Fenestrated and Branched Endovascular vs. Open Repair for Complex Abdominal Aortic Aneurysms: A Design Stratified...

Complex abdominal aortic aneurysm repair remains challenging, and randomised comparisons between open surgical repair (OSR) and fenestrated and or branched endovascular aortic repair (FBEVAR) are lacking. This study compared peri-operative and long term outcomes using a design stratified approach.

MEDLINE, Scopus, and Cochrane were searched through to June 2025 for comparative OSR vs. FBEVAR studies.

The primary outcome was thirty day mortality; secondary outcomes were spinal cord ischaemia, neurological events, acute kidney injury, renal failure, and dialysis. Propensity score matched studies were analysed as primary and unadjusted crude estimate studies as secondary; certainty was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Long term survival and reintervention were explored using reconstructed time to event data from published Kaplan-Meier curves.

Eighteen studies, including 11 298 patients, were analysed: nine propensity score matched and nine unadjusted crude estimate studies. In propensity score matched studies, FBEVAR was associated with a lower thirty day mortality rate (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.56 - 0.92; p = .010) and acute kidney injury rates (OR 0.54, 95% CI 0.38 - 0.76; p < .001). In unadjusted crude estimate studies, FBEVAR was associated with lower acute kidney injury (OR 0.45, 95% CI 0.22 - 0.94; p = .030), renal failure (OR 0.30, 95% CI 0.20 - 0.47; p < .001), and dialysis rates (OR 0.33, 95% CI 0.21 - 0.52; p < .001) but a higher spinal cord ischaemia rate (OR 3.93, 95% CI 2.00 - 7.73; p < .001). Spinal cord ischaemia was not significantly different in propensity score matched studies, and neurological events did not differ in either analytic framework. Certainty was low for propensity score matched analyses and very low for unadjusted crude estimate analyses. In exploratory reconstructed time to event analyses, FBEVAR was associated with higher all cause mortality (hazard ratio 1.50, 95% CI 1.24 - 1.83; p < .001) and re-intervention rates (hazard ratio 3.94, 95% CI 3.30 - 4.70; p < .001). All GRADE certainties were low or very low.

In propensity score matched studies, FBEVAR was associated with lower early mortality and acute kidney injury rates, whereas exploratory long term analyses were associated with higher all cause mortality and re-intervention compared with OSR. Findings support individualised repair selection balancing early risk against durability, within limitations of observational evidence and low to very low certainty.