Endovascular Aneurysm Repair (EVAR)

What is endovascular aneurysm repair?

Endovascular aneurysm repair (EVAR) is a minimally invasive surgical procedure used to treat abdominal aortic aneurysms (AAAs) and, in some cases, thoracic aortic aneurysms (TAAs). An aneurysm is an abnormal bulging or ballooning of a blood vessel, in this case, the aorta, the largest artery in the body. If left untreated, aortic aneurysms can be life-threatening because they have the potential to rupture, leading to severe internal bleeding.

In EVAR, the goal is to reinforce the weakened and bulging wall of the aorta by placing a stent graft, a fabric-covered metal mesh tube, within the aneurysm. This enhances the artery and prevents further expansion, reducing the risk of rupture.

Endovascular aneurysm repair is a less invasive alternative to open surgical repair, which involves a large incision in the abdomen or chest and replacing the damaged aorta with a synthetic graft. However, not all aortic aneurysms are suitable for EVAR. The eligibility for this procedure depends on various factors, including the size and location of the aneurysm, the anatomy of the blood vessels, and the patient’s overall health. A vascular surgeon or interventional radiologist will assess these factors to determine the most appropriate treatment approach for each patient.

Why might I need EVAR?

You might need endovascular aneurysm repair (EVAR) if you have been diagnosed with an abdominal aortic aneurysm (AAA) or, in some cases, a thoracic aortic aneurysm (TAA). The decision to undergo EVAR is typically based on several factors, and it is made by a vascular surgeon or interventional radiologist in consultation with the patient. Here are some common reasons why you might need EVAR:

Aortic Aneurysm Diagnosis: EVAR treats aortic aneurysms, abnormal bulges or balloon-like enlargements of the aorta, the body’s largest artery. These aneurysms can occur in the abdominal aorta (AAA) or the thoracic aorta (TAA).

Aneurysm Size: The size of the aneurysm is a crucial factor in determining whether EVAR is necessary. Generally, EVAR is considered when the aneurysm reaches a certain size threshold, often around 5.5 centimetres (about 2.2 inches) for AAAs. A watchful waiting approach with regular monitoring may be recommended for smaller aneurysms.

Aneurysm Growth Rate: The rate at which the aneurysm grows is essential. Rapidly growing aneurysms or those that have increased in size significantly within a short period may require intervention.

Symptoms: Some aneurysms can cause symptoms, such as abdominal or back pain, which can be an indication for treatment. However, many aneurysms are asymptomatic and are detected incidentally during medical imaging.

Risk of Rupture: The primary concern with aortic aneurysms is the risk of rupture, which can be life-threatening due to massive internal bleeding. The risk of rupture is influenced by the size of the aneurysm and other factors. EVAR is often recommended to reduce the risk of rupture.

Anatomy and Location: The anatomy and location of the aneurysm within the aorta are considered when determining the suitability of EVAR. The feasibility of placing a stent graft to seal off the aneurysm depends on the specific characteristics of the aneurysm and the surrounding blood vessels.

Patient’s Health and Age: The overall health and age of the patient play a role in the decision-making process. Some patients may not be suitable candidates for open surgical repair due to other medical conditions or age-related factors, making EVAR a more convenient option.

Patient Preferences: Patient preferences and their involvement in the decision-making process are essential. Patients may choose EVAR because it is a less invasive procedure with potentially shorter recovery times than open surgical repair.

Complex Aortic Anatomy: In some cases, patients with complex aortic anatomy, such as tortuous or highly calcified vessels, may benefit from EVAR because it can be technically challenging to perform open surgical repair.

It’s essential to thoroughly discuss with your healthcare provider and vascular surgeon to understand the specific reasons for recommending EVAR in your case. They will consider your medical history, the characteristics of the aneurysm, and other relevant factors to make an informed decision about the most appropriate treatment approach for your condition.

Who is a candidate for endovascular aneurysm repair?

The suitability of a patient for endovascular aneurysm repair (EVAR) depends on several factors, including the specific characteristics of the abdominal aortic aneurysm (AAA) or thoracic aortic aneurysm (TAA), the patient’s overall health, and the anatomy of the aorta and surrounding blood vessels. Here are the key considerations that make someone a candidate for EVAR:

Ultimately, the decision to undergo EVAR is made individually after a comprehensive vascular surgeon or interventional radiologist evaluation. They will consider all relevant factors to determine whether EVAR is the most appropriate treatment option for your condition. It’s essential to have open and informed discussions with your healthcare provider to understand your candidacy and the potential benefits and risks of the procedure.a

What is fenestrated endovascular aneurysm repair (FEVAR)?

