Endovascular Repair in High-Risk Uncomplicated Type B Aortic Dissection: A Systematic Review and Single-Arm Meta-Analysis

BACKGROUND: High-risk features in patients with uncomplicated type B aortic dissection (hrTBAD) have been associated with adverse aortic events and poor prognosis when managed with optimal medical therapy (OMT) alone. However, the role of thoracic endovascular aortic repair (TEVAR) in this specific subgroup remains controversial. While some studies suggest that early endovascular intervention may improve long-term aortic remodeling and reduce late complications, others emphasize the potential procedural risks and lack of randomized evidence. To address these uncertainties, we conducted a systematic review and single-arm meta-analysis to evaluate the early and long-term outcomes of TEVAR in patients with hrTBAD. METHODS: We searched MEDLINE, Embase, and Cochrane Library through January 2025 for studies reporting outcomes of TEVAR in hrTBAD. Eligible studies were observational cohorts or trials including patients with hrTBAD, as defined by Society for Vascular Surgery criteria. Data were synthesized using random-effects models. Individual patient data were reconstructed from Kaplan-Meier curves to estimate pooled survival. RESULTS: Ten retrospective cohort studies involving 1971 patients were included. Pooled early mortality was 1.22% (95% confidence interval [CI], 0.14%-2.96%), stroke 3.29%, spinal cord ischemia 1.10%, and early Stanford type A dissection 0.40%. Late outcomes showed survival rates of 88.0% at 1 year, 84.0% at 3 years, and 77.4% at 5 years. Reintervention occurred in 6.63%, with considerable heterogeneity. Late complications included retrograde type A dissection (2.27%), aortic rupture (2.63%), and stent-induced new entry (3.10%). Aortic remodeling analysis revealed a mean thoracic diameter reduction of 4.29 mm and a false lumen thrombosis rate of 14.65%. CONCLUSION: Thoracic endovascular aortic repair in hrTBAD patients is associated with low early mortality and favorable long-term survival and aortic remodeling, especially when performed during the subacute phase. Despite encouraging results, current evidence is limited to non-randomized studies. Further prospective trials are needed to refine patient selection and determine long-term efficacy.Clinical ImpactThis meta-analysis reinforces that thoracic endovascular aortic repair (TEVAR) for high-risk uncomplicated type B aortic dissection (hrTBAD) is safe and potentially beneficial, demonstrating low early mortality and encouraging aortic remodeling outcomes. However, the procedure is not devoid of complications, such as stroke, spinal cord ischemia, stent-induced new entry (SINE), or retrograde dissection, which may be infrequent in conservatively managed patients. Until randomized evidence becomes available, TEVAR should be considered on a case-by-case basis, integrating anatomical risk profiles, institutional expertise, and individualized prognostic assessment within multidisciplinary decision-making.