Comparisons of open surgical repair, thoracic endovascular aortic repair, and optimal medical therapy for acute and subacute type B aortic dissection: a systematic review and meta-analysis
Aortic dissection is attributed to blood entering the media layer due to aortic intimal tearing. It is a life-threatening emergency, and it is associated with a high mortality rate . Type B aortic dissection (TBAD) does not involve the ascending aorta, and its prognosis is relatively better . However, the optimal treatment of TBAD remains unclear. Most patients with TBAD use antihypertensive medications as standard care, while emergency surgical interventions are performed for patients with acute TBAD presenting with severe complications, and the prognosis is poor for patients treated with surgical procedures . Surgical interventions for TBAD include open surgical repair (OSR) and thoracic endovascular aortic repair (TEVAR). OSR is an effective treatment for TBAD in the aorta at adjacent or remote sites; however, treated patients remain at risk for aneurysm formation after surgery . Thus, TEVAR is more favorable than OSR for patients presenting with complications and is associated with better aortic remodeling and prevention of subsequent aortic rupture . A prior systematic review and meta-analysis identified 18 studies and found that TEVAR showed a lower risk of in-hospital mortality, cardiac and pulmonary complications, and shorter length of hospital stay than OSR. Moreover, TEVAR is associated with a reduced risk of long-term mortality, an elevated risk of paraplegia, higher complete thrombosis of the false lumen, and a longer length of hospital stay than the optimal medical therapy (OMT) . However, several included studies reported the same population and the results may have been overestimated. Thus, this systematic review and meta-analysis were performed to compare the treatment effects of OSR, TEVAR, and OMT in patients with acute and subacute TBAD.   Search strategy and selection criteria The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform this systematic review and meta-analysis . Studies that had assessed treatment strategies for acute or subacute TBAD were eligible for inclusion, and the publication language and status were not restricted. The electronic databases PubMed, Embase, and the Cochrane Library were systematically searched from their inception to September 2024, and the searched keywords included (“aortic dissection” AND “type B” OR “DeBakey III”) AND (“stent” OR “endovascular” OR “surgery” OR “medical” OR “medication”). We also reviewed the reference lists of original and review articles to identify any new eligible studies that met the inclusion criteria. Literature search and study selection were independently performed by two reviewers, and conflicts were resolved through group discussion until a consensus was reached. The inclusion criteria were as follows: (1) patients: all patients diagnosed with acute or subacute TBAD; (2) intervention and control: OSR, TEVAR, or OMT; (3) outcomes: at least one in-hospital mortality, long-term mortality, acute renal failure, stroke, paraplegia, myocardial infarction (MI), mesenteric ischemia, limb ischemia, reintervention, respiratory failure, and bleeding; and (4) study design: randomized controlled trials (RCTs), prospective or retrospective cohort studies. Articles that reported the most informative and complete data were selected when data were published more than once. Studies were excluded if they: (1) used alternative interventions or controls; (2) did not report investigated outcomes; and (3) were case reports or review articles. Data collection and quality assessment Two reviewers applied a standardized flow to extract all relevant information from the included studies, and any inconsistencies between the data collected by reviewers were resolved by discussion until a consensus was reached. The following data were collected: first author’s surname; publication year; study design; region; sample size; mean age; male proportion; hypertension proportion; coronary artery disease (CAD) proportion; Marfan syndrome proportion; prior aortic dissection proportion; diabetes mellitus (DM) proportion; aneurysm