Fenestrated endovascular aneurysm repair (FEVAR) is an advanced minimally invasive surgical procedure used to treat complex abdominal aortic aneurysms (AAAs) that involve the renal arteries or other important branch vessels of the aorta. FEVAR is a modification of traditional endovascular aneurysm repair (EVAR), specifically designed for cases where standard EVAR or open surgical repair may not be feasible due to the location and extent of the aneurysm.

The critical feature of FEVAR is custom-designed stent grafts with openings, or fenestrations, strategically positioned to align with the branching arteries of the aorta. These fenestrations allow blood flow to the renal arteries, mesenteric arteries (supplying the intestines), or other vital vessels while excluding the aneurysm from circulation.

FEVAR is a complex procedure that requires specialized training and experience. Vascular surgeons or interventional radiologists typically perform it with expertise in endovascular techniques. FEVAR is considered a valuable option for patients with AAAs involving the renal arteries or other branches because it allows for repairing aneurysms while preserving blood flow to vital organs. However, it is not suitable for all patients or all types of aneurysms, and the decision to pursue FEVAR is made on an individual basis after careful evaluation by the medical team.

What is the difference between EVAR and TEVAR?

Endovascular aneurysm repair (EVAR) and thoracic endovascular aneurysm repair (TEVAR) are both minimally invasive surgical procedures used to treat aortic aneurysms, but they target different parts of the aorta and have some key differences:

Target Area:
EVAR (Endovascular Aneurysm Repair): EVAR primarily treats abdominal aortic aneurysms (AAAs). It involves placing a stent graft, a fabric-covered metal mesh tube, within the abdominal aorta to exclude the aneurysm and reinforce the weakened aortic wall.

TEVAR (Thoracic Endovascular Aneurysm Repair): TEVAR, on the other hand, is used to treat thoracic aortic aneurysms (TAAs). It targets aneurysms in the thoracic (chest) portion of the aorta, which includes the ascending aorta, aortic arch, and descending thoracic aorta.

Anatomy:
EVAR: EVAR is typically performed in the lower part of the aorta, below the diaphragm, where the abdominal aorta is located.

TEVAR: TEVAR addresses aneurysms in the upper portion of the aorta, within the chest cavity. This includes the ascending aorta, aortic arch, and descending thoracic aorta.

Aneurysm Location:
EVAR: EVAR is used for aneurysms below the renal arteries, which supply blood to the kidneys. It is not typically used for aneurysms that extend into or involve the thoracic aorta.

TEVAR: TEVAR is specifically designed to treat aneurysms in the thoracic aorta, which can be life-threatening if ruptured.

Procedure Variation:
EVAR: EVAR involves placing a stent graft within the abdominal aorta, often through access points in the groin or femoral arteries.

TEVAR: TEVAR involves placing a stent graft within the thoracic aorta, usually through access points in the groin, subclavian arteries, or carotid arteries, depending on the location of the aneurysm.

Branch Vessels:
EVAR: In standard EVAR, the primary concern is sealing off the aneurysm without obstructing branch vessels. Custom fenestrated or branched stent grafts may be used for complex cases to maintain blood flow to specific branch vessels like the renal arteries.

TEVAR: TEVAR involves addressing branch vessels of the aortic arch, such as the brachiocephalic artery, left common carotid artery, and left subclavian artery, as these vessels originate from the aortic arch.

Indications and Eligibility:
EVAR: EVAR is indicated for patients with abdominal aortic aneurysms that meet certain size and anatomical criteria.

TEVAR: TEVAR is used for patients with thoracic aortic aneurysms, dissections, or traumatic injuries involving the thoracic aorta.

EVAR and TEVAR are less invasive alternatives to open surgical repair, offering advantages such as reduced recovery time and shorter hospital stays. However, the choice between EVAR and TEVAR depends on the location and type of the aortic aneurysm and the patient’s medical condition and anatomy. The decision is made after a thorough vascular surgeon or interventional radiologist evaluation.

What are the benefits of an endovascular aneurysm repair procedure?

Endovascular aneurysm repair (EVAR) offers several benefits compared to traditional open surgical repair for abdominal aortic aneurysms (AAAs). These benefits have contributed to the widespread adoption of EVAR as a preferred treatment approach for many patients with suitable aneurysms. Here are some of the critical advantages of EVAR:

Minimally Invasive: EVAR is a minimally invasive procedure involving small incisions rather than a large abdominal or thoracic incision. This leads to less trauma to the body and reduced postoperative pain.

Reduced Hospital Stay: Patients undergoing EVAR typically have shorter hospital stays than open surgery. Many patients can be discharged within a few days after the procedure.

