Outcomes of Custom Made and Off the Shelf Endografts for Preservation of the Left Subclavian Artery during Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-analysis

OBJECTIVE: This systematic review aimed to evaluate the safety, feasibility, and effectiveness of dedicated endovascular techniques for left subclavian artery (LSA) preservation during thoracic endovascular aortic repair (TEVAR) (PROSPERO CRD42024568126). DATA SOURCES: MEDLINE, Scopus, Embase, and Cochrane Library databases. REVIEW METHODS: A systematic literature search followed the PRISMA guidelines. Eligible studies reported on patients with aortic pathologies treated with a single branched or single fenestrated endograft, off the shelf or custom made, intended for preservation of the LSA. Risk of bias was assessed using the Cochrane ROBINS-I tool, and the certainty of evidence using the GRADE framework. A proportion meta-analysis was performed reporting pooled rates with 95% confidence intervals (CIs). RESULTS: Twenty-one studies (1 123 patients) published between 2015 and 2024 were included. The most common indication for treatment was type B aortic dissection, followed by thoracic aneurysm. Off the shelf devices were used in 23.7% and custom made devices in 76.3%. The pooled technical success rate was 98.75% (95% CI 97.89 - 99.49%) and 30 day mortality rate was 0.87% (95% CI 0.22 - 1.81%). The pooled 30 day stroke rate was 1.32% (95% CI 0.51 - 2.38%) and spinal cord ischaemia rate 0.06% (95% CI 0 - 0.59%). At 12 months, the pooled mortality rate was 2.5% (95% CI 1.27 - 4.02%). A subgroup analysis stratified by geographical region (Asian vs. European and North American studies) showed a higher incidence of stroke and 30 day cardiovascular events in European and North American studies, and higher 12 month target vessel occlusion rates in Asian studies. However, according to the GRADE classification, the overall certainty of the evidence was low. Considerable clinical and methodological heterogeneity and the use of devices not available outside Asia further limit the generalisability of the results. CONCLUSION: Despite the low evidence of the available data, the use of custom made and off the shelf single branched or fenestrated endografts for LSA preservation during TEVAR shows promising feasibility, safety, and durability in selected patients managed at high volume centres.