Minimally invasive versus conventional techniques for proximal aortic surgery: A systematic review and meta-analysis of reconstructed patient-level data

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Abstract
Objective: Minimally invasive techniques represent a safe alternative to full sternotomy in proximal aortic surgery. This meta-analysis evaluates their efficacy in aortic root, ascending aortic, and aortic arch procedures compared with the conventional approach. Methods: A PRISMA-compliant systematic review and meta-analysis of matched cohorts was conducted, comparing minimally invasive surgery with full sternotomy. MEDLINE was searched for eligible studies. Continuous variables were analyzed using standardized mean differences and categorical data with odds ratios. Kaplan–Meier-derived individual patient data were used to assess survival. Subgroup analysis for elective cases was performed. Results: Seventeen studies with 3113 matched patients were included. Mean age was 58.1 ± 13.3 years for minimally invasive group versus 58.1 ± 12.8 years in full-sternotomy group (p = 0.29). Postoperative blood loss (612.5 versus 883.2 mL, p < 0.01), number of red blood cell units transfused (1.0 versus 2.2, p < 0.01) and postoperative ventilation time (15.3 versus 19.2 h, p < 0.01) were significantly lower in the minimally invasive group. Similarly, overall hospital (8.4 versus 9.4 days, p < 0.01) and intensive care unit stay (1.5 versus 1.8 days, p < 0.01) were decreased in minimally invasive group. Overall survival was significantly improved in minimally invasive patients (Hazard Ratio: 0.54, p = 0.045), which was not confirmed by two-stage meta-analysis (Hazard Ratio: 0.72, p = 0.29). Bypass and cross-clamp times, reinterventions, bleeding events and wound infections were comparable between the two groups. Conclusion: Minimally invasive proximal aortic surgery reduces perioperative morbidity, hospitalization and transfusion requirements compared with full sternotomy. While a survival benefit requires further confirmation, these findings support minimally invasive approaches as an effective and safe alternative in selected patients.

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