Endovascular vs. open surgical repair in retrograde type a dissection & intramural hematoma: A study-level meta-analysis

Abstract OBJECTIVES Retrograde type A intramural haematoma (IMH) and aortic dissection are serious conditions requiring prompt surgical intervention. While open surgery is the traditional treatment, Thoracic Endovascular Aortic Repair (TEVAR) has emerged as a less invasive alternative. This meta-analysis compares the clinical outcomes of TEVAR versus open surgery for these conditions. METHODS A systematic review and study-level meta-analysis were conducted using study-level data extracted from published reports and analyzed using DerSimonian-Laird random-effects model, in line with the PRISMA guidelines. The study was prospectively registered with PROSPERO (registration ID: CRD42024594305). Databases including PubMed, Ovid MEDLINE, and EMBASE were searched for studies reporting outcomes on either open aortic repair or TEVAR for retrograde type A IMH/dissection that were published between 1st January 2000 and 31st March 2025. We included literatures that did not directly compare the two modalities and then pooled the event rates for comparison. RESULTS The meta-analysis included 24 studies—one comparative and 23 single-arm studies—with a total of 709 patients, comprising 259 who underwent open surgery and 450 who received TEVAR. The pooled in-hospital mortality was 3.9% (95% CI: 2.2–6.7; I 2 = 0.0%) for TEVAR and 12.5% (95% CI: 8.7–17.7; I 2 = 20.6%) for open surgery, showing a significant difference (logit event rate difference: –1.27; 95% CI: –1.94 to –0.60). TEVAR also showed fewer neurological complications, such as stroke and paraplegia (TEVAR: 4.1% 95% CI: 2.2 to 7.4; I2 = 0.0% vs Open: 11.6% 95% CI: 7.6 to 17.2; I2 = 30.9%), compared to open surgery. TEVAR also had a higher rate of false lumen thrombosis and IMH regression in the descending aorta (TEVAR: 97.4% 95% CI: 88.3 to 99.5; I2 = 0% vs Open: 72.0% 95% CI: 51.5 to 86.2; I2 = 50.8%). However, no significant differences were found in long-term mortality or the need for reintervention between the two groups. CONCLUSIONS This meta-analysis synthesizes current evidence for the use of TEVAR in retrograde type A IMH/dissection and use available information on open surgery as a reference. Our results suggested that TEVAR may be a safe and feasible alternative, with satisfactory short-term and long-term outcomes. Further large-scale studies are needed to clarify TEVAR’s role and its efficacy against open surgery.