Six randomised controlled trials and 34 clinical prediction studies were included. Three trials met all eight quality criteria, two met five criteria, and one met three criteria; most unmet criteria were rated unclear.
Compared with open repair, endovascular repair reduced 30-day mortality (OR 0.35, 95% CI 0.19 to 0.63; three trials) and medium-term aneurysm-related mortality (HR 0.49, 95% CI 0.29 to 0.83; two trials), but there was no significant difference in all-cause mortality. Endovascular repair was associated with more complications and re-interventions, with no improvement in health-related quality of life.
The review of cost-effectiveness studies found that endovascular repair was not cost-effective, compared with open repair (two good studies), but it was more cost-effective than no surgery for patients unfit for open repair (earlier study). A model submitted by a manufacturer suggested that endovascular repair was more cost-effective than open repair for fit patients.
The authors' analysis found that endovascular repair was not cost-effective, compared with open repair, but this was sensitive to variations in the model assumptions and the initial risk of death during surgery.