The Efficacy Of Stanford Type B Dissection Hybrid Technique Versus Total Endovascular Repair For Left Subclavian Artery Reconstruction: A Meta-Analysis

BACKGROUND:The optimal surgical approach to thoracic endovascular aortic repair(TEVAR)with reconstruction of the left subclavian artery(LSA)for Stanford B entrapment is still controversial.The purpose of our study was to describe the early and mid-term clinical outcomes of using a hybrid technique versus total endovascular repair,and to evaluate the advantages and disadvantages of both methods when reconstructing the LSA.METHODS:We conducted a comparison of published literature on Pub Med,Embase,Cochrane library,CNKI,Wanfang,and Vip databases until September 30,2022.This included all studies that compared total endovascular repair(TER)with hybrid technique(HT)for LSA reconstruction.Mortality,endoleak,stroke,spinal cord ischemia,left upper extremity ischemia,reintervention,operative time,and length of hospital stay were used as outcome indicators to measure the differences between the two techniques.We conducted a meta-statistical analysis using R software version4.2.2.RESULTS:The study included a total of 21 retrospective studies with a combined sample of1848 patients,with 1215 patients in the HT group and 632 patients in the TER group.The TER group were divided into four subcategories,including the Chimney graft group(CG group)with 403 patients,Single-branched stent graft group(SBSG group)with 36 patients,In Vitro Fenestration group(IVF group)with 160 patients,and In Situ Fenestration group(ISF group)with 33 patients.All included articles were retrospective studies.The meta-analysis revealed that TER had a higher incidence of endoleak compared to HT [OR=2.61,95% CI(1.63,～4.18),p<0.01].Moreover,TER was found to be associated with shorter operative time than HT [MD=-65.79,95% CI(-83.63,-47.96),p<0.01] and shorter hospital stay than HT [MD=-2.84,95% CI(-4.63,-1.05),P<0.01].Conversely,there was no statistically significant difference in the incidence of death [OR=0.92,95% CI(0.54,1.58),P=0.76],stroke [OR=1.02,95% CI(0.58,1.80),P=0.87],spinal cord ischemia [OR=1.38,95% CI(0.57,3.29),P=0.86],left upper extremity ischemia [OR=1.22,95% CI(0.59,2.52),P=0.59] and reintervention [OR=0.85,95% CI(0.51,1.41),P=0.48] between TER and HT.However,subgroup analysis indicated a higher risk of endoleak with the chimney technique [OR=4.29,95% CI(2.4,7.68),P<0.01] and a higher risk of left upper extremity ischemia with the In Vitro Fenestration technique [OR=3.91,95% CI(1.14,13.40),P=0.032] when compared to the hybrid procedure.CONCLUSION:We found that both TER and HT for LSA reconstruction are safe and feasible,with TER being associated with shorter operative time and length of hospital stay.However,the chimney technique has a higher risk of endoleak,while The In Vitro Fenestration technique was found to be the most appropriate technique for endoluminal repair at present.As the number of studies increases and technology evolves,single-branch stent graft technology may become the most appropriate surgical option in the future.It is important to note that the included studies were retrospective,and there is a need for further randomized controlled trials(RCTs)or prospective cohort studies to confirm the best surgical approach for LSA reconstruction.