Covered endovascular reconstruction of the aortic bifurcation: A systematic review aggregated data and individual participant data meta-analysis

BACKGROUND:We investigated the early and mid-term efficacy and safety of covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aorto-iliac disease (AID). METHODS:A systematic search on PubMed, Scopus and Web of science for articles published by August 2023 was performed. The primary endpoints were primary patency and secondary patency. RESULTS:Eleven retrospective case series, involving 579 patients, were incorporated in the review with 88.9% of the included lesions being categorized as trans-Atlantic Inter-Society Consensus Document (TASC) C or D. The pooled primary patency estimates at twelve, twenty-four and thirty-six months were 94.4% (95% CI:89.4-99.7), 84.4% (95% CI:72.3-98.5) and 83.8% (95% CI:71.4-98.3) respectively. The mean primary patency time, representing the period during which individuals remained event-free, was 51.9 months (95% CI:43.6-55.4). The pooled thirty-six months primary patency for studies with a predominantly claudicant patient population (>75% of patients) was 89.4% (95% CI:78.5-100), compared to 71.5% (95% CI:45.6-100.0) for studies with a mixed population (50% of patients). The pooled thirty-six months primary patency for studies with a predominantly TASC D patient population (>82% of patients) was 70.4% (95% CI: 46.4-100.0) compared to 91.0% (95% CI: 79.1-100) for studies with a more homogenous cohort. The pooled secondary patency estimates at twelve, twenty-four and thirty-six months were 98.6% (95% CI:96.2-100), 97% (95% CI: 93.1-100) and 97% (95% CI:93.1-100). The pooled technical success, thirty-day mortality and thirty-day systemic complications estimates were 95.9% (95% CI: 93.7- 97.4), 1.9% (95% CI:1.0-3.5) and 6.4% (95% CI:4.4-9.1). The pooled intraoperative and post-operative thirty-day CERAB-related complications estimates were 7.3% (95% CI:2.0-23.0) and 4.2% (95% CI:0.7-21.0) respectively. The pooled major amputation and target lesion reinterventions by the end of follow-up were 1.9% (95% CI:1.0-3.4) and 13.9% (95% CI:9.9-19.2) respectively. The pooled access site complication estimate was 11.7% (95% CI:5.9-21.7). CONCLUSION:While this review has showcased the safety and feasibility of the CERAB technique in treating AID, it has also highlighted the necessity for a close and prolonged follow-up period extending beyond one year. Moreover, the favorable secondary patency estimates predominantly attained via endovascular reinterventions emphasize a potentially advantageous characteristic of the CERAB technique, particularly valuable when addressing late-stage AID disease or anatomically complex lesions.