Abstract: No new studies were identified for this update. A single RCT with a total of 30 PAAs met the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the certainty of the evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 93.3% in the endovascular group and 100% in the surgery group (RR 0.94, 95% CI 0.78 to 1.12; moderate-certainty evidence). The assisted patency rate at one year was similar in both groups (RR 1.00, 95% CI 0.88 to 1.13; moderate-certainty evidence). There was no clear evidence of a difference between the two groups in the primary or assisted patency rates at four years (13 grafts were patent from 15 PAA treatments in each group; RR 1.00, 95% CI 0.76 to 1.32; moderate-certainty evidence); the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001; moderate-certainty evidence). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.90 minutes, 95% CI -137.71 to -102.09; P < 0.001; moderate-certainty evidence). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report. Evidence to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs is limited to data from one small study. At one year there is moderate-certainty evidence that primary patency may be improved in the surgery group but assisted primary patency rates were similar between groups. At four years there was no clear benefit from either endovascular stent graft or surgery to primary or assisted primary patency (moderate-certainty evidence). As both operating time and hospital stay were reduced in the endovascular group (moderate-certainty evidence), it may represent a viable alternative to open repair of PAA. A large multicenter RCT may provide more information in the future. However, difficulties in recruiting enough patients are likely, unless it is an international collaboration including a number of high volume vascular centres.

Plain-language summary: An extensive search of the medical literature databases was performed (current up to 29 January 2019). Only one completed RCT was found. In the published RCT, 30 PAAs were treated (15 by the endovascular technique and 15 by the surgical technique). Each case was followed up for a minimum of four years. In the group of participants treated using the endovascular technique there were two blockages. One case was re-stented and the other case required a surgical bypass. In the surgical group too, there were two blockages, which did not require any treatment. There were no limb losses. The time taken to complete the procedure and the length of hospital stay were shorter in the endovascular group. No information on wound complications was given in the trial report. The major limitation of this study was that there were only 15 PAAs in each group so our certainty in the evidence is downgraded from high to moderate. Due to the limitations of the current evidence, we are unable to determine the effects of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs. A larger multicenter clinical trial is required so we can be more confident in the findings. We cannot say if there was a clear overall benefit on patency to either group (moderate-certainty evidence). As both operating time and hospital stay were reduced in the endovascular group (moderate certainty evidence), it may represent a viable alternative to open repair of PAA.