Aortic aneurysm repair - endovascular
EVAR; Endovascular aneurysm repair - aorta; AAA repair - endovascular; Repair - aortic aneurysm - endovascular
Endovascular abdominal aortic aneurysm (AAA) repair is surgery to repair a widened area in your aorta. This is called an aneurysm. The aorta is the large artery that carries blood to your belly, pelvis, and legs.
An aortic aneurysm is when a part of this artery becomes too large or balloons outward. It occurs due to weakness in the wall of the artery.
This procedure is done in an operating room, in the radiology department of the hospital, or in a catheterization lab. You will lie on a padded table. You may receive general anesthesia (you are asleep and pain-free) or epidural or spinal anesthesia. During the procedure, your surgeon will:
- Make a small surgical cut near the groin, to find the femoral artery.
- Insert a thin, flexible tube (catheter) into the artery through the cut.
- Insert a stent (a metal coil) and a man-made (synthetic) graft along the catheter.
- Then use a dye to define the extent of the aneurysm.
- Use x-rays to guide the stent graft up into your aorta, to where the aneurysm is located.
- Next open the stent using a spring-like mechanism and attach it to the walls of the aorta. Your aneurysm will eventually shrink around it.
- Use x-rays and dye again to make sure the stent is in the right place and your aneurysm is not bleeding inside your body.
- Remove the catheter and close the surgical cut where the catheter was inserted.
Why the Procedure Is Performed
Endovascular aneurysm repair (EVAR) is done because your aneurysm is very large, growing quickly, or is leaking or bleeding.
You may have an AAA that is not causing any symptoms or problems. Your health care provider may have found this problem when you had an ultrasound or CT scan for another reason. There is a risk that this aneurysm may open up (rupture) if you do not have surgery to repair it. However, surgery to repair the aneurysm may also be risky. In such cases, EVAR is an option.
You and your provider must decide whether the risk of having this surgery is smaller than the risk for rupture if you do not have surgery to repair the problem. The provider is more likely to recommend that you have surgery if the aneurysm is:
- Larger (about 2 inches or 5 centimeters)
- Growing more quickly (a little less than 1/4 inch or 0.5 centimeter over the last 6 to 12 months)
EVAR has a lower risk of developing complications compared to open surgery. Your provider is more likely to suggest this type of repair if you have other serious medical problems or are an older person.
Your blood vessels are the transport system that carries blood to and from your heart, to the rest of your body. Usually, everything runs pretty smoothly with this system, but sometimes there can be a problem. For example, one of the large blood vessels that supplies blood to your abdomen and lower body can swell up or bulge. This bulge is called an abdominal aortic aneurysm, and it can be pretty serious if it breaks open, or ruptures. Let's talk about abdominal aortic aneurysm. This is the descending aorta, one of the large blood vessels that sends blood to your abdomen and legs. Over a period of many years, this blood vessel can start to bulge. Although doctors aren't sure exactly what causes an aneurysm, they do know that it's more common in males over 60 and people who are overweight, who smoke, or who have high blood pressure or cholesterol. Eventually, if not treated, the aneurysm can pop open or rupture, and spill blood into your abdominal cavity or into the wall of the artery. If an aneurysm ruptures, it is considered a true medical emergency. So, how do you find out if you have an aneurysm? You may not realize that you have one, because often aneurysms don't cause any symptoms until they rupture. An imaging test like a CT scan or ultrasound may help in finding a suspected aneurysm. If it does break open, you may feel severe pain in your stomach. That pain may spread to your groin, buttocks, or legs. You could also feel sick to your stomach, have clammy skin, and your heart may beat faster than normal. If you have any of these symptoms, see your doctor, who can examine you. Your doctor may also recommend an imaging test to see for sure if you have an aneurysm. Treatments for aneurysms vary depending on how severe the aneurysm is. If you're not having symptoms, and your aneurysm is small and hasn't broken open, your doctor may suggest just checking it every six months to make sure it doesn't get bigger. If it's bigger than 2 inches, you'll probably need to have surgery. The goal is to perform surgery before complications and symptoms develop. The surgeon will replace the damaged, bulging section of blood vessel with a section of man-made vessel, commonly called a graft. It's better to avoid getting an aneurysm than to have to treat it. Eat a healthy diet, watch your cholesterol and blood pressure levels, and quit smoking to help prevent an aneurysm from forming in the first place. Men who are over the age of 65 and have ever smoked or who have a close relative who's had an abdominal aortic aneurysm should have one screening ultrasound done to check for an abdominal aortic aneurysm. If you're having any symptoms of an abdominal aneurysm, like severe pain in your belly or back, it's very important that you get medical help right away. Go to the emergency room or call your health care provider for immediate help. Small aneurysms are easy to treat with surgery. But once they get larger and rupture, they can be life threatening.