proportion; disease status; intervention; follow-up duration; and reported outcomes. The methodological quality of the RCTs was assessed using the risk of bias described by the Cochrane Collaboration , and the quality of observational studies was assessed using the Newcastle-Ottawa Scale (NOS) . Inconsistent results regarding quality assessment were resolved by an additional reviewer who referred to the full text of the article. Statistical analysis The treatment effects of OSR, TEVAR, or OMT for TBAD were assigned as categorical data, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated before data pooling. Subsequently, a random-effects model was used to calculate the pooled effect estimates, which considered the underlying variations across the included studies . Heterogeneity among the included studies for specific outcomes was assessed using I 2 and Q statistics, and significant heterogeneity was defined as I 2 > 50·0% or P < 0·10 . The robustness of the pooled conclusion was assessed using sensitivity analysis through the sequential removal of single studies . Subgroup analyses were performed for in-hospital mortality and long-term mortality on the basis of country, sample size, mean age, male proportion, and disease status, while the difference between subgroups were assessed using the interaction P test . Publication bias was assessed using both qualitative and quantitative methods, including funnel plots and Egger-Begg tests . All reported P values were 2-sided, and the inspection level was 0.05. All analyses were performed using the STATA software (version 14.0; Stata Corporation, College Station, TX, USA).   The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform this systematic review and meta-analysis . Studies that had assessed treatment strategies for acute or subacute TBAD were eligible for inclusion, and the publication language and status were not restricted. The electronic databases PubMed, Embase, and the Cochrane Library were systematically searched from their inception to September 2024, and the searched keywords included (“aortic dissection” AND “type B” OR “DeBakey III”) AND (“stent” OR “endovascular” OR “surgery” OR “medical” OR “medication”). We also reviewed the reference lists of original and review articles to identify any new eligible studies that met the inclusion criteria. Literature search and study selection were independently performed by two reviewers, and conflicts were resolved through group discussion until a consensus was reached. The inclusion criteria were as follows: (1) patients: all patients diagnosed with acute or subacute TBAD; (2) intervention and control: OSR, TEVAR, or OMT; (3) outcomes: at least one in-hospital mortality, long-term mortality, acute renal failure, stroke, paraplegia, myocardial infarction (MI), mesenteric ischemia, limb ischemia, reintervention, respiratory failure, and bleeding; and (4) study design: randomized controlled trials (RCTs), prospective or retrospective cohort studies. Articles that reported the most informative and complete data were selected when data were published more than once. Studies were excluded if they: (1) used alternative interventions or controls; (2) did not report investigated outcomes; and (3) were case reports or review articles.   Two reviewers applied a standardized flow to extract all relevant information from the included studies, and any inconsistencies between the data collected by reviewers were resolved by discussion until a consensus was reached. The following data were collected: first author’s surname; publication year; study design; region; sample size; mean age; male proportion; hypertension proportion; coronary artery disease (CAD) proportion; Marfan syndrome proportion; prior aortic dissection proportion; diabetes mellitus (DM) proportion; aneurysm proportion; disease status; intervention; follow-up duration; and reported outcomes. The methodological quality of the RCTs was assessed using the risk of bias described by the Cochrane Collaboration , and the quality of observational studies was assessed using the Newcastle-Ottawa Scale (NOS) . Inconsistent results regarding quality assessment were resolved by an additional reviewer who referred to the full text of the article.   