Endovascular aneurysm repair (EVAR) wins early, especially in ruptured and high-risk Abdominal aortic aneurysm — but open repair still wins durability in younger, fitter patients. This review maps where the trade-off truly lies: early survival and faster recovery versus lifelong surveillance, reintervention burden, renal decline, endoleaks, and uncertain late risks.
Human-verified editorial review
Verified by World ID proof-of-human. This editorial layer was submitted from a SAIMSARA account verified as a unique human.
Abstract: The aim of this paper is to synthesize contemporary evidence comparing endovascular aneurysm repair (EVAR) and open surgical repair (OSR) across elective and emergency settings. Specifically, this review evaluates perioperative and long-term mortality, reintervention rates, postoperative complications (including renal and cardiac events), cost-effectiveness, and patient-reported quality of life. The review utilises 775 original studies with 8334526 total participants (topic deduplicated ΣN). The mapped evidence indicates that EVAR confers a clear early perioperative survival advantage over OSR in both elective (1.7% vs 4.7%) and ruptured (17.9% vs 32.1%) abdominal aortic aneurysm presentations, but this benefit attenuates over time and is offset by substantially higher reintervention rates (16.7%–31.6% vs 4.6%–6.9%) and signals of inferior late survival in younger and lower-risk cohorts. Across the synthesized topics, recurrent signals support open repair durability advantages in fitter patients, endovascular advantages in elderly, obese, and ruptured presentations, and persistent concerns regarding endoleaks, delayed renal decline, arterial stiffness, and possible abdominal cancer risk after endovascular repair. The evidence map also highlights that hospital and surgeon volume, frailty, hostile neck anatomy, and socioeconomic access modulate outcomes more strongly than the choice of repair alone. Clinically, these patterns support an individualized, risk-stratified approach in which endovascular repair is prioritized for ruptured aneurysms and high-risk or elderly patients with suitable anatomy, while open repair remains a durable option for younger low-risk candidates treated at high-volume centers. A major uncertainty is the heterogeneity of long-term outcomes across anatomic complexity, device generation, and health system context, suggesting that future research should focus on prospective, registry-linked comparative studies that integrate frailty, anatomic suitability, late renal and oncologic outcomes, and conversion strategies after failed endovascular repair to refine patient selection in the contemporary endovascular era.
Final search date and database lock: 2026-04-28 16:22:57 CEST
Plan: Pro (expanded craft tokens; source: PubMed)
Source: PubMed
Total Abstracts/Papers: 2425
Downloaded Abstracts/Papers: 2425
Included original and non-original Abstracts/Papers (all): 894
Included original Abstracts/Papers (Vote counting by direction of effect): 775
Reference Index (links used in paper): 159
Total participants (topic deduplicated ΣN): 8334526
Get access to the full paper
Unlock the full evidence map
The full evidence review, including the Introduction, Methods, Results, Discussion, Conclusion, figures, and complete reference index, opens after purchase or sign-in.
The Evidence Object JSON is a separate machine-readable evidence product: a concentrated synthesis of results, topic-level evidence, and discussion across original and non-original studies. It can be directly input into your LLM, agent, or RAG workflow.