Risks for any surgery are:
- Blood clots in the legs that may travel to the lungs
- Breathing problems
- Infection, including in the lungs, urinary tract, and belly
- Heart attack or stroke
- Reactions to medicines
Risks for this surgery are:
- Bleeding around the graft that needs more surgery
- Bleeding before or after procedure
- Blockage of the stent
- Damage to a nerve, causing weakness, pain, or numbness in the leg
- Kidney failure
- Poor blood supply to your legs, your kidneys, or other organs
- Problems getting or keeping an erection
- Surgery is not successful and you need an open surgery
- The stent slips
- The stent leaks and requires open surgery
Before the Procedure
Your provider will examine you and order tests before you have surgery.
Always tell your provider what drugs you are taking, even drugs, supplements, or herbs you bought without a prescription.
If you are a smoker, you should stop. Your provider can help. Here are other things you will need to do before your surgery:
- About two weeks before your surgery, you will visit your provider to make sure any medical problems, such as diabetes, high blood pressure, and heart or lung problems, are well treated.
- You also may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), and naprosyn (Aleve, Naproxen).
- Ask which drugs you should still take on the day of your surgery.
- Always tell your provider if you get a cold, flu, fever, herpes breakout, or other illness before your surgery.
The evening before your surgery:
- DO NOT drink anything after midnight, including water.
On the day of your surgery:
- Take any medicines your doctor told you to take with a small sip of water.
- You will be told when to arrive at the hospital.
After the Procedure
Most people stay in the hospital for a few days after this surgery, depending on the type of procedure they had. Most often, the recovery from this procedure is faster and with less pain than with open surgery. Also, you will most likely be able to go home sooner.
During a hospital stay, you may:
- Be in the intensive care unit (ICU), where you will be watched very closely at first
- Have a urinary catheter
- Be given medicines to thin your blood
- Be encouraged to sit on the side of your bed and then walk
- Wear special stockings to prevent blood clots in your legs
- Receive pain medicine into your veins or into the space that surrounds your spinal cord (epidural)
Recovery after endovascular repair is quick in most cases.
You will need to be watched and checked regularly to make sure your repaired aortic aneurysm is not leaking blood.
Braverman AC, Schemerhorn M. Diseases of the aorta. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 63.
Brinster CJ, Sternbergh WC. Endovascular aneurysm repair techniques. In: Sidawy AN, Perler BA, eds. Rutherford's Vascular Surgery and Endovascular Therapy. 9th ed. Philadelphia, PA: Elsevier; 2019:chap 73.
Fanelli F, Falcone GM. Endovascular aortic repair. In: Mauro MA, Murphy KP, Thomson KR, Venbrux AC, Morgan RA, eds. Image-Guided Interventions. 3rd ed. Philadelphia, PA: Elsevier; 2021:chap 20.
Last reviewed on: 10/30/2020
Reviewed by: Deepak Sudheendra, MD, RPVI, FSIR, Director of DVT & Complex Venous Disease Program, Assistant Professor of Interventional Radiology & Surgery at the University of Pennsylvania Perelman School of Medicine, with an expertise in Vascular Interventional Radiology & Surgical Critical Care, Philadelphia, PA.Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.