The treatment effects of OSR, TEVAR, or OMT for TBAD were assigned as categorical data, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated before data pooling. Subsequently, a random-effects model was used to calculate the pooled effect estimates, which considered the underlying variations across the included studies . Heterogeneity among the included studies for specific outcomes was assessed using I 2 and Q statistics, and significant heterogeneity was defined as I 2 > 50·0% or P < 0·10 . The robustness of the pooled conclusion was assessed using sensitivity analysis through the sequential removal of single studies . Subgroup analyses were performed for in-hospital mortality and long-term mortality on the basis of country, sample size, mean age, male proportion, and disease status, while the difference between subgroups were assessed using the interaction P test . Publication bias was assessed using both qualitative and quantitative methods, including funnel plots and Egger-Begg tests . All reported P values were 2-sided, and the inspection level was 0.05. All analyses were performed using the STATA software (version 14.0; Stata Corporation, College Station, TX, USA).   Literature search and study selection Overall, 6,832 publications were identified through the literature searches; of these, 2,016 were excluded because of duplication. Further, 4,719 articles were excluded because of irrelevant titles or abstracts. The remaining 97 studies were retrieved for full-text evaluation, and five articles were identified from manual reviews of reference lists. Of the 102 full-text evaluations, 71 were excluded for the following reasons: other interventions ( n = 29), studies reporting the same population ( n = 20), no appropriate controls ( n = 18), and insufficient data ( n = 4). Finally, the remaining 31 studies were selected for meta-analysis , and Fig. shows the details regarding the literature search and study selection. Study characteristics Table shows the baseline characteristics of the included studies and patients. Of the 31 included studies, 3 were RCTs, and the remaining 28 were retrospective cohort studies. Overall, 34,681 patients with acute and subacute TBAD were identified in 31 studies, with sample sizes ranging from 24 to 9,165. Moreover, the follow-up duration ranged from in-hospital to 60.0 months. Twenty-one studies included patients with acute TBAD, and the remaining 10 studies included patients with acute and subacute TBAD. Tables S1 and S2 presents the methodological quality of the included studies; the included trials were of low to moderate quality, while the included observational studies were of moderate to high quality. In-hospital mortality The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of in-hospital mortality were 6, 9, and 12 studies, respectively. The summary results indicated OSR were associated with an increased risk of in-hospital mortality as compared with OMT (OR: 2.41; 95%CI: 1.67–3.49; P < 0.001) and TEVAR (OR: 2.67; 95%CI: 1.92–3.72; P < 0.001) (Fig. ). However, there was no significant difference between TEVAR and OMT for the risk of in-hospital mortality (OR: 1.09; 95%CI: 0.52–2.32; P = 0.817). There was no evidence of heterogeneity for OSR versus OMT ( I 2 = 0.0%; P = 0.444), while potential significant heterogeneity for OSR versus TEVAR ( I 2 = 40.7%; P = 0.096) and TEVAR versus OMT ( I 2 = 71.2%; P < 0.001). Sensitivity analyses found the pooled conclusions were stability and not altered by sequential removing single study (Figs. S1-S3). Subgroup analyses found OSR was associated with an increased risk of in-hospital mortality as compared with OMT and TEVAR in mostly subgroups. Moreover, TEVAR versus OMT was associated with a reduced risk of in-hospital mortality if pooled studies conducted in Eastern countries and patients with acute and subacute TBAD (Table ). Concerning potential biases in the published literature related to in-hospital mortality, neither the Egger’s test nor Begg’s test detected statistically significant evidence of publication bias when comparisons of, OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT, thus adding credibility to our findings (Figs. S4-S6). Long-term