Medium and Long Term Time-to-Event Outcomes After Elective Fenestrated and Branched Endovascular Repair of Complex Abdominal and Thoracoabdominal Aortic Aneurysms: A Contemporary Systematic Review

Abstract Objective To define contemporary medium and long term survival and durability outcomes after elective fenestrated and branched endovascular aortic repair (F/BEVAR) for complex abdominal and thoracoabdominal aneurysms and to assess the certainty of the available evidence. Data Sources MEDLINE, Embase and the Cochrane Library were searched from January 2000 to February 2026, supplemented by citation screening. Review Methods Published Kaplan Meier time-to-event data were digitised and reconstructed into individual patient datasets. Pooled survival probabilities were generated using validated methods for meta-analytic methods for survival curves. Certainty of evidence was assessed using the GRADE framework. Results Twenty-four studies comprising 8,886 patients were included. Pooled overall survival was 91.3% (95% CI: 90.7, 91.9) at 1 year, 73.0% (95%CI: 71.9, 74.0) at 3 years and 55.4% (95% CI: 53.9, 56.8) at 5 years. Estimated median overall survival was 6.36 years. At 5 years, freedom from aneurysm-related mortality was 96.4% (95%CI: 95.3, 97.2), freedom from reintervention was 66.5% (95%CI: 64.6, 68.2), and target vessel patency (TVP) was 94.8% (95%CI: 93.3, 96.0). Certainty of evidence was low for overall survival, aneurysm related mortality and reintervention, and very low for TVP. Conclusion Elective F/BEVAR provides durable aneurysm exclusion with low aneurysm related mortality; however, long term survival declines substantially. There is a need for more robust survival data and improved tools to support patient selection, shared decision making, and assessment of anticipated benefit when considering prophylactic complex endovascular repair. What this paper adds This study provides a time-to-event synthesis of medium and long term outcomes after elective F/BEVAR for complex abdominal and thoracoabdominal aortic aneurysms, analysing reconstructed survival data from 8,886 patients across 24 studies published between 2000 and 2025. This analysis provides empirical survival data to inform recent European Society for Vascular Surgery guidance, demonstrating a median survival of 6.36 years and showing that most late deaths are not aneurysm related. These findings quantify the divergence between procedural durability and long term survival, supporting an individualised treatment strategy grounded in assessment of life expectancy, competing risk and shared decision making.