Faster Recovery: The recovery period after EVAR is generally shorter than after open surgical repair. Patients can return to normal activities more quickly, although the timeline varies depending on individual factors.

Lower Risk of Infection: Because EVAR involves smaller incisions, surgical site infection risk is lower than open surgery.

Less Blood Loss: EVAR typically results in less blood loss during the procedure than open surgery, reducing the need for blood transfusions.

Reduced Postoperative Pain: Patients often experience less postoperative pain and discomfort with EVAR, improving overall comfort during recovery.

General Anesthesia Not Always Required: While general anaesthesia is sometimes used for EVAR, local or regional anaesthesia is also an option for certain patients. This can be advantageous for individuals who may not be suitable candidates for general anaesthesia.

Preservation of Collateral Blood Flow: In some cases, EVAR allows for the preservation of collateral blood flow to essential organs and arteries, such as the renal and iliac arteries, which can be critical for maintaining organ function.

Lower Mortality Risk: EVAR is associated with lower short-term mortality rates than open surgical repair. However, long-term outcomes may vary depending on the aneurysm size and patient characteristics.

It’s important to note that EVAR is unsuitable for all patients or all types of aortic aneurysms. The decision to undergo EVAR is made individually after a thorough vascular surgeon or interventional radiologist evaluation. The choice between EVAR and open surgery depends on the aneurysm size, location, patient anatomy, and overall health. Patients considering EVAR should have a detailed discussion with their healthcare provider to understand their case’s potential benefits and risks.

What happens during an endovascular aneurysm repair procedure?

Endovascular aneurysm repair (EVAR) is a minimally invasive surgical procedure used to treat abdominal aortic aneurysms (AAAs) and, in some cases, thoracic aortic aneurysms (TAAs). During EVAR, a stent graft, a fabric-covered metal mesh tube, is placed inside the aorta to reinforce the weakened aortic wall and exclude the aneurysm from circulation. Here’s an overview of what happens during an EVAR procedure:

Preparation:
Before the procedure, you will receive anaesthesia, which may be general anaesthesia or regional anaesthesia (epidural or spinal anaesthesia). This ensures you are comfortable and immobile during the procedure.

Access Site Preparation:
The surgical team typically makes a small incision in each groin area near the femoral arteries. These incisions serve as access points for catheters and guidewires.

Guidewire Placement:
A thin, flexible guidewire is inserted through one of the groin incisions and guided through the femoral artery and up into the aorta, reaching the site of the aneurysm.

Catheter Insertion:
Over the guidewire, a catheter is introduced and advanced through the femoral artery and into the aorta until it reaches the location of the aneurysm.

Stent-Graft Delivery:
The stent graft, compressed onto a delivery system, is introduced through the catheter and positioned within the aorta. The stent graft is designed to fit snugly within the aorta and extend beyond the aneurysm.

Stent-Graft Deployment:
Once the stent graft is positioned correctly, it is carefully deployed. As it expands, the fabric-covered portion of the stent graft adheres to the walls of the aorta, sealing off the aneurysm and allowing blood to flow through the stent graft instead of the aneurysm sac.

Confirmation and Adjustment:
X-ray imaging, often with fluoroscopy or angiography, is used throughout the procedure to monitor the placement of the stent-graft and ensure it is correctly positioned. The surgical team may make adjustments as needed to achieve proper placement and sealing.

Completion:
Once the stent-graft is securely in place and the aneurysm is excluded, the catheters and delivery system are removed from the body.

Closure of Access Sites:
The incisions in the groin are closed with sutures or adhesive, and pressure is applied to promote proper healing.

Endovascular aneurysm repair is generally associated with less pain and a shorter recovery than open surgical repair. However, the specific details of the procedure may vary based on individual patient factors and the complexity of the aneurysm. Your vascular surgeon or interventional radiologist will provide personalized information and guidance regarding your EVAR procedure and postoperative care.

What is recovery from an endovascular aneurysm repair procedure like?

Recovery from an endovascular aneurysm repair (EVAR) procedure can vary depending on individual factors, the complexity of the procedure, and your overall health. However, EVAR is generally associated with a shorter and less intensive recovery than open surgical repair for abdominal aortic aneurysms (AAAs). Here’s what you can usually expect during the recovery process after EVAR:

Immediate Postoperative Period:

After the EVAR procedure, you will be closely monitored in a recovery area, often in the intensive care unit (ICU) or a specialized cardiac care unit. This monitoring ensures that your vital signs are stable and no immediate complications.

Depending on your circumstances, you may remain in the hospital for a variable period, typically ranging from a few days to a week or longer.

