Comparative Outcomes of Endovascular and Open Surgical Repair for Extracranial Carotid Artery Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND: Extracranial carotid artery aneurysms (ECAAs) are rare lesions managed by open surgical repair (OpR) or endovascular repair (ER). We compared the perioperative and long-term outcomes of both strategies. METHODS: A Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-compliant systematic review and meta-analysis, registered in International Prospective Register of Systematic Reviews (PROSPERO), was performed. Comparative studies were pooled using random-effects models, and separate single-arm meta-analyses were conducted for OpR and ER. RESULTS: Twenty-six retrospective studies involving 707 patients and 725 procedures were included (574 OpR and 151 ER). Six comparative studies (228 procedures) showed no significant differences between ER and OpR in 30-day mortality (odds ratio [OR], 2.58; 95% confidence interval [CI], 0.53-12.52), 30-day stroke (OR, 1.08; 95% CI, 0.30-3.91), late stroke, reintervention, or primary patency. In the single-arm analyses, pooled 30-day mortality and stroke rates after OpR were 1.18% and 4.29%, respectively. No 30-day deaths and one stroke were reported after ER, yielding a pooled stroke rate of 1.25% (95% CI, 0.18-8.34). Primary patency was high after both OpR (98.44%) and ER (94.50%). CONCLUSION: Observational evidence suggests similar perioperative outcomes and similar observed late event rates for ER and OpR in ECAAs, although heterogeneous follow up and the absence of time-to-event analyses limit formal comparison of long-term durability. Both approaches were associated with low mortality, stroke, reintervention rates, and excellent primary patency. Open repair remains supported by a larger body of evidence and longer follow up, whereas evidence for ER remains comparatively limited. Because treatment allocation in the available studies was influenced by patient characteristics, anatomical complexity, and surgical risk, the observed similarity in outcomes should not be interpreted as evidence of therapeutic equivalence. Given the observational design and the predominantly moderate-to-serious risk of bias of the included studies, these findings should be interpreted with caution.