[2] Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. — https://doi.org/10.1016/s0140-6736(05)66627-5
[3] Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. — https://doi.org/10.1016/s0140-6736(16)31135-7
[30] Long-Term Outcomes of Endovascular vs Open Surgical Repair for Abdominal Aortic Aneurysms: A Meta-Analysis of Randomized Trials. — https://doi.org/10.1016/j.carrev.2020.02.015
[33] Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm. — https://doi.org/10.1002/bjs.5911
[47] Comparative effectiveness of endovascular versus open repair of ruptured abdominal aortic aneurysm in the Medicare population. — https://doi.org/10.1016/j.jvs.2013.08.093
[54] Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms: A Comparative Study and Meta-Analysis of the Literature. — https://doi.org/10.1177/1538574415602780
[58] Treatment Trends and Outcomes of Endovascular versus Open Thoracoabdominal Aortic Aneurysm Repair - A Single-center Comparative Cohort Study. — https://doi.org/10.1097/sla.0000000000006848
[82] Meta-Analysis and Meta-Regression Analysis of Outcomes of Endovascular and Open Repair for Ruptured Abdominal Aortic Aneurysm. — https://doi.org/10.1016/j.ejvs.2019.12.023
[90] Endovascular aortic aneurysm repair (EVAR) has significantly lower perioperative mortality in comparison to open repair: a systematic review. — https://doi.org/10.1016/s1015-9584(08)60071-8
[95] Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years. — https://doi.org/10.1002/bjs.10430
[98] Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials. — https://doi.org/10.1002/bjs.9464
[105] Short Term and Long Term Clinical Outcomes of Endovascular versus Open Repair for Juxtarenal and Pararenal Abdominal Aortic Aneurysms Using Propensity Score Matching: Results from Juxta- and pararenal aortic Aneurysm Multicentre European Study (JAMES). — https://doi.org/10.1016/j.ejvs.2023.02.070
[106] Elective endovascular vs. open repair for abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. — https://doi.org/10.1016/j.ejvs.2011.07.011
[121] Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair. — https://doi.org/10.1016/j.jvs.2017.08.057
[125] Predictors of Acute Kidney Injury Following Elective Open and Endovascular Aortic Repair for Abdominal Aortic Aneurysm. — https://doi.org/10.3400/avd.oa.18-00029
[135] Cost disparity between open repair and endovascular aneurysm repair for abdominal aortic aneurysm: a single-institute experience in Japan. — https://doi.org/10.1007/s00595-011-0041-4
[138] Quality of life from a randomized trial of open and endovascular repair for abdominal aortic aneurysm. — https://doi.org/10.1002/bjs.10130
[139] Comparison of outcomes for open abdominal aortic aneurysm repair and endovascular repair in patients with chronic renal insufficiency. — https://doi.org/10.1097/sla.0b013e3182a15ada
[143] Editor's Choice - Short Term and Long Term Outcomes After Endovascular or Open Repair for Ruptured Infrarenal Abdominal Aortic Aneurysms in the Vascular Quality Initiative. — https://doi.org/10.1016/j.ejvs.2019.12.032
[144] Factors impacting functional health and resource utilization following abdominal aortic aneurysm repair by open and endovascular techniques. — https://doi.org/10.1007/s10016-005-6860-2
[151] In-hospital mortality risk after endovascular and open aortic aneurysm repairs for ruptured abdominal aortic aneurysms. — https://doi.org/10.1016/j.jvs.2024.07.022
[156] Factors associated with preference of choice of aortic aneurysm repair in the PReference for Open Versus Endovascular repair of AAA (PROVE-AAA) study. — https://doi.org/10.1016/j.jvs.2022.06.018
[162] Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. — https://doi.org/10.1016/s0140-6736(04)16979-1
[192] A population-based cohort study examining the risk of abdominal cancer after endovascular abdominal aortic aneurysm repair. — https://doi.org/10.1016/j.jvs.2018.09.058
[226] Abdominal Compartment Syndrome After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Single-Center Experience of Total Endovascular Care for Ruptured Abdominal Aneurysms. — https://doi.org/10.1177/15266028251328494
