Six-Year Outcomes of Total Arch Replacement vs Debranching With TEVAR for Aortic Arch Pathologies: Meta-Analysis of Kaplan-Meier–Derived Data From Propensity Score

Abstract

Background:

Total arch replacement (TAR) and debranching plus thoracic endovascular aortic repair (TEVAR) serve as significant therapeutic options for aortic arch pathologies. It remains unclear whether one of these approaches should be considered preferable. Our study aimed to compare the long-term outcomes of these 2 approaches.

Methods:

We carried out a pooled meta-analysis of time-to-event data extracted from studies published by December 2023. Eligibility criteria included populations with any aortic arch pathology who underwent debranching plus TEVAR or TAR, propensity score–matched (PSM) studies (prospective/retrospective; single-center/multicentric), and the outcomes included follow-up for overall survival/mortality and/or reinterventions.

Results:

Eleven PSM studies met our eligibility criteria, including a total of 1142 patients (571 matched pairs). We did not observe any statistically significant difference in the risk of all-cause death between the groups (hazard ratio [HR]=1.20, 95% confidence interval [CI]=0.91-1.56, p=0.202), but patients who underwent TAR had a significantly lower risk of late aortic reinterventions compared with patients who underwent debranching plus TEVAR (HR=0.38, 95% CI=0.23-0.64, p<0.001). Our meta-regression analyses for all-cause mortality identified statistically significant coefficients for age (coefficient=−0.047; p=0.012) and type A aortic dissections (coefficient=0.012; p=0.010).

Conclusions:

Debranching plus TEVAR and TAR demonstrate no statistically significant differences in terms of survival in patients with aortic arch pathologies, but TAR is associated with lower risk of late aortic reinterventions over time. Although older patients may benefit more from debranching plus TEVAR rather than from TAR, patients with dissections may benefit more from TAR.

Clinical Impact

Although the 2 strategies seem to be equally valuable in terms of survival, total aortic arch replacement (when compared with debranching plus TEVAR to treat patients with aortic arch pathologies) is associated with reduction of late aortic reinterventions over time in patients with and without aortic dissections. However, we should consider debranching plus TEVAR in older patients as it is associated with lower risk of death in this population. The novelty of our study lies in the fact that, instead of comparing study-level effect estimates, we analyzed the outcomes with reconstructed time-to-event data. This offered us the opportunity of performing our analyses with a mathematically appropriate model which consider events and time; however, these findings might be under the influence of treatment allocation bias.

Keywords

aortic diseases thoracic aorta endovascular procedures cardiovascular surgical procedures cardiac surgical procedures meta-analysis

Introduction

Total arch replacement (TAR) has been considered the standard surgical approach for aortic arch pathologies.^1,2 Despite improvements in surgical outcomes of TAR with experience accumulation and technical advancements, the mortality and morbidity of TAR remain non-negligible.^3,4 In recent years, hybrid surgical aortic arch repair combining open surgical aortic arch debranching and thoracic endovascular aortic repair (TEVAR) has gained popularity as a less aggressive approach and an alternative to TAR as it does not require cardiopulmonary bypass (in cases not involving the ascending aorta) and circulatory arrest.^5,6

Previous meta-analyses^5,6 which focused on early outcomes showed no statistically significant differences in terms of operative mortality, but rather differences in the rates of renal failure⁵ and stroke.⁶ Unfortunately, there is a lack of studies with longer follow-up of these patients beyond the initial periprocedural period and a lack of randomized controlled trials (RCTs) directly comparing TAR vs debranching plus TEVAR in the scenario of aortic arch pathologies. Although RCTs are not published, observational studies remain the main source of information.

To address this literature gap, we performed a systematic review with meta-analysis of reconstructed time-to-event data of propensity score–matched (PSM) studies with follow-up beyond the periprocedural period to compare outcomes of TAR vs debranching plus TEVAR in the setting of aortic arch pathologies.

Methods

Eligibility Criteria, Databases, and Search Strategy

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.⁷ Using the PICOS strategy (Population, Interventions, Comparison, Outcome, and Study design), studies were included if the following criteria were fulfilled:

The population comprised patients with any aortic arch pathology requiring intervention.

There was an intervention group undergoing debranching plus TEVAR.

There was a second intervention group undergoing TAR.

Outcomes studied included follow-up (accompanied by Kaplan-Meier curves) for overall survival/mortality and/or reinterventions;

The study design would be included if it were an observational PSM study (prospective/retrospective; matched; single-center/multicentric).

