Open vs. Endovascular Aortic Repair: Guidelines and Real-World Outcomes

Abdominal aortic aneurysm (AAA) remains a critical vascular condition with significant morbidity and mortality, necessitating timely intervention through either open surgical repair (OSR) or endovascular aortic repair (EVAR). This review evaluates the latest clinical guidelines and real-world outcomes of these two approaches, synthesizing evidence from randomized controlled trials, large-scale registry data, and emerging technological advancements. OSR, traditionally the gold standard, offers superior long-term durability but carries higher perioperative risks, whereas EVAR provides a less invasive alternative with reduced short-term mortality but requires lifelong surveillance due to its higher reintervention rates. The management of ruptured AAA is also explored, with EVAR demonstrating a survival advantage in anatomically suitable cases, though OSR remains the only option for hemodynamically unstable patients. The evolution of complex aneurysm repair, including fenestrated and branched EVAR, is discussed, highlighting its expanding role in high-risk patients. Additionally, the integration of artificial intelligence and computational modeling is revolutionizing preoperative planning, enhancing procedural outcomes and patient selection. Despite these advances, the need for standardized long-term surveillance protocols post-EVAR remains a critical challenge. By combining contemporary evidence with technological innovations, this review provides a comprehensive perspective on optimizing AAA management, guiding future research, and improving patient outcomes. © 2025 Elsevier B.V., All rights reserved.