From the Guidelines
Endovascular Aneurysm Repair (EVAR) is indicated for patients with abdominal aortic aneurysms (AAAs) measuring ≥55 mm in men or ≥50 mm in women, as recommended by the 2024 ESC guidelines 1. The criteria for EVAR also include anatomical requirements such as adequate proximal and distal landing zones, access vessel diameter, and limited angulation of the aortic neck. Patients should have a life expectancy of at least 2 years to justify the procedure and its follow-up requirements. EVAR is particularly beneficial for high-risk surgical patients with significant comorbidities. Some key points to consider when evaluating patients for EVAR include:
- Anatomical suitability for EVAR, including adequate landing zones and access vessel diameter
- Life expectancy of at least 2 years
- Presence of significant comorbidities that may increase the risk of open repair
- Ability to comply with required follow-up imaging and treatment The procedure involves placing a stent graft via the femoral arteries to exclude the aneurysm from circulation, reducing rupture risk. Post-procedure, patients require lifelong surveillance with imaging (CT angiography or duplex ultrasound) to monitor for complications like endoleaks, device migration, or aneurysm enlargement. EVAR offers lower perioperative mortality and shorter recovery compared to open repair, though long-term outcomes and reintervention rates must be considered in the decision-making process, as noted in the 2024 ESC guidelines 1 and the 2022 ACC/AHA guideline 1. It's also important to consider the role of routine surveillance after EVAR, as outlined in the 2022 ACC/AHA guideline 1, which recommends baseline surveillance imaging with CT and continued surveillance with duplex ultrasound at 12 months and then annually thereafter. Overall, the decision to perform EVAR should be based on a comprehensive evaluation of the patient's individual characteristics, including anatomical suitability, life expectancy, and comorbidities, as well as the potential benefits and risks of the procedure, as recommended by the 2024 ESC guidelines 1 and the 2022 ACC/AHA guideline 1.
From the Research
Indications for EVAR
- Abdominal aortic aneurysms (AAA) are typically treated with Endovascular Aneurysm Repair (EVAR) in current practice 2
- EVAR is an established approach to treating AAA, with lower periprocedural mortality and morbidity than open surgical repair 2, 3
- The procedure is less invasive, resulting in a shorter hospital stay, less pain, and less chance of morbidity 4
Guidelines for EVAR
- Aneurysm neck morphology, iliac anatomy, and access vessel anatomy need careful assessment for the successful performance of EVAR 2
- Regular and long-term follow-up with imaging is mandatory after EVAR, and patients who are less likely to comply are less favorable EVAR candidates 2
- Endoleaks are the most frequent complication of EVAR, and most can be managed with transcatheter or endovascular means 2, 5, 3
- The use of conscious sedation with local anesthesia and percutaneous femoral access has further decreased the morbidity of the procedure 5
- Current devices can more effectively manage increasingly "hostile" aneurysm necks, while chimney grafts or dedicated fenestrated stent-grafts can be used for juxta-renal disease with favorable results 6, 5
Patient Selection
- Patient selection is crucial, and individual patient factors heavily influence the selection of the mode of repair 3
- An improved strategy to predict endoleak development could further help direct treatment choice for patients and improve both early and late outcomes 3
- Understanding the currently available evidence for each option is essential to select the most suitable procedure for each patient 6