mortality The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of long-term mortality were 6, 9, and 19 studies, respectively. There were no significant differences for long-term mortality, irrespective comparisons of OSR versus OMT (OR: 1.81; 95%CI: 0.83–3.95; P = 0.138), OSR versus TEVAR (OR: 1.29; 95%CI: 0.94–1.78; P = 0.113), and TEVAR versus OMT (OR: 0.78; 95%CI: 0.58–1.05; P = 0.104) (Fig. ). There were significant heterogeneity among included studies when comparisons of OSR versus OMT ( I 2 = 63.4%; P = 0.018), OSR versus TEVAR ( I 2 = 66.1%; P = 0.003) and TEVAR versus OMT ( I 2 = 75.3%; P < 0.001). Sensitivity analysis found OSR might associated with an increased risk of long-term mortality as compared with TEVAR, and TEVAR versus OMT might showed lower risk of long-term mortality (Figs. S7-S9). Subgroup analyses found OSR versus OMT was associated with an increased risk of long-term mortality when pooling studies conducted in Eastern countries, and sample size < 100. OSR versus TEVAR showed an elevated risk of long-term mortality when pooled studies conducted in Western countries, mean age ≥ 65.0 years, and male proportion < 70.0%. TEVAR versus OMT was associated with a reduced risk of long-term mortality when pooled studies conducted in Eastern countries (Table ). Regarding potential publication biases in the long-term mortality data, neither Egger’s test nor Begg’s test detected statistically significant evidence of such biases (Figs. S10-S12). Acute renal failure The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of acute renal failure were 6, 6, and 11 studies, respectively. We noted OSR was associated with an increased risk of acute renal failure as compared with TEVAR (OR: 1.98; 95%CI: 1.61–2.42; P < 0.001), whereas OSR versus OMT (OR: 1.45; 95%CI: 0.60–3.49; P = 0.411), and TEVAR versus OMT (OR: 1.15; 95%CI: 0.78–1.70; P = 0.476) were not associated with statistically significant (Fig. ). There was no evidence of heterogeneity for OSR versus TEVAR ( I 2 = 0.0%; P = 0.681), whereas potential significant heterogeneity for comparisons of OSR versus OMT ( I 2 = 77.5%; P < 0.001) and TEVAR versus OMT ( I 2 = 49.0%; P = 0.033). The summary results for comparisons of OSR versus TEVAR, and TEVAR versus OMT on the risk of acute renal failure were stability, whereas OSR might associated with an increased risk of acute renal failure as compared with OMT (Figs. S13-S15). There were no significant publication bias for acute renal failure (Figs. S16-S18). Stroke The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of stroke were 5, 8, and 13 studies, respectively. We noted TEVAR versus OMT was associated with an increased risk of stroke (OR: 1.77; 95%CI: 1.41–2.21; P < 0.001), whereas OSR versus OMT (OR: 0.96; 95%CI: 0.29–3.15; P = 0.942) and OSR versus TEVAR (OR: 1.40; 95%CI: 0.75–2.63; P = 0.294) on the risk of stroke were not associated statistically significant (Fig. ). There were no significant heterogeneity across included studies when comparisons of OSR versus OMT ( I 2 = 15.6%; P = 0.315), OSR versus TEVAR ( I 2 = 31.8%; P = 0.174), and TEVAR versus OMT ( I 2 = 3.4%; P = 0.412). Sensitivity analysis found OSR might associated with an increased risk of stroke as compared with TEVAR, whereas the conclusions for comparisons of OSR versus OMT and TEVAR versus OMT on the risk of stroke were stability (Figs. S19-S21). No significant publication bias was observed for stroke (Figs. S22-S24). Other adverse events Table shows the summary results of the effects of OSR, TEVAR, and OMT on the risk of other adverse events. We observed that OSR versus OMT was associated with an increased risk of paraplegia (OR: 3.60; 95%CI: 2.20–5.89; P < 0.001), limb ischemia (OR: 7.80; 95%CI: 2.39–25.49; P = 0.001) and bleeding (OR: 9.54; 95%CI: 6.57–13.85; P < 0.001). Moreover, OSR versus TEVAR showed elevated risks of MI (OR: 2.76; 95%CI: 1.64–4.65; P < 0.001), respiratory failure (OR: 2.19; 95%CI: 1.73–2.76; P < 0.001), and bleeding (OR: 1.88; 95%CI: 1.33–2.67; P < 0.001), and lower risk of reintervention (OR: 0.30; 95%CI: 0.10–0.89; P = 0.030). Furthermore, we observed that TEVAR versus OMT was associated with an increased risk of limb ischemia (OR: 13.00; 95%CI: 4.33–39.06; P < 0.001), and bleeding (OR: 3.65; 95%CI: 2.40–5.55; P < 0.001).   