The following sources were searched for articles meeting our inclusion criteria and published by December 2023: PubMed/MEDLINE, EMBASE, CENTRAL/CCTR (Cochrane Controlled Trials Register). The search terms and their combinations are as follows: (“aortic arch” OR “aortic arch pathology” OR “aortic arch dissection” OR “non-A-non-B aortic dissection” OR “aortic arch aneurysm” OR “aortic arch ulcer” OR “aortic arch replacement” OR “aortic arch repair” OR “total aortic arch repair” OR “total aortic arch replacement” OR “frozen elephant trunk” OR “FET”) AND (“hybrid” OR “debranching” OR “thoracic endovascular aortic repair” OR “TEVAR”).

The following steps were taken for study selection: (1) identification of titles of records through database search; (2) removal of duplicates; (3) screening and selection of abstracts; (4) assessment for eligibility through full-text articles; and (5) final inclusion in study. Studies were selected by 2 independent reviewers (N.I. and X.J.). When there was disagreement, a third reviewer made the decision to include or exclude the study (D.A.). Ethical approval was not applicable for this study, as it consisted of a systematic review and meta-analysis. There were no language restrictions.

Assessment of Risk of Bias

The Cochrane tool ROBINS-I (Risk of Bias in Non-Randomized Studies of Interventions)⁸ were systematically used to assess included studies for risk of bias. Two independent reviewers assessed risk for bias (J.A.B. and S.Y). When there was a disagreement, a third reviewer checked the data and made the final decision (D.A.).

Statistical Analysis

The “curve approach”^9,10 which reconstructs individual patient data based on the published Kaplan-Meier graphs from the included studies was adopted. In this meta-analysis, the 2-stage approach was used as described by Liu et al¹¹ based on the R package “IPDfromKM” (version 0.1.10). In the first stage, raw data coordinates (time, survival probability) were extracted from each treatment arm in each of the Kaplan-Meier curves. In the second stage, the data coordinates were processed based on the raw data coordinates from the first stage in conjunction with the numbers at risk at given timepoints, and individual patient data were reconstructed.

Finally, the reconstructed individual patient data from all studies were merged to create the study data set. The cumulative incidence of the outcomes at follow-up in both treatment arms (debranching plus TEVAR vs TAR) were visually assessed using Kaplan-Meier estimates with the R packages “survival” (version 3.2-13) and “survminer” (version 0.4.9). Hazard ratios (HR) with 95% confidence intervals (CIs) for the difference between both treatment arms were calculated using a Cox regression model with the R package “coxphw” (version 4.0.2), incorporating study as a random effect. The proportionality of the hazards of the Cox model was checked with the Grambsch-Therneau test and diagnostic plots based on the Schoenfeld residuals.¹² Our protocol stated that flexible parametric survival models with B-splines and landmark analysis would be performed in case the proportional hazards assumption was violated as apparent either from these tests or from visual inspection of the Kaplan-Meier curves.

Much like Cox regression models, flexible parametric survival models (also known as Royston-Parmar models or generalized survival models) with B-splines provide HRs with 95% CIs as a measure of association between exposures and outcome, with the addition that they allow the time effect(s) to be smooth.^13,14 As a result, they do not depend on proportional hazards and can capture a wide range of hazard shapes. In this study, baseline hazard rate was modeled based on a spline with 4 degrees of freedom (dfs; 3 intermediate knots and 2 knots at each boundary, placed at quartiles of distribution of events), using the R package “rstpm2” (version 1.5.2). Interactions between treatment arm and time were added to the model using a second spline function. The resulting output estimates time-varying HRs with 95% CIs for every given timepoint during follow-up.

To assess total lifetime gain or loss with TEVAR, the restricted mean survival time (RMST)¹⁵ was calculated in the groups for all-cause mortality and aortic-related mortality and compared the difference between the groups (debranching plus TEVAR vs TAR). The RMST is a statistical measure used to describe the average survival time of a patient population, considering the limit of follow-up time. The difference between the RMST with debranching plus TEVAR and that with TAR represents the lifetime gain (if positive) or loss (if negative) with debranching plus TEVAR.

Mixed-effects meta-regression was performed using the DerSimonian-Laird estimator to verify possible modulating effect of covariates. Scatter plots were constructed with size of the points proportional to sample size. In addition, based on the mixed-effects meta-regression model, the predicted average HR as a function of the baseline variable is presented with corresponding 95% CI bounds.

All analyses were completed with R Statistical Software (version 4.1.1, Foundation for Statistical Computing, Vienna, Austria).

