| Summary: | Background: Minimally Invasive Staged Segmental Artery Coil Embolization (MIS<sup>2</sup>ACE) is a novel technique of spinal cord preconditioning used to reduce the risk of paraplegia in thoracoabdominal aortic aneurysm (TAAA) repair. In this study, we report our experience with MIS<sup>2</sup>ACE, including both degenerative and post-dissection TAAA, while we attempt to systematically summarize relevant data available in the literature. Design: single-center observational study with systematic review of the literature and meta-analysis. Methods: Initial retrospective analysis of 7 patients undergoing MIS<sup>2</sup>ACE over 12 sessions with a subsequent systematic review of the literature and meta-analysis of the available published data (PROSPERO protocol number: CRD42023477411). Baseline patient and aneurysm characteristics, along with procedural technique and outcomes, were analyzed. One-arm pooling of proportions was used to summarize available published data. Results: We treated seven patients (5 males, 71%) with a median age of 69 years (IQR 55,69). According to the Crawford classification, five patients (1%) had extent II TAAA, and two (29%) had extent III TAAA. Five patients (71%) had post-dissection -TAAA; four of them were after Stanford type A dissection, and one had a chronic type B dissection. Three patients (43%) had connective tissue disease. Of the seven patients, six (86%) underwent previous aortic surgery, while the median aneurysm diameter was 58 mm (IQR 55,58). MIS<sup>2</sup>ACE was successful in 11 sessions (92%). The median number of embolized arteries was 4 (IQR 1,4). There were no periprocedural complications in any embolization. The median embolization-operation time interval was 37.0 days (IQR 31,78). Two patients had open and five endovascular treatment. There were no events of spinal cord ischemia either after MIS<sup>2</sup>ACE or after the aortic repair. Out of the 432 initially retrieved articles, we included two studies in the meta-analysis, including patients with MIS<sup>2</sup>ACE for spinal cord preconditioning in addition to our cohort. The prevalence of pooled postoperative spinal cord ischemia among MIS<sup>2</sup>ACE patients is 1.9% (95% CI −0.028 to 0.066, <i>p</i> = 0.279; 3 studies; 81 patients, 127 coiling sessions). Conclusions: While the current published data is limited, our study further confirms that MIS<sup>2</sup>ACE is a technically feasible and safe option for spinal cord preconditioning.
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