Overall, 6,832 publications were identified through the literature searches; of these, 2,016 were excluded because of duplication. Further, 4,719 articles were excluded because of irrelevant titles or abstracts. The remaining 97 studies were retrieved for full-text evaluation, and five articles were identified from manual reviews of reference lists. Of the 102 full-text evaluations, 71 were excluded for the following reasons: other interventions ( n = 29), studies reporting the same population ( n = 20), no appropriate controls ( n = 18), and insufficient data ( n = 4). Finally, the remaining 31 studies were selected for meta-analysis , and Fig. shows the details regarding the literature search and study selection.   Table shows the baseline characteristics of the included studies and patients. Of the 31 included studies, 3 were RCTs, and the remaining 28 were retrospective cohort studies. Overall, 34,681 patients with acute and subacute TBAD were identified in 31 studies, with sample sizes ranging from 24 to 9,165. Moreover, the follow-up duration ranged from in-hospital to 60.0 months. Twenty-one studies included patients with acute TBAD, and the remaining 10 studies included patients with acute and subacute TBAD. Tables S1 and S2 presents the methodological quality of the included studies; the included trials were of low to moderate quality, while the included observational studies were of moderate to high quality.   The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of in-hospital mortality were 6, 9, and 12 studies, respectively. The summary results indicated OSR were associated with an increased risk of in-hospital mortality as compared with OMT (OR: 2.41; 95%CI: 1.67–3.49; P < 0.001) and TEVAR (OR: 2.67; 95%CI: 1.92–3.72; P < 0.001) (Fig. ). However, there was no significant difference between TEVAR and OMT for the risk of in-hospital mortality (OR: 1.09; 95%CI: 0.52–2.32; P = 0.817). There was no evidence of heterogeneity for OSR versus OMT ( I 2 = 0.0%; P = 0.444), while potential significant heterogeneity for OSR versus TEVAR ( I 2 = 40.7%; P = 0.096) and TEVAR versus OMT ( I 2 = 71.2%; P < 0.001). Sensitivity analyses found the pooled conclusions were stability and not altered by sequential removing single study (Figs. S1-S3). Subgroup analyses found OSR was associated with an increased risk of in-hospital mortality as compared with OMT and TEVAR in mostly subgroups. Moreover, TEVAR versus OMT was associated with a reduced risk of in-hospital mortality if pooled studies conducted in Eastern countries and patients with acute and subacute TBAD (Table ). Concerning potential biases in the published literature related to in-hospital mortality, neither the Egger’s test nor Begg’s test detected statistically significant evidence of publication bias when comparisons of, OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT, thus adding credibility to our findings (Figs. S4-S6).   The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of long-term mortality were 6, 9, and 19 studies, respectively. There were no significant differences for long-term mortality, irrespective comparisons of OSR versus OMT (OR: 1.81; 95%CI: 0.83–3.95; P = 0.138), OSR versus TEVAR (OR: 1.29; 95%CI: 0.94–1.78; P = 0.113), and TEVAR versus OMT (OR: 0.78; 95%CI: 0.58–1.05; P = 0.104) (Fig. ). There were significant heterogeneity among included studies when comparisons of OSR versus OMT ( I 2 = 63.4%; P = 0.018), OSR versus TEVAR ( I 2 = 66.1%; P = 0.003) and TEVAR versus OMT ( I 2 = 75.3%; P < 0.001). Sensitivity analysis found OSR might associated with an increased risk of long-term mortality as compared with TEVAR, and TEVAR versus OMT might showed lower risk of long-term mortality (Figs. S7-S9). Subgroup analyses found OSR versus OMT was associated with an increased risk of long-term mortality when pooling studies conducted in Eastern countries, and sample size < 100. OSR versus TEVAR showed an elevated risk of long-term mortality when pooled studies conducted in Western countries, mean age ≥ 65.0 years, and male proportion < 70.0%. TEVAR versus OMT was associated with a reduced risk of long-term mortality when pooled studies conducted in Eastern countries (Table ). Regarding potential publication biases in the long-term mortality data, neither Egger’s test nor Begg’s test detected statistically significant evidence of such biases (Figs. S10-S12).   