Results

Study Selection and Patients’ Characteristics

After excluding duplicates and non-eligible studies, 11 studies^16
–26 met our eligibility criteria (Figure 1), including a total of 1142 patients (571 patients in the debranching plus TEVAR group and 571 patients in the TAR group).

Characteristics of the studies and patients are shown in Tables 1 and 2, respectively. All studies were PSM observational studies. Five studies were carried out in China,^16
–19,22 4 studies in Japan countries,^20,23,24,26 1 study in Korea²¹ and 1 study in the United States.²⁵ The overall population had mean age ranging from 46.4 to 79.0 years, and the proportion of female patients ranged from 11.1 to 79.2%. Only 5 studies^{17,19,21
–23} reported whether Marfan patients were included and the prevalence ranged from 0.0% to 6.3%. Five studies^{16,20,21,23,26} excluded type A aortic dissections (TAADs) and 4 studies had high prevalence of TAAD^17
–19,22 ranging from 72.8% to 100.0%. Six studies^{16
–19,22,26} reported that TAR included frozen elephant trunk (FET) in 100.0% of cases, whereas 3 studies^20,21,24 reported that TAR did not include FET in their populations.

Table 1.

Characteristics of the Observational Studies Comparing Debranching Plus Thoracic Endovascular Aortic Repair (TEVAR) vs Total Aortic Arch Replacement (TAR) for Aortic Arch Pathologies.

Study	Study design	Country	Total sample(n)	Debranching+TEVAR(n)	TAR(n)	Adjustment for possible confounders and/or multivariable analysis
Tian et al¹⁶	NR, NP, SC	China	32	16	16	Yes (PSM)
Liu et al¹⁷	NR, NP, SC	China	118	59	59	Yes (PSM)
Liu et al¹⁸	NR, NP, SC	China	180	90	90	Yes (PSM)
Zhang et al¹⁹	NR, NP, SC	China	218	109	109	Yes (PSM)
Seike et al²⁰	NR, NP, SC	Japan	100	50	50	Yes (PSM)
Joo et al²¹	NR, NP, SC	Korea	96	48	48	Yes (PSM)
Ma et al²²	NR, NP, SC	China	52	26	26	Yes (PSM)
Yoshitake et al²³	NR, NP, SC	Japan	144	72	72	Yes (PSM)
Hiraoka et al²⁴	NR, NP, SC	Japan	86	43	43	Yes (PSM)
Preventza et al²⁵	NR, NP, SC	The United States	50	25	25	Yes (PSM)
Iba et al²⁶	NR, NP, SC	Japan	70	35	35	Yes (PSM)

Abbreviations: NR, non-randomized; NP, non-prospective; PSM, propensity score matching; SC, single-center; TAR, total arch replacement; TEVAR, thoracic endovascular aortic repair.

Table 2.

Baseline Characteristics of the Populations in the Observational Studies Comparing Debranching Plus Thoracic Endovascular Aortic Repair (D+TEVAR) vs Total Aortic Arch Replacement (TAR) for Aortic Arch Pathologies.

Study	Age(mean)D+TEVAR/TAR	FemaleSex (%)D+TEVAR/TAR	SAH(%)D+TEVAR/TAR	DM(%)D+TEVAR/TAR	Marfan syndrome(%)D+TEVAR/TAR	Renal failure (%)D+TEVAR/TAR	TAAD(%)D+TEVAR/TAR	FET(%)D+TEVAR/TAR
Tian et al¹⁶	47.3/46.4	25.0/18.7	75.0/93.8	0/0	NA	12.6/6.3	0.0/0.0	-/100
Liu et al¹⁷	59.5/58.1	32.2/28.8	81.4/78.0	5.1/3.4	0.0/0.0	5.1/6.8	81.4/86.4	-/100
Liu et al¹⁸	57.8/57.1	34.4/37.8	86.7/92.2	2.2/4.4	NA	1.1/2.2	72.2/77.8	-/100
Zhang et al¹⁹	60.2/60.7	33.0/33.0	81.7/84.4	3.7/5.5	3.7/5.5	5.5/4.6	84.4/89.0	-/100
Seike et al²⁰	79.0/79.0	28.0/24.0	NA	NA	NA	8.0/10.0	0.0/0.0	-/0.0
Joo et al²¹	67.8/67.6	79.2/79.2	81.3/77.1	20.8/22.9	2.1/6.3	31.3/35.4	0.0/0.0	-/0.0
Ma et al²²	50.4/50.7	23.1/15.4	84.6/84.6	34.6/34.6	0.0/0.0	NA	100/100	-/100
Yoshitake et al²³	73.0/72.8	12.5/11.1	NA	NA	0.0/0.0	1.4/5.6	0.0/0.0	-/NA
Hiraoka et al²⁴	73.2/73.9	30.2/25.6	83.7/88.4	16.3/14.0	NA	4.7/4.7	NA	-/0.0
Preventza et al²⁵	68.0/67.8	56.0/52.0	88.0/96.0	12.0/4.0	NA	28.0/24.0	8.0/12.0	-/NA
Iba et al²⁶	75.7/76.3	17.0/29.0	94.0/94.0	14.0/14.0	NA	17.0/11.0	0.0/0.0	-/100

