Abdominal Aortic Aneurysm and EVAR: Systematic Review with ☸️SAIMSARA.

• Generated: 2026-02-17 02:51:17 CET
• Plan: Pro (expanded craft tokens; source: Europe PMC)
• Source: Europe PMC
• Scope: Titles/Abstracts (tiab)
• Keyword Gate: Fuzzy (≥60% of required terms, minimum 2 terms matched in title/abstract)
• Total Abstracts/Papers: 3648
• Downloaded Abstracts/Papers: 3648
• Included original Abstracts/Papers: 2652
• Total study participants (naïve ΣN): 5870437

• Bias: Qualitatively inferred from study design fields.

• EVAR vs. Open Surgical Repair (OSR) Outcomes:
• EVAR is associated with lower perioperative/30-day mortality compared to OSR for AAA [13, 43, 257, 328, 355, 403, 509, 546, 621, 684, 742, 757, 907, 968, 997, 1162, 1192, 1508, 1509, 1510, 1511, 1529, 1539, 1609, 1689, 1733, 1882, 1889, 2034, 2054, 2060, 2488, 2503, 2504, 2508, 2523].
• Long-term overall and aneurysm-related mortality rates are often comparable between EVAR and OSR, though some studies suggest OSR may offer better long-term survival, particularly for younger, fitter patients [47, 133, 232, 255, 257, 299, 509, 514, 538, 590, 594, 607, 612, 897, 932, 1162, 1838, 2062].
• EVAR is associated with fewer postoperative complications, shorter hospital stays, and reduced blood loss compared to OSR [13, 73, 256, 257, 403, 757, 1015, 1370, 1643, 1689, 1733, 1838, 2488, 2503, 2508].
• OSR is associated with lower reintervention rates and secondary rupture rates compared to EVAR [13, 47, 232, 560, 575, 594, 595, 607, 897, 997, 1827, 2297].
• Ruptured AAA (rAAA) Management:
• EVAR for rAAA is associated with lower perioperative mortality compared to OSR [39, 208, 215, 257, 307, 328, 355, 423, 459, 486, 546, 561, 563, 599, 621, 750, 759, 810, 829, 861, 892, 900, 968, 1128, 1131, 1192, 1508, 1511, 1539, 1689, 1719, 1733, 1800, 1865, 1873, 1889, 1971, 2016, 2034, 2060, 2213, 2241, 2408, 2508, 2539, 2568].
• Hostile neck anatomy in rAAA is common, and while standard EVAR may require adjunctive procedures, it remains effective [173, 307, 335, 128, 1523].
• Specific techniques like chimney EVAR (Ch-EVAR) [45, 569] and balloon occlusion with thrombin injection [266, 750] are used for rAAA.
• Endoleaks and Reinterventions:
• Type II endoleaks (T2EL) are common after EVAR [111, 112, 119, 125, 203, 210, 223, 226, 239, 243, 250, 262, 273, 287, 290, 314, 399, 406, 432, 438, 440, 461, 470, 476, 498, 519, 521, 531, 533, 534, 541, 554, 602, 605, 624, 631, 637, 736, 822, 843, 852, 1042, 1058, 1181, 1182, 1558, 1602, 1815, 1835, 1837, 2020, 2022, 2030, 2308, 2435, 2476].
• Risk factors for T2EL include maximum aneurysm diameter, IMA diameter, number of patent lumbar arteries, and low preoperative NLR [112, 210, 314, 470, 534, 1182, 1602, 2435].
• Preemptive embolization of aortic side branches (IMA, lumbar arteries) can reduce T2EL incidence and promote sac shrinkage [50, 203, 226, 239, 250, 287, 406, 461, 533, 541, 602, 631, 843, 852, 1110, 1181].
• Type Ia endoleaks are associated with hostile neck anatomy (length, diameter, angulation, calcification) [11, 22, 45, 217, 332, 345, 396, 458, 472, 578, 597, 620, 697, 748, 831, 833, 839, 840, 845, 882, 920, 1032, 1145, 1161, 1640, 1719, 1853, 1899, 2026, 2031, 2249, 2261, 2271, 2493].
• Late aortic rupture (LAR) after EVAR has high mortality and is often due to type Ia and Ib endoleaks [297, 593, 2543].
• Reinterventions are common after EVAR, with rates up to 33.8% [111, 824, 1824, 2297].
• Anatomical Challenges & Device Adaptations:
• Complex aneurysms (juxtarenal, pararenal, thoracoabdominal) benefit from f-EVAR, b-EVAR, and Ch-EVAR, offering high technical success [93, 150, 217, 303, 334, 343, 356, 358, 391, 394, 444, 449, 527, 569, 578, 579, 586, 588, 597, 650, 677, 742, 751, 753, 787, 812, 849, 870, 874, 876, 916, 918, 922, 1015, 1029, 1032, 1054, 1184, 1189, 1462, 1491, 1529, 1571, 1582, 2078, 2217, 2225, 2237, 2506, 2517].
• Hostile neck anatomy (short, wide, angulated, conical, calcified) increases risk of endoleaks and reinterventions [22, 217, 332, 345, 396, 457, 472, 517, 565, 595, 697, 828, 831, 882, 1515, 1522, 1552, 1853, 2261, 2271, 2286, 2320].
• Specific devices and techniques (e.g., Heli-FX EndoAnchors [289, 1523], Kabedon technique [51], physician-modified grafts [90, 1189], custom-made semi-branch stent-grafts [150], bundle wire technique [303]) are developed to address complex anatomies.
• Iliac artery characteristics (narrow, tortuous, oversizing, length, diameter) influence limb occlusion and endoleak risk [65, 213, 409, 424, 626, 641, 1011, 1129, 1823, 1599, 1961, 2089, 2505].
• Patient-Specific Factors and Risk Stratification:
• Older age (octogenarians) is associated with increased mortality risk after EVAR [22, 156, 514, 625, 827, 837, 925, 1192, 1193, 1447, 1508, 1510, 1800, 2050, 2221, 2260].
• Female patients exhibit distinct vascular morphology (narrower, shorter, more angulated necks, smaller vessel diameters), impacting EVAR suitability and increasing risk of Type I endoleaks and complications [22, 86, 345, 428, 572, 833, 979, 1107, 1581, 1638, 1798, 2089, 2242, 642].
• Comorbidities like chronic kidney disease (CKD) [74, 302, 1441], poor nutritional status [53, 196, 359, 1545, 556], sarcopenia [100, 104, 556, 1195], and chronic obstructive pulmonary disease (COPD) [46, 196, 2269] are predictors of adverse outcomes and mortality.
• Preoperative biomarkers (e.g., NLR, PLR, L-FABP, hsCRP, D-dimer, miRNA-1281) can predict mortality, AKI, and endoleak risk [79, 136, 209, 300, 314, 614, 624, 664, 666, 825, 967, 1718].
• Imaging, Monitoring, and AI:
• Computed tomography angiography (CTA) is crucial for preoperative planning, postoperative follow-up, and complication detection [60, 537, 859, 1036, 1135, 1430, 2251, 2414].
• Intravascular ultrasound (IVUS) offers benefits in reducing contrast and radiation, especially for renal impairment patients [15, 505, 1358].
• AI and machine learning models show promise in predicting endoleak risk [131, 545], sac regression [181, 195], and long-term survival [53, 66, 104, 196], as well as accurate AAA diameter measurement and segmentation [320, 733, 582, 510, 929].
• Value-based imaging strategies emphasize ultrasound for screening and follow-up to reduce radiation and costs [97, 285, 374, 526, 1870].
• Hemodynamic and Aortic Wall Changes:
• EVAR induces hemodynamic alterations, including increased aortic stiffness and changes in flow velocity and energy loss [16, 304, 522, 523, 1139, 1880].
• Aneurysm sac shrinkage is a key indicator of treatment success, influenced by factors like aneurysm wall enhancement (AWE) [102], intraluminal thrombus (ILT) characteristics [195, 908], and preemptive embolization [50, 203, 226, 239, 250, 287, 406, 461, 533, 541, 602, 631, 843, 852, 1110, 1181].
• Sac expansion can occur even without endoleak, potentially due to hypoxia in the aortic wall [381, 2356].
• Healthcare System and Cost-Effectiveness:
• EVAR is generally more cost-effective than OSR, offering higher quality-adjusted life years (QALYs) at a lower cost [39, 325, 357, 590, 757, 1476, 1543, 1221].
• Centralization of vascular services and protocol-based treatment for rAAA can improve outcomes [164, 204, 423, 1539, 1865, 1873].
• Disparities exist in post-EVAR surveillance and emergency service use, particularly for older, female, Black, and socioeconomically disadvantaged patients [143, 272, 2242].
• Medicare reimbursement for complex EVAR may be inadequate [787].