The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of acute renal failure were 6, 6, and 11 studies, respectively. We noted OSR was associated with an increased risk of acute renal failure as compared with TEVAR (OR: 1.98; 95%CI: 1.61–2.42; P < 0.001), whereas OSR versus OMT (OR: 1.45; 95%CI: 0.60–3.49; P = 0.411), and TEVAR versus OMT (OR: 1.15; 95%CI: 0.78–1.70; P = 0.476) were not associated with statistically significant (Fig. ). There was no evidence of heterogeneity for OSR versus TEVAR ( I 2 = 0.0%; P = 0.681), whereas potential significant heterogeneity for comparisons of OSR versus OMT ( I 2 = 77.5%; P < 0.001) and TEVAR versus OMT ( I 2 = 49.0%; P = 0.033). The summary results for comparisons of OSR versus TEVAR, and TEVAR versus OMT on the risk of acute renal failure were stability, whereas OSR might associated with an increased risk of acute renal failure as compared with OMT (Figs. S13-S15). There were no significant publication bias for acute renal failure (Figs. S16-S18).   The number of studies reported the comparisons of OSR versus OMT, OSR versus TEVAR, and TEVAR versus OMT on the risk of stroke were 5, 8, and 13 studies, respectively. We noted TEVAR versus OMT was associated with an increased risk of stroke (OR: 1.77; 95%CI: 1.41–2.21; P < 0.001), whereas OSR versus OMT (OR: 0.96; 95%CI: 0.29–3.15; P = 0.942) and OSR versus TEVAR (OR: 1.40; 95%CI: 0.75–2.63; P = 0.294) on the risk of stroke were not associated statistically significant (Fig. ). There were no significant heterogeneity across included studies when comparisons of OSR versus OMT ( I 2 = 15.6%; P = 0.315), OSR versus TEVAR ( I 2 = 31.8%; P = 0.174), and TEVAR versus OMT ( I 2 = 3.4%; P = 0.412). Sensitivity analysis found OSR might associated with an increased risk of stroke as compared with TEVAR, whereas the conclusions for comparisons of OSR versus OMT and TEVAR versus OMT on the risk of stroke were stability (Figs. S19-S21). No significant publication bias was observed for stroke (Figs. S22-S24).   Table shows the summary results of the effects of OSR, TEVAR, and OMT on the risk of other adverse events. We observed that OSR versus OMT was associated with an increased risk of paraplegia (OR: 3.60; 95%CI: 2.20–5.89; P < 0.001), limb ischemia (OR: 7.80; 95%CI: 2.39–25.49; P = 0.001) and bleeding (OR: 9.54; 95%CI: 6.57–13.85; P < 0.001). Moreover, OSR versus TEVAR showed elevated risks of MI (OR: 2.76; 95%CI: 1.64–4.65; P < 0.001), respiratory failure (OR: 2.19; 95%CI: 1.73–2.76; P < 0.001), and bleeding (OR: 1.88; 95%CI: 1.33–2.67; P < 0.001), and lower risk of reintervention (OR: 0.30; 95%CI: 0.10–0.89; P = 0.030). Furthermore, we observed that TEVAR versus OMT was associated with an increased risk of limb ischemia (OR: 13.00; 95%CI: 4.33–39.06; P < 0.001), and bleeding (OR: 3.65; 95%CI: 2.40–5.55; P < 0.001).   This comprehensive quantitative systematic review and network meta-analysis were based on 31 studies involving 34,681 patients with acute and subacute TBAD who were treated with OSR, TEVAR, or OMT. These findings extend those previous systematic reviews  and provide exploratory results. This analysis revealed OSR versus OMT showed elevated risk of in-hospital mortality, paraplegia, limb ischemia, and bleeding; OSR versus TEVAR was associated with an increased risk of in-hospital mortality, acute renal failure, MI, respiratory failure, or bleeding, and lower risk of reintervention; TEVAR versus OMT showed an elevated risk of stroke, limb ischemia, and bleeding. Considering the methodological quality of the included studies, most (28/31) were retrospective cohort studies. Of the three included RCTs, all reported a high risk of blinding of participants, personnel, and other biases. Moreover, a trial conducted by Brunkwall et al. reported a high or unclear risk of bias, according to the Cochrane Collaboration . Furthermore, the methodological quality of observational studies is restricted by the representativeness of the exposed cohort, selection