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Background  The erosion of the early mortality advantage of elective endovascular aneurysm repair ( EVAR ) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation.    Methods  An individual‐patient data meta‐analysis of four multicentre randomized trials of  EVAR   versus  open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm‐related mortality and reintervention.    Results  The analysis included 2783 patients, with 14 245 person‐years of follow‐up (median 5·5 years). Early (0–6 months after randomization) mortality was lower in the  EVAR  groups (46 of 1393  versus  73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89;  P  = 0·010), primarily because 30‐day  operative mortality was lower in the  EVAR  groups (16 deaths  versus  40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm‐related mortality was significantly higher in the  EVAR  groups (19 deaths  versus  3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89;  P  = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under  EVAR . Those with peripheral artery disease had lower mortality under open repair (39 deaths  versus  62 for  EVAR ;  P  = 0·022) in the period from 6 months to 4 years after randomization.    Conclusion  The early survival advantage in the  EVAR  group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from  EVAR  compared with open repair. Aneurysm‐related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the  EVAR  group. Trial registration numbers:  EVAR ‐1,  ISRCTN55703451 ;  DREAM  (Dutch Randomized Endovascular Aneurysm Management),  NCT00421330 ;  ACE  (Anévrysme de l'aorte abdominale, Chirurgie  versus  Endoprothèse),  NCT00224718 ;  OVER  (Open  Versus  Endovascular Repair Trial for Abdominal Aortic Aneurysms),  NCT00094575 .

british journal of surgery

Meta‐analysis of individual‐patient data from  EVAR ‐1,  DREAM ,  OVER  and  ACE  trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years