[227] To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the state of Illinois? — https://doi.org/10.1016/j.jvs.2005.01.005
[228] Open surgery for abdominal aortic aneurysm in the era of endovascular repair: comparison with long term results of endovascular repair using zenith stentgraft. — https://doi.org/10.3400/avd.oa.12-00101
[238] Endovascular repair of abdominal aortic aneurysm does not improve early survival versus open repair in patients younger than 60 years. — https://doi.org/10.1016/j.ejvs.2012.02.006
[240] Identifying Predictors of Postoperative Myocardial Infarction Following Repair of Abdominal Aortic Aneurysm Using a Retrospective Claims-Based Analysis. — https://doi.org/10.1053/j.jvca.2025.09.030
[243] [Mycotic aortic aneurysm-Representative cases : Case series of clinical case examples and the current literature on the treatment options of open surgical resection with prosthesis implantation (OR) and endovascular aortic repair (EVAR)]. — https://doi.org/10.1007/s00104-025-02375-z
[248] Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm. — https://doi.org/10.1002/bjs.9101
[253] Patients Older Than 80 Years Can Reach Their Normal Life Expectancy After Abdominal Aortic Aneurysm Repair: A Comparison Between Endovascular Aneurysm Repair and Open Surgery. — https://doi.org/10.1177/1526602818759757
[258] Risk-Adjusted Meta-analysis of 30-Day Mortality of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms. — https://doi.org/10.1016/j.avsg.2014.12.014
[259] Infected native aortic aneurysms: epidemiology, management, and outcomes based on a nationwide population-based study. — https://doi.org/10.1093/eurheartj/ehaf449
[260] Open Surgical Conversion After Endovascular Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis. — https://doi.org/10.7759/cureus.57271
[264] Management of failed endovascular aortic aneurysm repair with explantation or fenestrated-branched endovascular aortic aneurysm repair. — https://doi.org/10.1016/j.jvs.2018.03.418
[283] Cost-effectiveness of Elective Endovascular Aneurysm Repair Versus Open Surgical Repair of Abdominal Aortic Aneurysms. — https://doi.org/10.1016/j.ejvs.2016.03.001
[289] The Impact of Body Composition on Mortality and Hospital Length of Stay after Endovascular and Open Aortic Aneurysm Repair: A Retrospective Cohort Study. — https://doi.org/10.3390/nu16183205
[298] Endovascular Repair of Infrarenal Abdominal Aortic Aneurysm Results in Higher Hospital Expenses than Open Surgical Repair: Evidence from a Tertiary Hospital in Brazil. — https://doi.org/10.1016/j.avsg.2016.03.016
[306] Trends in annual open abdominal aortic surgical volumes for vascular trainees compared with annual national volumes in the endovascular era. — https://doi.org/10.1016/j.jvs.2022.03.887
[311] Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. — https://doi.org/10.1016/s0140-6736(05)66628-7
[314] Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life. — https://doi.org/10.1002/bjs.9018
[320] Clinical outcomes of chimney endovascular aneurysm repair versus open surgical repair for short-neck abdominal aortic aneurysms. — https://doi.org/10.1007/s00595-025-03104-z
[321] Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis. — https://doi.org/10.1016/s0140-6736(17)30639-6
[325] Editor's Choice - Re-interventions After Repair of Ruptured Abdominal Aortic Aneurysm: A Report From the IMPROVE Randomised Trial. — https://doi.org/10.1016/j.ejvs.2018.01.028
[335] Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm. — https://doi.org/10.1002/bjs.11123
[338] Similar long-term outcomes between endovascular aneurysm repair and open surgical repair for abdominal aortic aneurysms in octogenarian patients: a single-center study. — https://doi.org/10.4174/astr.2022.103.6.372
[354] A systematic review and meta-analysis evaluating the impact of obesity on outcomes of abdominal aortic aneurysm treatment. — https://doi.org/10.1016/j.jvs.2021.10.053
[364] Endovascular versus open surgery repair of intact abdominal aortic aneurysm: systematic review of randomized controlled trials and critical appraisal of meta-analyses. — https://doi.org/10.1186/s13643-025-03044-2