of the non-exposed cohort, and comparability based on the design or analysis. Thus, the conclusions of this study should be cautiously recommended in clinical practice, and further parallel comparisons of randomized controlled trials should be performed to verify the results of this study. The summary results indicated that OSR was associated with an elevated risk of in-hospital mortality as compared with TEVAR and OMT. Several reasons could explained the results of our study: (1) the severity of TBAD between groups are differing, and the subacute phase would be the optimal time for intervention, and suggested that there might be differences in the efficacy of TEVAR based on timing (hyperacute, acute, subacute, and chronic) in TBAD ; (2) OSR is always used for complicated TBAD, whereas patients with uncomplicated patients are always treated with OMT, which could affect the in-hospital mortality ; and (3) OSR is a more invasive surgical procedure that requires opening the chest and direct manipulation of the aorta, which not only increases the risk of bleeding and other complications during the surgery but also elevates the short-term mortality risk. However, no significant differences for the risk of long-term mortality when comparisons of OSR, TEVAR, and OMT, which was not consistent with previous meta-analyses . These results could explained by OSR can more thoroughly address the underlying issues causing TBAD, such as completely replacing the diseased vascular segment or reconstructing the blood flow pathway, which reduces the risk of future recurrent dissections or other cardiovascular events. Additionally, with improved postoperative care and adjustments to the patient’s lifestyle after recovery, those who successfully navigate the perioperative period often achieve better long-term outcomes. Finally, although using TEVAR could increase the true lumen diameter and reduce the false lumen diameter, aortic remodeling does not immediately translate into the prognosis of TBAD . OSR versus OMT increased the risk of paraplegia, limb ischemia, and bleeding. OSR is a highly invasive surgical procedure. During the operation, it requires opening the chest and directly manipulating the aorta, which can lead to inadequate blood supply to the spinal cord, thereby increasing the risk of paralysis. Additionally, direct manipulation of the vessels during surgery may damage surrounding vascular branches, leading to limb ischemia. Furthermore, the act of opening the chest itself increases the risk of intraoperative and postoperative bleeding, as this type of surgery involves extensive tissue incision and vascular exposure, making it more prone to hemorrhagic complications. OSR versus TEVAR showed an elevated risk of acute renal failure, MI, respiratory failure, or bleeding, and lower risk of reintervention. During OSR, the procedure requires opening the chest and directly manipulating the aorta, which can lead to prolonged hypotension and hemodynamic instability, thereby increasing the risk of acute kidney injury and MI. Additionally, the direct impact of the open-chest surgery on the lungs, along with postoperative pain and the need for mechanical ventilation, increases the likelihood of respiratory failure. Furthermore, the extensive tissue incision and vascular exposure during the surgery elevate the risk of intraoperative and postoperative bleeding. However, because OSR can more thoroughly address the underlying issues, completely replacing the diseased vascular segment or reconstructing the blood flow pathway, thus the risk of re-intervention is lower . We noted TEVAR was associated with an increased risk of stroke, limb ischemia, and bleeding as compared with OMT. During the TEVAR procedure, stent placement may be necessary to isolate ruptures or false lumens, which can occasionally compress or impact branch vessels, reducing blood flow to the limbs or vital organs and thereby increasing the risk of peripheral ischemia. Moreover, TEVAR, as a minimally invasive procedure, reduces the size of surgical incisions, it still carries risks of bleeding from the puncture site, vessel wall injury due to stent migration, and increased bleeding potential from subsequent anticoagulation