Systematic Review and Meta-analysis of Endovascular and Open Surgical Repair for Infective Native Aortic Aneurysms

Infective native aortic aneurysms (mycotic) are rare but highly lethal, and the optimal treatment strategy between endovascular repair and open surgical repair (OSR) remains debated because of a persistent trade-off between early survival and durable infection control. We performed a systematic review and meta-analysis comparing early and long-term outcomes of endovascular repair and OSR, complemented by a single-arm meta-analysis characterizing outcomes after endovascular repair.

PubMed, Embase, and the Cochrane Library were searched from inception to June 16, 2026. Comparative studies were pooled using inverse-variance random-effects models with REML estimation of between-study variance (ORs); single-arm proportions were pooled using logit-transformed, inverse-variance-weighted random-effects models. Risk of bias was assessed with ROBINS-I. Outcomes included 30-day and 1-year all-cause mortality, reinfection (a new or persistent infection requiring antimicrobial therapy or source control), sepsis recurrence (a new episode meeting sepsis criteria after initial clinical resolution), reintervention, and acute kidney injury (AKI).

Thirty-five retrospective studies were included: 18 comparative studies (2,853 enrolled patients; 1,305 endovascular repair and 1,548 OSR; 17 of which, comprising 2,836 patients, reported 30-day mortality) and 17 single-arm studies (444 endovascular repair patients; 16 of which reported 30-day mortality). Endovascular repair was associated with significantly lower 30-day mortality than OSR (OR 0.72, 95% CI 0.55-0.93) but not with 1-year mortality (8 studies, 1,630 patients; OR 1.23, 95% CI 0.66-2.29), and with a higher risk of reinfection (14 studies, 1,448 patients; OR 2.56, 95% CI 1.71-3.82). No significant differences were found for sepsis recurrence, reintervention, or AKI, though these comparisons were imprecise and compatible with both clinically meaningful benefit and harm, and should not be interpreted as evidence of equivalence between strategies. In the single-arm analysis, pooled 30-day mortality after endovascular repair was 6.5%, 1-year mortality was 22.4%, and reinfection was 14.7%.

In pooled analysis, endovascular repair was associated with lower early mortality compared with open surgical repair, although this finding was sensitive to the inclusion of a single large registry-based study and should be interpreted with caution. No significant difference in 1-year mortality was observed, but this comparison was imprecise and based on few studies and should not be interpreted as evidence that a survival advantage is absent. Endovascular repair carries a higher risk of reinfection. Careful patient selection, prolonged antimicrobial therapy, and structured postoperative surveillance remain essential regardless of the repair strategy chosen. Certainty of evidence for all comparative outcomes was very low (GRADE), reflecting the observational design, serious risk of confounding by indication, and imprecision of the pooled estimates.