[386] Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair. — https://doi.org/10.1016/j.jvs.2019.01.081
[387] Long-term outcomes and resource utilization of endovascular versus open repair of abdominal aortic aneurysms in Ontario. — https://doi.org/10.1016/j.jvs.2009.10.101
[388] Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is associated with lower 30-day mortality and better 5-year survival rates than open surgical repair. — https://doi.org/10.1016/j.jvs.2012.09.003
[392] A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm - results of a pilot study and lessons learned for future studies. — https://doi.org/10.1016/j.ejvs.2006.05.016
[401] Endovascular aneurysm repair is superior to open surgery for ruptured abdominal aortic aneurysms in EVAR-suitable patients. — https://doi.org/10.1016/j.jvs.2010.02.014
[416] Surgeon case volume, not institution case volume, is the primary determinant of in-hospital mortality after elective open abdominal aortic aneurysm repair. — https://doi.org/10.1016/j.jvs.2010.09.063
[417] Long-Term Outcomes of Open Versus Endovascular Treatment for Abdominal Aortic Aneurysm: Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data. — https://doi.org/10.1177/15266028231204805
[438] Cost-effectiveness analysis of endovascular versus open repair of abdominal aortic aneurysm in a high-volume center. — https://doi.org/10.1016/j.jvs.2018.11.018
[461] Arterial Stiffness Assessed by Cardio-Ankle Vascular Index in Patients With Abdominal Aortic Aneurysm and Its Alterations After Treatment. — https://doi.org/10.1177/15385744211023281
[463] Editor's Choice - Outcomes Following Intact and Ruptured Aneurysm Repair across Nations: Analysis of International Registry Data from the VASCUNET Collaboration 2014 - 2019. — https://doi.org/10.1016/j.ejvs.2024.02.019
[515] Endovascular Repair of Abdominal Aortic Aneurysm in Patients Physically Ineligible for Open Repair: Very Long-term Follow-up in the EVAR-2 Randomized Controlled Trial. — https://doi.org/10.1097/sla.0000000000002392
[519] Predictors and outcomes of endoleaks in the Veterans Affairs Open Versus Endovascular Repair (OVER) Trial of Abdominal Aortic Aneurysms. — https://doi.org/10.1016/j.jvs.2015.02.003
[541] Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: Analysis of the National Surgical Quality Improvement Program dataset. — https://doi.org/10.1016/j.jvs.2021.09.041
[547] Meta-analysis finds recurrent infection is more common after endovascular than after open repair of infected abdominal aortic aneurysm. — https://doi.org/10.1016/j.jvs.2021.07.240
[548] Association Between Hospital Volume and Failure to Rescue After Open or Endovascular Repair of Intact Abdominal Aortic Aneurysms in the VASCUNET and International Consortium of Vascular Registries. — https://doi.org/10.1097/sla.0000000000005044
[553] Open conversion after failed endovascular aneurysm repair is increasing and its 30-day mortality is higher than that after primary open repair. — https://doi.org/10.1016/j.jvs.2022.04.056
[554] Association between diabetes status and long-term outcomes following open and endovascular repair of infrarenal abdominal aortic aneurysms. — https://doi.org/10.1016/j.jvs.2024.08.030
[556] Editor's Choice - Endovascular vs. Open Repair for Abdominal Aortic Aneurysm: Systematic Review and Meta-analysis of Updated Peri-operative and Long Term Data of Randomised Controlled Trials. — https://doi.org/10.1016/j.ejvs.2019.11.030
[561] Cost-effectiveness and cost-utility of endovascular versus open repair of ruptured abdominal aortic aneurysm in the Amsterdam Acute Aneurysm Trial. — https://doi.org/10.1002/bjs.9356
[563] Open surgery (OS) versus endovascular aneurysm repair (EVAR) for hemodynamically stable and unstable ruptured abdominal aortic aneurysm (rAAA). — https://doi.org/10.1007/s00380-015-0736-3
[569] Plasma thrombin-antithrombin complex, prothrombin fragments 1 and 2, and D-dimer levels are elevated after endovascular but not open repair of infrarenal abdominal aortic aneurysm. — https://doi.org/10.1016/j.jvs.2012.12.030