Abbreviations: TAAD, type A aortic dissection; FET, frozen elephant trunk; DM, diabetes mellitus; SAH, systemic arterial hypertension; TEVAR, thoracic endovascular aortic repair; NA, non-available.

Figure 2 shows the assessment of risk of bias in the studies with ROBINS-I tools. For the domain of “bias due to confounding,” 2 studies were considered high risk due to remaining imbalances after the matching process. For the domain “bias due to selection of participants,” all studies were deemed moderate risk. For the domain “bias due to missing data,” all the studies were considered moderate risk. Owing to the observational nature of the studies included in this meta-analysis, our findings are subject to confounding, selection bias, and missing data.

All-Cause Mortality and Overall Survival

Figure 3 depicts the pooled Kaplan-Meier curve for all-cause mortality. The data of 1142 patients (571 patients in the debranching plus TEVAR group and 571 patients in the TAR group) were pooled from 11 studies. We did not find violation of the proportional hazards assumption in the Cox model (Grambsch-Therneau test; p=0.118). We did not observe any statistically significant difference in the risk of all-cause death between patients who underwent debranching plus TEVAR compared with patients who underwent TAR (HR=1.20, 95% CI=0.91-1.56, p=0.202).

Figure 4 presents the analysis of time-varying HRs for mortality based on flexible parametric survival models with B-splines. This revealed a tendency of higher risk with TAR in the beginning of the follow-up immediately after the procedure (although not statistically significant as we can see that the CI crosses HR 1 at all timepoints). The HR decreases rapidly and remains stable over time with no statistically significant difference.

Figure 5 presents the difference between the RMST with debranching plus TEVAR and that with TAR. No statistically significant lifetime gain or loss with debranching plus TEVAR when compared with TAR was observed.

Aortic Reinterventions

Figure 6 depicts the pooled Kaplan-Meier curve for aortic reinterventions. The data of 808 patients (404 patients in the debranching plus TEVAR group and 404 patients in the TAR group) were pooled from 6 studies. We did not find violation of the proportional hazards assumption in the Cox model (Grambsch-Therneau test; p=0.330). Patients who underwent TAR had a significantly lower risk of late aortic reinterventions compared with patients who underwent debranching plus TEVAR (HR=0.38, 95% CI=0.23-0.64, p<0.001).

Meta-Regression

We found statistically significant coefficients for the covariates age (Figure 7A) and TAAD (Figure 7B), which means that these covariates modulate the effect of treatments on the risk of all-cause mortality. Older populations tended to have lower risk of all-cause death with debranching plus TEVAR, whereas populations with higher prevalence of TAAD tended to have higher risk of all-cause death with debranching plus TEVAR.

No statistically significant coefficients for the following covariates were found: female sex, systemic arterial hypertension, diabetes mellitus, Marfan syndrome, renal failure, and FET (Supplemental Table 2). This means that these covariates did not have a modulating effect on our pooled results in terms of all-cause mortality.

Subgroup Analysis

Figure 8A depicts the pooled Kaplan-Meier curve for all-cause mortality. The data of 442 patients (221 patients in the debranching plus TEVAR group and 221 patients in the TAR group) were pooled from 5 studies with 0% cases of TAAD. We did not find violation of the proportional hazards assumption in the Cox model (Grambsch-Therneau test; p=0.223). We did not observe any statistically significant difference in the risk of all-cause death between patients who underwent debranching plus TEVAR compared with patients who underwent TAR (HR=0.84, 95% CI=0.53-1.33, p=0.450).

