Comparative outcomes: open vs endovascular repair with patient selection

Open bypass with autologous vein conduit remains the gold standard for durability, particularly in good-risk surgical candidates with adequate vein and distal runoff. [@huang2007] Long-term patency rates of 70–90% at 5 years have been consistently reported with vein bypass. [@galland2008] Endovascular repair with covered stent grafts offers advantages of lower perioperative morbidity and shorter hospital length of stay, [@cassar2005] making it attractive for high-risk patients or those lacking suitable vein conduit. However, endovascular repair is associated with higher reintervention rates and inferior long-term patency compared to open bypass, [@huang2007][@huang2007][@troisi2024] particularly in the challenging environment across the knee joint. Anatomic suitability requires adequate proximal and distal landing zones and careful consideration of stent-graft deformation dynamics with knee flexion. Reported primary patency at 3 years commonly ranges from 60–70% in early series, [@tielliu2005] with secondary interventions improving overall limb salvage rates. In the emergency setting, a systematic review and meta-analysis comparing endovascular versus open repair of popliteal artery aneurysms (PAAs) found that open repair was associated with superior primary patency, while endovascular repair offered lower perioperative complication rates; both approaches achieved comparable limb salvage outcomes. [@rebelo2022] Long-term follow-up data from dedicated PAA registries confirm that endovascular repair with self-expandable covered stents such as the Viabahn device yields acceptable patency over extended follow-up, though reintervention remains more frequent than after open bypass, underscoring the importance of lifelong surveillance after endovascular PAA repair. [@editors2025][@troisi2025-late]