WHAT THIS PAPER ADDSThe key findings of this study are that 5 year survival after elective infrarenal AAA repair is 69% and that this value has not improved over the period 1969e2011. A larger aneurysm diameter at the time of surgery was associated with poorer 5 year survival. This 5 year survival figure is disappointingly poor; patients diagnosed with a Dukes B colorectal cancer can expect better 5 year survival. More needs to be done to address the shortfall in survival to ensure that patients who can now reasonably expect to survive major aortic surgery live long enough to justify what remains a significant intervention.Background: Improved critical care, pre-operative optimization, and the advent of endovascular surgery (EVAR) have improved 30 day mortality for elective abdominal aortic aneurysm (AAA) repair. It remains unknown whether this has translated into improvements in long-term survival, particularly because these factors have also encouraged the treatment of older patients with greater comorbidity. The aim of this study was to quantify how 5 year survival after elective AAA repair has changed over time. Methods: A systematic review was performed identifying studies reporting 5 year survival after elective infrarenal AAA repair. An electronic search of the Embase and Medline databases was conducted to January 2014. Thirty-six studies, 60 study arms, and 107,814 patients were identified. Meta-analyses were conducted to determine 5 year survival and to report whether 5 year survival changed over time. Results: Five-year survival was 69% (95% CI 67 to 71%, I 2 ¼ 87%). Meta-regression on study midpoint showed no improvement in 5 year survival over the period 1969e2011 (log OR À0.001, 95% CI À0.014e0.012). Larger average aneurysm diameter was associated with poorer 5 year survival (adjusted log OR À0.058, 95% CI À0.095 to À0.021, I 2 ¼ 85%). Older average patient age at surgery was associated with poorer 5 year survival (adjusted log OR À0.118, 95% CI À0.142 to À0.094, I 2 ¼ 70%). After adjusting for average patient age, an improvement in 5 year survival over the period that these data spanned was obtained (adjusted log OR 0.027, 95% CI 0.012 to 0.042). Conclusion: Five-year survival remains poor after elective AAA repair despite advances in short-term outcomes and is associated with AAA diameter and patient age at the time of surgery. Age-adjusted survival appears to have improved; however, this cohort as a whole continues to have poor long-term survival. Research in this field should attempt to improve the life expectancy of patients with repaired AAA and to optimise patient selection.