• Patient Selection & Risk Stratification: EVAR is generally safer short-term than OSR, especially for older [1510, 2260] and frail patients [100, 648, 1560], but careful assessment of comorbidities (e.g., CKD, poor nutrition, sarcopenia) and anatomical factors (hostile neck, iliac artery dimensions) is critical to optimize outcomes and manage risks [22, 53, 86, 104, 156, 196, 302, 345, 359, 457, 472, 556, 572, 595, 611, 625, 827, 837, 908, 967, 1107, 1195, 1360, 1552, 1581, 1638, 1665, 1719, 1828, 2036, 2050, 2054, 2089, 2269, 2271, 2286, 2320].
• Enhanced Imaging & Pre-procedural Planning: Advanced imaging (IVUS, 4D-CT, CO2 angiography) and AI/ML tools are valuable for precise sizing, reducing contrast/radiation, predicting endoleaks, and optimizing stent-graft deployment, especially in complex anatomies [15, 60, 70, 97, 131, 186, 229, 313, 316, 320, 350, 374, 380, 505, 526, 537, 539, 582, 599, 733, 859, 1090, 1115, 1135, 1172, 1199, 1358, 1437, 1466, 1644, 1812, 1870, 2030, 2098, 2157, 2211, 2239, 2251, 2298, 2360, 2513, 2515].
• Proactive Endoleak Management: Preemptive embolization of aneurysm sac branches (IMA, lumbar arteries) should be considered to reduce the incidence of type II endoleaks and promote sac shrinkage, thereby potentially improving long-term durability and reducing reinterventions [50, 203, 226, 239, 250, 287, 406, 461, 533, 541, 602, 631, 843, 852, 1110, 1181, 2476, 2555].
• Lifelong Surveillance & Patient Education: Despite advancements, EVAR requires lifelong surveillance due to the risk of late complications like endoleaks, sac expansion, and rupture [56, 60, 113, 127, 290, 297, 399, 508, 537, 540, 562, 605, 620, 627, 665, 749, 824, 891, 935, 949, 1036, 1042, 1075, 1815, 1824, 1827, 1853, 1971, 2022, 2062, 2090, 2250, 2311, 2493, 2543]. Patient education on adherence to follow-up protocols is crucial [127, 2250].
• Addressing Sex-Specific Disparities: Women present with more challenging vascular anatomy and higher rates of Type I endoleaks and complications after EVAR, necessitating tailored strategies and possibly different IFU criteria [22, 86, 345, 428, 572, 833, 979, 1107, 1581, 1638, 1798, 2089, 2242, 642].