[571] Perioperative complications and early outcome after endovascular and open surgical repair of abdominal aortic aneurysms. — https://doi.org/10.1016/j.jvs.2003.10.018
[579] Editor's Choice - The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries. — https://doi.org/10.1016/j.ejvs.2018.01.014
[582] Long-term outcomes and factors influencing late survival following elective abdominal aortic aneurysm repair: A 24-year experience. — https://doi.org/10.1177/1708538115586682
[588] The inflammatory response to ruptured abdominal aortic aneurysm is altered by endovascular repair. — https://doi.org/10.1155/2013/482728
[591] Editor's Choice - Abdominal Compartment Syndrome After Surgery for Abdominal Aortic Aneurysm: A Nationwide Population Based Study. — https://doi.org/10.1016/j.ejvs.2016.03.011
[613] Volume-outcome relationships in open and endovascular repair of abdominal aortic aneurysm: administrative data 2006-2018. — https://doi.org/10.1002/bjs.11919
[625] Propensity score analysis demonstrates no long term survival benefit from contemporary endovascular aneurysm repair compared to open in Aotearoa New Zealand. — https://doi.org/10.1111/ans.18815
[628] Comprehensive Assessment of Factors Associated With In-Hospital Mortality After Elective Abdominal Aortic Aneurysm Repair. — https://doi.org/10.1001/jamasurg.2016.0782
[630] Reintervention rate after infrarenal aortic aneurysm repair is lower for open than endovascular repair with aneurysm sac shrinkage: a fifteen-year study. — https://doi.org/10.23736/s0392-9590.23.05028-9
[634] Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial. — https://doi.org/10.1001/jamasurg.2022.2935
[637] Results from a nationwide prospective registry on open surgical or endovascular repair of juxtarenal abdominal aortic aneurysms. — https://doi.org/10.1016/j.jvs.2021.06.031
[687] Sex Differences in Long-Term Survival and Cancer Incidence After Ruptured Abdominal Aortic Aneurysm Repair. — https://doi.org/10.3390/jcm13226934
[690] The AAA with a challenging neck: outcome of open versus endovascular repair with standard and fenestrated stent-grafts. — https://doi.org/10.1583/08-2531.1
[698] Ten-year comparison of all-cause mortality after endovascular or open repair of abdominal aortic aneurysms: a propensity score analysis. — https://doi.org/10.1007/s00268-012-1863-y
[740] Peri-Operative Mortality and Survival After Repair of Abdominal Aortic Aneurysm in Advanced Age Patients: A National Study from the Norwegian Registry for Vascular Surgery Focused on Nonagenarians. — https://doi.org/10.1016/j.ejvs.2023.09.038
[758] The Association Between Body Mass Index and Death Following Elective Endovascular and Open Repair of Abdominal Aortic Aneurysms in the Vascular Quality Initiative. — https://doi.org/10.1016/j.ejvs.2023.01.047
[762] Epidemiology of endovascular and open repair for abdominal aortic aneurysms in the United States from 2004 to 2015 and implications for screening. — https://doi.org/10.1016/j.jvs.2021.01.044
[793] Long-term decline in renal function is more significant after endovascular repair of infrarenal abdominal aortic aneurysms. — https://doi.org/10.1016/j.jvs.2017.12.051
[795] Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities. — https://doi.org/10.1016/j.jvs.2014.08.115
[801] Influence of endovascular surgery on abdominal aortic aneurysm management strategies from a national health insurance database survey. — https://doi.org/10.1097/jcma.0000000000001156
[816] Nationwide analysis of risk factors for in-hospital mortality in patients undergoing abdominal aortic aneurysm repair. — https://doi.org/10.1002/bjs.10714
[818] Association between neighborhood deprivation and presenting with a ruptured abdominal aortic aneurysm before screening age. — https://doi.org/10.1016/j.jvs.2022.03.009
[843] Preoperative hypoalbuminemia is associated with poor clinical outcomes after open and endovascular abdominal aortic aneurysm repair. — https://doi.org/10.1016/j.jvs.2016.10.110
[852] The Incidence of Ischemic Colitis after Repair of Ruptured Abdominal Aortic Aneurysms Is Decreasing in the Endovascular Era. — https://doi.org/10.1016/j.avsg.2017.08.045
