Endovascular Versus Open Repair for Descending Thoracic Aortic Aneurysm: A Systematic Review of Outcomes in Younger...

The management of descending thoracic aortic aneurysms (DTAAs) in younger patients (<65 years) presents a unique challenge, balancing the minimally invasive benefits of thoracic endovascular aortic repair (TEVAR) against the potential long-term durability of open surgical repair (open aortic repair (OAR)). While TEVAR is established as a superior option in older, higher-risk cohorts, its outcomes relative to OAR in a younger demographic with longer life expectancy remain unclear. This systematic review aims to compare the perioperative and long-term outcomes of TEVAR versus OAR specifically in younger patients. A systematic literature search was conducted across PubMed/MEDLINE, Scopus, Web of Science, and Embase from 2015 to 2025, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they directly compared TEVAR and OAR for DTAA in patients under 65 years. Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment using the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool. A narrative synthesis was undertaken due to significant clinical heterogeneity. Eight retrospective studies, encompassing 55,621 patients, were included. The evidence consistently demonstrated that TEVAR was associated with superior perioperative outcomes, including significantly lower mortality, reduced stroke rates, shorter hospital stays, and decreased transfusion requirements. However, TEVAR was consistently linked to a substantially higher long-term reintervention rate compared to OAR. The evidence on long-term survival was conflicting, with some studies showing comparable rates and others suggesting a potential survival advantage for TEVAR. For younger patients with DTAA, TEVAR offers a favorable perioperative safety profile but at the cost of significantly reduced long-term durability, necessitating a higher rate of reinterventions. The choice between strategies should be individualized, weighing the short-term benefits of TEVAR against the long-term durability of OAR, with particular caution advised against the elective use of TEVAR in patients with connective tissue disorders.