Outcomes of advanced EVAR versus open surgery in the management of complex abdominal aortic aneurysm repair: A systematic review and meta-analysis

Background Open surgery is still acknowledged as the gold standard for complex abdominal aortic aneurysm (c-AAA). Recently, advanced-endovascular aortic aneurysm repair (EVAR) for c-AAA has been developed, but its effectiveness compared to open surgery is still unclear. Method A systematic search was performed on the MEDLINE through PubMed and ScienceDirect databases. The search was aimed to investigate outcomes of both fenestrated- and chimney-EVAR (consider as advanced EVAR) compared to open surgery in c-AAA. Outcomes included postoperative complications, 30-day mortality, long-term mortality, and reintervention rate. Data were collected using the Mantel–Haenszel fixed effects model with relative risk (RR) as the effect size with 95% confidence interval (CI). Results A total of 25 studies ( n = 12,845 patients) were included in our study. The results demonstrated that advanced-EVAR correlated with diminished postoperative complications (RR 0.53; 95% CI 0.49–0.57; p < 0.001) compared to open surgery. Advanced-EVAR was associated with lower 30-day mortality compared to open surgery (RR 0.66; 95% CI 0.53–0.82; p < 0.001). Subgroup analysis revealed that fenestrated-EVAR resulted in superior outcomes ( p < 0.001), whereas the chimney-EVAR subgroup did not show significant differences ( p = 0.79), compared to open surgery in terms of 30-day mortality. Unfortunately, advanced-EVAR was associated with a higher long-term mortality rate (RR 1.46; 95% CI 1.20–1.78; p < 0.001) and a higher reintervention rate (RR 1.26; 95% CI 1.01–1.59; p = 0.04) compared to open surgery. Conclusion Advanced EVAR, especially fenestrated-EVAR, presented better short-term outcomes compared to open surgery; however, it failed to demonstrate superiority over open surgery in improving long-term outcomes.