Endovascular Versus Open Repair for Non-Complex Abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis

The risk of rupture and mortality associated with abdominal aortic aneurysms (AAA) necessitates timely surgical intervention. Open surgical repair (OSR) and endovascular aneurysm repair (EVAR) are the two primary surgical techniques, frequently compared for efficacy and safety. EVAR is less invasive and reduces perioperative mortality but carries a higher risk of long-term complications. This meta-analysis evaluates short- and long-term outcomes of EVAR and OSR in infrarenal non-complex AAA. A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Primary outcomes included perioperative mortality, long-term all-cause mortality, and aneurysm-related mortality. Secondary outcomes assessed reintervention, complication and limb graft occlusion (LGO) rates. Random-effects model were used for statistical analysis. Compared with OSR, EVAR significantly reduced perioperative mortality (OR = 0.45; 95% CI: 0.27-0.75; p = 0.002; I2 = 63%). At the longest follow-up (6-15 years), all-cause mortality did not differ significantly (OR = 1.06; 95% CI: 0.97-1.17; p = 0.22). Aneurysm-related mortality showed a non-significant trend toward higher rates after EVAR (OR = 1.17; 95% CI: 0.88-1.56; p = 0.29). Secondary interventions were significantly more frequent after EVAR (OR = 2.27; 95% CI: 1.32-3.93; p = 0.003). Pooled analysis demonstrated over fourfold increased odds of LGO with EVAR compared to OSR (OR = 4.07; 95% CI: 2.15-7.71; p < 0.0001). Endoleaks were the most common EVAR-related complication, with higher rates of Type I endoleak and LGO for Zenith Flex versus Endurant II in the Enzen Trial. EVAR confers a perioperative survival benefit over OSR but does not improve long-term all-cause mortality. Late aneurysm-related deaths, reinterventions, and LGO are more frequent after EVAR, emphasizing the need for lifelong surveillance and careful patient selection.