• Long-term Outcomes in Complex EVAR: Further long-term studies are needed to assess the durability and reintervention rates of f-EVAR, b-EVAR, and Ch-EVAR for complex aneurysms, especially beyond 5 years [58, 93, 343, 358, 394, 444, 449, 558, 569, 586, 812, 870, 916, 918, 1029, 1529, 2078, 2217, 2237, 2506].
• Optimal Surveillance Protocols: Research is needed to define optimal, cost-effective, and patient-compliant surveillance protocols that balance early detection of complications with reduced radiation exposure and healthcare burden [97, 143, 285, 374, 562, 891, 1036, 1870, 2250, 2297, 2414].
• Biomarker-Guided Management: Prospective studies are warranted to validate the clinical utility of emerging biomarkers (e.g., L-FABP, NLR, D-dimer, miRNA-1281) for predicting AKI, endoleaks, sac regression, and long-term mortality, potentially enabling personalized follow-up and interventions [79, 136, 189, 209, 300, 314, 603, 614, 624, 664, 666, 825, 967, 1718].
• Impact of Aortic Stiffness & Hemodynamics: Further research is needed to understand the long-term clinical implications of EVAR-induced changes in aortic stiffness and hemodynamic forces on stent-graft integrity, aortic neck dilatation, and overall cardiovascular health [16, 19, 159, 304, 428, 442, 522, 523, 565, 817, 855, 1139, 1279, 1427, 1812, 1880, 2249, 2321, 2356, 2360, 2430, 2433, 2461, 2493].
• EVAR in Specific High-Risk Populations: More robust evidence (e.g., RCTs) is needed for EVAR outcomes in understudied high-risk groups, such as pregnant patients [1], those with infective aneurysms [124, 199, 244, 267, 277, 349, 385, 532, 601, 640, 910, 913, 983, 1163, 2086, 2403, 2449, 2541], and those with complex comorbidities like horseshoe kidney [94, 413, 606, 1662] or concomitant cancer [75, 1596, 2238, 252].

• Heterogeneous Study Designs — The variability in study designs (case reports, cohorts, mixed studies) limits the ability to perform robust meta-analysis and draw definitive conclusions.
• Lack of Standardized Outcomes — Inconsistent reporting of specific metrics (e.g., 30-day vs. perioperative mortality) and follow-up durations across studies hinders direct comparisons.
• Selection Bias in EVAR — EVAR is often preferentially offered to higher-risk patients or those with specific anatomies, potentially biasing outcome comparisons with OSR.
• Limited Long-Term Data — While some studies extend to 10+ years, comprehensive long-term data for newer EVAR techniques and devices, especially for complex aneurysms, remain sparse.
• Qualitative Bias in Synthesis — The qualitative synthesis of disparate numerical and descriptive data may introduce interpretation bias.

• Standardized Outcome Reporting — Implement standardized reporting of perioperative and long-term outcomes for EVAR to facilitate future meta-analyses.
• Comparative Effectiveness Research — Conduct more head-to-head comparative studies (e.g., RCTs) comparing advanced EVAR techniques with OSR for complex AAAs.
• AI-Driven Predictive Models — Develop and validate AI/ML models for personalized risk prediction and treatment planning, integrating comprehensive patient and anatomical data.
• Biomarker Validation Trials — Design prospective trials to validate the clinical utility of novel biomarkers for early detection of complications and personalized surveillance strategies.
• Patient-Centered Outcome Measures — Incorporate patient-reported outcomes (e.g., quality of life, functional status) more consistently in long-term follow-up studies.