Optimal Timing of Pre-emptive Thoracic Endovascular Aortic Repair in Uncomplicated Type B Aortic Dissection: A Network Meta-Analysis

Background: This network meta-analysis compares outcomes of optimal medical therapy (OMT) and pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection at different phases of chronicity. Methods: MEDLINE and EMBASE were searched through November 2023. Pooled short-term outcomes (short-term mortality, perioperative complications) and long-term outcomes (all-cause mortality, aortic-related mortality, aortic re-intervention rates) were calculated. Results: Systematic review identified 17 studies (2 randomized controlled trials, 3 propensity score matching, and 2 inverse probability weighting). Subacute-phase intervention had lower short-term mortality than the acute-phase (hazard ratio HR 95% confidence interval [CI]=0.60 0.38-0.94, p=0.027). No significant differences were observed in aortic rupture and paraplegia. Acute-phase TEVAR had a higher stroke incidence than subacute-phase intervention (HR 95% CI=2.63 1.36-5.09, p=0.042), chronic (HR 95% CI=2.5 1.03-6.2, p=0.043), and OMT (HR 95% CI=1.57 1.12-2.18, p=0.008). Acute-phase TEVAR had higher long-term all-cause mortality than subacute-phase intervention (HR 95% CI=1.34 1.03-1.74, p=0.03). Optimal medical therapy had elevated long-term all-cause mortality compared with subacute-phase TEVAR (HR 95% CI=1.67 1.25-2.33, p<0.001) and increased long-term aortic-related mortality vs acute-phase (HR 95% CI=2.08 1.31-3.31, p=0.002) and subacute-phase (HR 95% CI=2.6 1.62-4.18, p<0.01) interventions. No significant differences were observed in aortic re-intervention rates. Conclusions: Pre-emptive TEVAR may offer lower all-cause mortality and aortic-related mortality than OMT. Considering lower short-term mortality, perioperative stroke rate, and long-term mortality, our findings support pre-emptive TEVAR during the subacute phase. Clinical Impact The optimal timing of pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection remains uncertain. This network meta-analysis suggests that the subacute phase (14-90 days from symptom onset) emerges as the optimal timing for pre-emptive TEVAR. This window is associated with lower rates of short-term complications and higher long-term survival rates compared with alternative strategies.