal aortic aneurysms (TAAAs) and juxta/pararenal abdominal aortic aneurysms, reported as complex aortic aneurysms (cAAAs), represent a technical and clinical challenge with endovascular repair embodying a preferred option for high-risk patients. However, in case of nonelective presentation, both technical and clinical management and outcomes remain limited in literature. The aim of this study is to report indications, treatments, and outcomes of nonelective endovascular repair of TAAAs and cAAAs. Methods: This study is a systematic review and meta-analysis performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) and after PROSPERO registration. Primary end points were the indications, technical success, and procedure-related mortality. Secondary end points were spinal cord ischemia (SCI), grade 3 SCI, dialysis, and respiratory events. Meta-regression was performed for nonintact vs intact aneurysms. Subgroup analysis was performed in studies involving exclusively TAAA repair. Results: Of 687 articles screened, we selected 18 articles involving 953 patients: TAAAs were 68% (51% Crawford I-III and 49% Crawford IV-V) and cAAAs were 32%. Indications for nonelective treatment were contained of free rupture, symptoms, and large aneurysm diameter. Branched endograft, physician-modified/in situ endograft, parallel graft, and fenestrated endograft were used in 54%, 30%, 14%, and 2%, respectively. Technical success was 94.4%. Overall procedural-related mortality was 16.8% (95% confidence interval: 0.13-0.22; nonintact: 24.5% vs intact: 11.8%; P < .001). Pooled rate for SCI and grade 3 SCI was 12.3% (nonintact: 21.9% vs intact: 8.9%; P = .007) and 5.2% (nonintact: 8.5% vs intact: 2.2%; P = .02), respectively. Pooled rate for permanent dialysis was 3.6% (nonintact: 6.1% vs intact: 1.7%; P = .08) and for respiratory events 14.1% (nonintact: 20.7% vs intact: 9.3%; P = .024). Subgroups analysis for TAAAs reported procedure-related mortality in 18.7% (nonintact: 24.8% vs intact: 12.6%; P = .08); SCI, grade 3 SCI, dialysis, and respiratory events occurred in 16.4% (nonintact: 21.9% vs intact: 9.7%; P = .06), 5.6% (nonintact:8.1% vs intact: 2.8%; P = .08), 5.4% (nonintact: 7.2% vs intact: 2.6%; P = .36), and 18.2% (nonintact: 23.1 vs intact: 10.5%; P = .10), respectively. No statistical differences in metaregression for nonintact vs intact TAAAs. Conclusions: The indications for nonelective endovascular treatment of TAAA and cAAA are heterogeneous. Technical success is elevated while early mortality and spinal cord injuries were higher for ruptured aneurysm. Interestingly, TAAA outcomes seemed not to be influenced by rupture.