therapy. Finally, the insertion of catheters and stents can disturb plaques or thrombi on the vessel walls, causing these materials to dislodge and travel to the brain via the bloodstream, leading to ischemic stroke. Additionally, the surgical procedure itself may generate small air bubbles, which can enter the circulation and cause cerebral vascular occlusion. Although TEVAR is a less invasive surgical method, these potential risk factors contribute to a relatively higher incidence of stroke. This study has some limitations. Firstly, our analysis encompassed data drawn from both RCTs and retrospective cohort studies, which might have introduced recall and selection biases that impacted the overall evidence quality. Secondly, a handful of outcomes were documented in a limited number of studies included, with low event frequencies, potentially undermining our statistical power to discern meaningful differences between diverse treatment modalities. Thirdly, disparities in the severity of TBAD across the OSR, TEVAR, and OMT cohorts could have skewed patient prognoses, complicating comparative interpretations. Lastly, reliance solely on published literature for our analysis may have obscured nuanced insights due to unavailable details and potentially introduced publication bias, skewing the aggregate findings.   This study systematically comparisons the effects of OSR, TEVAR, and OMT for treating acute and subacute TBAD. We noted OSR was associated with an increased risk of in-hospital mortality when compared with TEVAR and OMT. OSR versus OMT showed an increased risk of paraplegia, limb ischemia, and bleeding, whereas OSR versus TEVAR showed an elevated risk of acute renal failure, MI, respiratory failure, or bleeding, and lower risk of reintervention. Finally, TEVAR was associated with an increased risk of stroke, limb ischemia, and bleeding when compared with OMT. Further large-scale RCTs should be performed to verify the findings of this study owing to it could eliminate imbalances in patient characteristics.   Additional file 1: Table S1. Quality scores of observational studies using Newcastle-Ottawa Scale. Table S2. Methodological quality assessment using the Cochrane Risk of bias tool of randomized controlled trials describing outcomes. Figure S1. Sensitivity analysis for TEVAR versus OMT on the risk of in-hospital mortality. Figure S2. Sensitivity analysis for OSR versus OMT on the risk of in-hospital mortality. Figure S3. Sensitivity analysis for OSR versus TEVAR on the risk of in-hospital mortality. Figure S4. Funnel plot for TEVAR versus OMT on the risk of in-hospital mortality. Figure S5. Funnel plot for OSR versus OMT on the risk of in-hospital mortality. Figure S6. Funnel plot for OSR versus TEVAR on the risk of in-hospital mortality. Figure S7. Sensitivity analysis for TEVAR versus OMT on the risk of long-term mortality. Figure S8. Sensitivity analysis for OSR versus OMT on the risk of long-term mortality. Figure S9. Sensitivity analysis for OSR versus TEVAR on the risk of long-term mortality. Figure S10. Funnel plot for TEVAR versus OMT on the risk of long-term mortality. Figure S11. Funnel plot for OSR versus OMT on the risk of long-term mortality. Figure S12. Funnel plot for OSR versus TEVAR on the risk of long-term mortality. Figure S13. Sensitivity analysis for TEVAR versus OMT on the risk of acute renal failure. Figure S14. Sensitivity analysis for OSR versus OMT on the risk of acute renal failure. Figure S15. Sensitivity analysis for OSR versus TEVAR on the risk of acute renal failure. Figure S16. Funnel plot for TEVAR versus OMT on the risk of acute renal failure. Figure S17. Funnel plot for OSR versus OMT on the risk of acute renal failure. Figure S18. Funnel plot for OSR versus TEVAR on the risk of acute renal failure. Figure S19. Sensitivity analysis for TEVAR versus OMT on the risk of stroke. Figure S20. Sensitivity analysis for OSR versus OMT on the risk of stroke. Figure S21. Sensitivity analysis for OSR versus TEVAR on the risk of stroke. Figure S22. Funnel plot for TEVAR versus OMT on the risk of stroke. Figure S23. Funnel plot for OSR versus OMT on the risk of stroke. Figure S24. Funnel plot for OSR versus TEVAR on the risk of stroke.   