Branch-First Technique of Aortic Arch Replacement: A Systematic Review and Meta-Analysis

Objectives. Aortic arch replacement is a major surgical intervention. This meta-analysis aims to combine the international literature on the branch-first technique to describe its outcomes and offer a comparison to the standard techniques. Methods. PubMed and Cochrane were searched for studies on the branch-first technique in aortic arch surgery including those comparing this technique with the conventional ones. Mortality, neurological complications, bleeding, and renal replacement therapy were the major endpoints of interest. Subgroup analysis was performed for both single- and double-armed studies. Odds ratios with 95% confidence interval were used as summary estimates. The random-effects model was used for all outcomes. Results. Ten studies from three countries with a total of 498 patients were included. Proportional analysis of the branch-first technique estimated mortality of (3%, 95% CI [0.02-0.05]), neurological complications of (8%, 95% CI [0.03-0.13]), re-exploration for bleeding of (9%, 95% CI [0.05-0.13]), and renal replacement therapy of (9%, 95% CI [0.05-0.12]). This meta-analysis revealed no significant differences between the branch-first technique and the conventional technique in mortality (5% vs. 15%, OR = 0.32, 95% CI [0.08-1.18], p=0.09, I2 = 40%), neurological complications (10% vs. 16%, OR = 0.53, 95% CI [0.24-1.21], p=0.13, I2 = 0%), or renal replacement therapy (12% vs. 14%, OR = 0.72, 95% CI [0.33-1.59], p=0.41, I2 = 0%). Conclusions. Branch-first technique provides a promising alternative approach in aortic arch surgery with no different surgical risks and potentially reduced operative complexity. Randomised controlled trials are needed to further investigate the safety and advantages of this technique.