Figure 8B depicts the pooled Kaplan-Meier curve for aortic reinterventions. The data of 410 patients (205 patients in the debranching plus TEVAR group and 205 patients in the TAR group) were pooled from 4 studies with 0% cases of TAAD. We did not find violation of the proportional hazards assumption in the Cox model (Grambsch-Therneau test; p=0.431). Patients who underwent TAR had a significantly lower risk of late aortic reinterventions compared with patients who underwent debranching plus TEVAR (HR=0.08, 95% CI=0.03-0.23, p<0.001).

Discussion

Summary of Evidence

To the best of our knowledge, this is the first and largest meta-analysis of pooled reconstructed time-to-event data (with Kaplan-Meier–derived time-to-event data) comparing debranching plus TEVAR with TAR in patients with aortic arch pathologies.

The main findings of our study were the following:

In the overall 6-year follow-up, debranching plus TEVAR and TAR did not present statistically significant difference in overall survival.

Although not statistically significantly different, there seems to be a tendency of higher risk with TAR in the beginning of the follow-up immediately after the procedure in comparison with debranching plus TEVAR.

No lifetime gain or loss with debranching with TEVAR when compared with TAR.

In the overall 6-year follow-up, debranching plus TEVAR presented a higher risk of late aortic reinterventions in comparison with TAR.

Older populations tended to benefit more from debranching plus TEVAR, whereas populations with higher prevalence of TAAD tended to benefit more from TAR.

Our findings for survival and risk of late aortic reinterventions in the total sample remained consistent when we selected populations with aortic arch pathologies and no cases of TAAD.

These findings should be considered in the light of the presence of moderate-to-high risk of bias in the studies.

Comments

A recently-published meta-analysis²⁷ comparing debranching plus TEVAR vs TAR in the context of aortic arch pathologies evidenced that, in the context of aortic arch repair, debranching plus TEVAR was associated with lower rates of postoperative blood transfusion, acute renal failure, reoperation for bleeding, postoperative pulmonary complications, shorter length of intensive care unit stays, and hospital stays. On the contrary, TAR was associated with lower rates of spinal cord ischemia, postoperative permanent paraplegia, stroke, and all-cause death at 3 and 5 years of follow-up. We should keep in mind some aspects in that study:

Patients in the TAR group had fewer comorbid factors and were younger than those in the debranching plus TEVAR group—this happened because most of studies included were non-PSM studies (6 out of 16), whereas we included only PSM studies (11 out of 11) to minimize the impact of imbalances between the groups.

The authors excluded all studies in which FET combined with TAR (while we included studies with FET, which makes our study more compatible with contemporary practices).

Although their analyses for immediate outcomes can be considered valid (as they pooled the events immediate after the procedures over the same period), their analyses of follow-up data are to be seen with caution (as they combined HRs with different timepoints and follow-ups without taking into account that these HRs are time-to-event data, and thus, the authors should have the aspect of different timepoints and follow-ups in the studies considered while pooling and analyzing the data).

In the past, several authors have attempted to either pool median survival times, event rates or risk estimated from survival estimates at given timepoints, or direct estimates of the odds ratio, relative risk, or HRs across studies. All these approaches have been shown to be limiting and unsatisfactory, as they fail to recognize some of the central tenets of survival analysis such as censoring and the proportional hazards assumption.⁹ In response to inconsistent reporting that resulted from these diverging approaches, the “curve approach” has emerged as an alternative strategy for meta-analyses of aggregated time-to-event data,¹⁰ whereby meta-analysts can reconstruct individual patient data based on the published Kaplan-Meier graphs and this is exactly how this study was carried out, which eventually contributed to the different results in terms of survival over time—although Chen et al²⁷ found an advantage in the TAR group in terms of survival, we did not observe this advantage. Therefore, the study by Chen et al²⁷ should be seen as a study focused on immediate outcomes but not on follow-up.

Indeed, our analyses of the hazards over time (Figure 4) and RMST (Figure 5) do not support any advantage of one procedure over the other as observed by Chen et al,²⁷ although the hazards tended to be higher immediately after the procedure in the TAR group (as evidenced in Figure 4). However, we should be cautious about concluding that our survival findings were different from those published by Chen et al²⁷ only due to statistical aspects. The fact that we included only PSM studies (and consequently with fewer imbalances between the populations) and the presence of FET in 58.7% of our overall population highly likely played a role in our findings. As mentioned before, Chen et al²⁷ excluded all cases with FET from their analyses while we included FET as an important aspect to be analyzed in our study. Although we did not find any advantage in survival in our pooled analyses and no modulating factor of FET on survival, we found a statistically significant difference in terms of late aortic reinterventions favoring the TAR group, which probably happens owing to the promotion of aortic remodeling by concomitant FET similarly to what happens with TEVAR in the descending aorta.²⁸