Pain Management:

You may experience discomfort or pain in the groin area or incision sites. Pain medications will be provided to manage this discomfort.

Over-the-counter or prescription pain relievers may be recommended after discharge to manage ongoing pain.

Activity Restrictions:

As recommended by your healthcare provider, you will be advised to avoid strenuous activities and heavy lifting for a specific period, typically for a few weeks to a few months.

Gradually, you can resume light activities such as walking, but following your healthcare provider’s guidance on activity restrictions is essential.

Diet and Medications:

You will receive dietary instructions, including guidance on hydration and nutrition.

Medications, such as blood thinners or antiplatelet drugs, may be prescribed to prevent blood clots or other complications. It’s crucial to adhere to the prescribed medication regimen.

Follow-Up Appointments:

You will have scheduled follow-up appointments with your healthcare provider to monitor your recovery, assess the stent graft’s position, and check for potential issues.

Regular imaging studies, such as CT scans or angiography, may be performed to evaluate the success of the EVAR procedure and the exclusion of the aneurysm.

Lifestyle Modifications:

Your healthcare provider may recommend lifestyle changes to reduce the risk of future aneurysms or cardiovascular events. This may include dietary modifications, exercise recommendations, smoking cessation, and blood pressure management.

Wound Care:

If you have incisions, you will receive instructions on wound care and monitoring for signs of infection or other complications.

It’s crucial to follow your healthcare provider’s postoperative instructions carefully, attend all follow-up appointments, and communicate any concerns or changes in your condition. Overall, EVAR offers a quicker and less painful recovery than open surgical repair. Still, individual experiences can vary, and successful recovery depends on proper postoperative care and adherence to medical recommendations.

When should I consult my healthcare provider?

Consult your healthcare provider promptly if you experience any of the following symptoms or conditions after undergoing an endovascular aneurysm repair (EVAR) procedure:

Pain and Discomfort
Fever
Swelling or Redness
Changes in Limb or Organ Function
Bleeding
Shortness of Breath
Chest Pain
Neurological Symptoms
Wound Issues
Medication Reactions
Follow-Up Appointments
Any New or Concerning Symptoms

Remember that timely communication with your healthcare provider can help address potential issues and complications early, significantly impacting your overall recovery and well-being. If you are unsure whether a symptom or concern requires immediate attention, it’s best to err on the side of caution and seek medical advice.

What happens after I recover from EVAR?

After you have recovered from endovascular aneurysm repair (EVAR), it’s essential to continue with a long-term plan for monitoring and maintaining your vascular health. Here are some critical considerations for the period following your recovery from EVAR:

Regular Follow-Up Appointments: You must continue attending regular follow-up appointments with your vascular surgeon or interventional radiologist. These appointments are essential for monitoring the stent graft’s status, assessing the aneurysm’s exclusion, and identifying any potential issues or complications.

Imaging Studies: Your healthcare provider may schedule periodic imaging studies, such as CT scans or angiography, to evaluate the condition of the stent graft and the aorta. The frequency and timing of these studies will depend on your specific case and your healthcare team’s recommendations.

Blood Pressure Management: Effective blood pressure management is crucial for vascular health and the long-term success of the EVAR procedure. Follow your healthcare provider’s recommendations for blood pressure control, which may include lifestyle modifications and medications.

Medication Management: If you have been prescribed medications after EVAR, such as blood thinners or antiplatelet drugs, continue to take them as directed. These medications are often used to prevent blood clots and maintain stent-graft patency.

Lifestyle Modifications: Make and maintain lifestyle changes that promote vascular health. This may include quitting smoking, adopting a heart-healthy diet, engaging in regular physical activity, and managing other risk factors, such as diabetes and high cholesterol.

Vascular Health Monitoring: Pay attention to any changes in your vascular health, including developing new symptoms or concerns related to your cardiovascular system. Report any unusual symptoms to your healthcare provider promptly.

Physical Activity: Engage in regular physical activity, as your healthcare provider recommends. Exercise can help maintain overall cardiovascular fitness and lower the risk of complications.

Stress Management: Find effective ways to manage stress, as chronic stress can impact cardiovascular health. Relaxation techniques, mindfulness, and stress reduction strategies can be beneficial.

Remember that EVAR is a treatment for aortic aneurysms but does not eliminate the risk of future vascular issues. Long-term management and a commitment to a heart-healthy lifestyle are essential for ensuring the continued success of the procedure and your overall vascular well-being. Your healthcare provider will work with you to develop a personalized plan to help you maintain optimal vascular health in the years following EVAR.

Endovascular Aneurysm Repair (EVAR)