Background <p>A few randomized controlled trials (RCTs) have investigated endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in patients with intact aortic abdominal aneurysm (AAA).</p> Objective <p>We aimed to evaluate the efficacy of EVAR vs OSR in patients with intact AAA.</p> Methods <p>We included RCTs and searched MEDLINE and the Cochrane Library on 28 December 2024 without limits. The beneficial primary outcome was overall survival, and the adverse primary outcome was reintervention. In both cases, the outcome measure was the hazard ratio (HR). Two people independently selected studies and extracted data. Management of missing data included deducing time-to-event data from published survival curves and contacting study authors.</p> Results <p>We retrieved 723 references from electronic databases and additional sources and included four RCTs. The pooled HR on overall survival favors neither EVAR nor OSR (HR = 1.02 [95% CI 0.93 to 1.12]), but the pooled HR on reintervention favors OSR (HR = 2.14 [95% CI 1.70 to 2.70]). Statistical heterogeneity was low, and the risk of bias had no noteworthy impact on the results.</p> Conclusions <p>Pooled data from four randomized controlled trials on intact aortic abdominal aneurysm favor not EVAR regarding overall survival but favor OSR with respect to reintervention.</p> Systematic review registration <p>PROSPERO CRD42024539841</p>