In addition, despite the absence of difference in survival, we observed that age and the presence of TAAD had a modulating effect on our findings as evidenced in our meta-regression analyses (Figure 7). Although older populations presented lower hazards with debranching plus TEVAR, populations with higher proportions of TAAD tended to present higher hazards with debranching plus TEVAR when compared with TAR. It stands to reason that older populations would benefit less from a more aggressive approach such as TAR (which includes cardiopulmonary bypass, hypothermic circulatory arrest) as it is not uncommon that other factors (such as frailty, more comorbidities) may be at play. Contrarily, a more aggressive approach such as TAR would be beneficial for patients with a life-threatening disease such as TAAD and, indeed, TAR has been shown to be associated with better long-term survival and lower risk of need of late aortic reinterventions in the follow-up of patients treated for TAAD when compared with proximal aortic replacement without TAR.²⁹

Limitations

Owing to the absence of randomized trials in this specific scenario, this meta-analysis exclusively comprised observational studies susceptible to biases. Our results should be interpreted with caution, considering the overall risk of bias assessed and found to be moderate-to-high despite the inclusion of PSM studies exclusively (Figure 2). One should also bear in mind that incompleteness of follow-up in the individual studies reverberates in our pooled results, and we observed low number of patients at risk at longer follow-up.

Another limitation arises from our inability to determine whether patients treated with one approach or the other were suitable for both treatments. Some (or even many) of these patients might not have been suitable for both approaches; thus, patients treated with one of the approaches may have represented a subgroup with less favorable outcomes. Furthermore, the trigger for TEVAR or FET in these patients could not be clearly identified in the studies, which may have been the presence of high-risk features as established in the guidelines but are not clearly documented in the included studies (which may have led to treatment allocation bias). The surgeons’ expertise with TAR, FET, and TEVAR adds to the confounding components. Furthermore, lack of granularity in terms of description of the procedural details (such as type of stent graft, sizing strategies for circulatory arrest in TAR, etc) and single-center experience (very likely highly specialized in each study) may potentially limit the generalizability of our findings.

Another important aspect to be considered is that the TAAD populations included in this study comprised both complicated and uncomplicated cases. On one hand, this could add an additional selection bias. On the other hand, we see uncomplicated and complicated cases in both arms (debranching plus TEVAR and TAR with/without FET).

Furthermore, these analyses are not based on individual patient data and, hence, they are less granular and carry the risk of type II error due to absence of some variables which may have played a role in our final results. In addition, as we showed in our Table 1, our populations are mostly non-Western (from China, Japan, and Korea). The overall sample size for the Western cohorts was considerably small and corresponded to only 4.4% of cases. This points to the need of more studies in the Western world looking into this matter as the findings of our study may not be applicable to Western populations.

Conclusions

Our meta-analysis revealed that debranching plus TEVAR and TAR demonstrate no statistically significant differences in terms of survival in patients with aortic arch pathologies, but TAR is associated with lower risk of late aortic reinterventions over time; however, the underlying data are not strong enough to draw robust clinical conclusions and RCTs with large sample sizes and longer follow-up are warranted to elucidate this question.

Supplemental Material

sj-docx-1-jet-10.1177_15266028241266207 – Supplemental material for Six-Year Outcomes of Total Arch Replacement vs Debranching With TEVAR for Aortic Arch Pathologies: Meta-Analysis of Kaplan-Meier–Derived Data From Propensity Score–Matched Studies

Supplemental material, sj-docx-1-jet-10.1177_15266028241266207 for Six-Year Outcomes of Total Arch Replacement vs Debranching With TEVAR for Aortic Arch Pathologies: Meta-Analysis of Kaplan-Meier–Derived Data From Propensity Score–Matched Studies by Michel Pompeu Sá, Nidhi Iyanna, Xander Jacquemyn, James A. Brown, Sarah Yousef, Danial Ahmad, Michael J. Singh, Derek Serna-Gallegos and Ibrahim Sultan in Journal of Endovascular Therapy

Footnotes

Acknowledgements

None.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: I.S. receives institutional research support from Abbott, Artivion, Boston Scientific, Edwards, Medtronic, and Terumo Aortic. All other authors have reported that they have no relationships relevant to the contents of this study to disclose.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Michel Pompeu Sá

Danial Ahmad

Supplemental Material

Supplemental material for this article is available online.

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