EARLY STROKE AFTER AORTIC ARCH REPAIR: COMPARATIVE AND PROPORTIONAL META-ANALYSES OF OPEN, HYBRID, AND TOTAL ENDOVASCULAR STRATEGIES.

OBJECTIVE

Early stroke remains one of the most devastating complications after aortic arch repair. This systematic review and meta-analysis evaluated early stroke after open, hybrid, and total endovascular aortic arch repair using separate comparative and proportional frameworks.

METHODS

PubMed, Scopus, and Web of Science were searched from inception through July 27, 2026. Observational studies reporting neurological outcomes after adult open, hybrid, or total endovascular aortic arch repair were included. The primary comparative meta-analysis pooled propensity score-matched or weighted studies comparing hybrid with open repair using random-effects restricted maximum likelihood models with Hartung-Knapp adjustment. Separate proportional random-effects meta-analyses estimated pooled stroke incidences for each strategy. Risk of bias was assessed using ROBINS-I and the Joanna. Briggs Institute Critical Appraisal Checklist. The protocol was prospectively registered in PROSPERO (CRD420261461659).

RESULTS

Thirty-four studies were included. Seven propensity score-matched or weighted cohorts comprising 948 patients (474 open and 474 hybrid repairs) contributed to the primary comparative meta-analysis. No significant difference in early stroke was identified between hybrid and open repair (OR 1.99, 95% CI 0.46-8.58; P=.292; I2=52.9%). Post hoc comparative analyses restricted to dissection cohorts (3 cohorts; 572 patients) and Zone 0 hybrid repair (3 cohorts; 448 patients) were also inconclusive and highly imprecise. In descriptive proportional analyses, pooled early-stroke incidences were 5.3% after open, 7.5% after hybrid, and 6.4% after total endovascular repair. Technique-stratified incidences were 6.1% for conventional open repair, 4.4% for open repair with frozen elephant trunk, and 5.3% for branched total endovascular repair.

CONCLUSION

Adjusted comparative evidence showed no significant difference in early stroke between hybrid and open aortic arch repair. Evidence for total endovascular repair remains predominantly non-comparative. Treatment should be individualised according to aortic pathology, urgency, anatomy, operative risk, and institutional expertise.