Journal of Cardiology and Heart Failure

ABSTRACT

Background

Porcelain aorta (PA) presents a major technical challenge in cardiovascular surgery due to the risks associated with aortic cross-clamping. Both open and endovascular surgical approaches have been utilized to manage this condition, yet comparative outcome data remain limited and fragmented.

Objective

This systematic review and meta-analysis aimed to evaluate perioperative and mid-term outcomes of open and endovascular strategies in patients with coexisting porcelain aorta and to summarize the available evidence regarding these treatment approaches.

Methods

A comprehensive literature search identified 350 studies, of which 20 met the inclusion criteria, encompassing 1249 patients. Among them, 385 underwent open surgery and 864 received endovascular interventions. The primary outcomes analyzed included 30-day mortality, stroke, bleeding, and other complication rates. Secondary outcomes comprised ICU stay duration, technical success, 1- and 5-year survival, and re-intervention rates. Sensitivity analyses and publication bias assessments were conducted. Study quality was appraised using the ROBINS-I v2 tool and the Joanna Briggs Institute (JBI) checklists.

Results

The pooled 30-day mortality rate was 3.1% (95% CI: 0.7%–6.7%) in studies of open surgery and 5.4% (95% CI: 2.7%–8.9%) in studies of endovascular procedures. The pooled complication rate, excluding stroke and bleeding, was 26.3% (95% CI: 13.3%–41.4%) and 40.4% (95% CI: 27.0%–54.5%), respectively. Stroke and bleeding rates were similar across both groups. ICU stay was longer in studies of open surgery, while technical success rates were high in both approaches. One-year survival estimates were comparable, whereas long-term survival data remained limited. Re-intervention rates were low in both groups. A single study evaluating hybrid approaches reported favorable short-term outcomes. Sensitivity analyses identified studies contributing to heterogeneity, and publication bias was detected in selected outcomes.

Conclusion

Both open and endovascular strategies for the management of porcelain aorta demonstrated acceptable outcomes in separate single-arm meta-analyses. However, because pooled estimates were derived from non-comparative analyses and substantial clinical heterogeneity and selection bias were present across studies, no conclusions regarding the superiority of one approach over the other can be drawn. Hybrid approaches appear promising but remain supported by limited evidence. Treatment decisions should be individualized based on patient characteristics, anatomical considerations, and surgical expertise.

Keywords: Porcelain Aorta; Hostile Aorta; Endovascular; Surgical; SRMA; Single Arm Meta-Analysis; Outcomes