Why choose endovascular (minimally invasive procedure using a stent graft) repair over conventional open repair for aneurysm treatment?

Choosing Endovascular Repair vs. Conventional Open Repair for Aortic Aneurysms

For most patients with descending thoracic aortic aneurysms and suitable anatomy, endovascular repair (TEVAR/EVAR) is recommended over open surgical repair due to reduced perioperative mortality and morbidity. 1

Decision Algorithm Based on Aneurysm Location

For Descending Thoracic Aortic Aneurysms (TAA):

• First-line approach: TEVAR is recommended for patients with suitable anatomy 1
• Benefits include:
  • Reduced perioperative mortality (<1% vs 4-5% with open repair) 1
  • Decreased perioperative morbidity 1
  • Shorter hospital stay 1, 2
  • Faster recovery 2

For Thoracoabdominal Aortic Aneurysms (TAAA):

• Ruptured TAAA: Open repair is recommended (Class I recommendation) 1
• Intact TAAA with connective tissue disorders (Marfan, Loeys-Dietz, vascular Ehlers-Danlos): Open repair is recommended (Class I recommendation) 1
• Intact degenerative TAAA with suitable anatomy: Endovascular repair may be considered in centers with expertise (Class IIb recommendation) 1

For Abdominal Aortic Aneurysms (AAA):

• First-line approach: EVAR should be considered for patients with suitable anatomy and reasonable life expectancy (>2 years) 1
• The 2022 ACC/AHA and 2024 ESC guidelines both support endovascular repair to reduce perioperative morbidity and mortality 1

Key Factors Influencing the Decision

Anatomical Considerations:

• Favorable for EVAR:

  • Proximal neck length >10-15mm and diameter <30mm 3
  • Neck angulation <60° 3
  • Mural thrombus/calcification covering <90% of aortic circumference 3
  • Adequate iliac access vessel diameter and minimal tortuosity 3

• Unfavorable for EVAR (favor open repair):

  • More than 50% of patients have aneurysm morphology unsuitable for conventional EVAR 3
  • Complex anatomy requiring fenestrated or branched endografts 1, 3

Patient-Related Factors:

• Favor EVAR:

  • Advanced age 1
  • Multiple comorbidities 1
  • Higher surgical risk 1
  • Ability to comply with lifelong surveillance 3

• Favor open repair:

  • Younger patients with longer life expectancy 1
  • Connective tissue disorders 1
  • Limited life expectancy (<2 years) - neither approach recommended 1
  • Inability to comply with follow-up imaging 3

Long-Term Considerations

EVAR Disadvantages:

• Higher reintervention rates (5.1% vs 1.7% for open repair) 3, 4
• Need for lifelong surveillance 3, 5
• Risk of endoleaks (16-30% complication rate) 5
• Higher long-term costs 4

Open Repair Disadvantages:

• Higher perioperative mortality (4.7% vs 1.7% for EVAR) 6
• Longer hospital stay 2
• Higher immediate postoperative complications 4
• Incisional hernia risk, especially in obese patients 1

Surveillance Requirements After EVAR

• Initial imaging at 1 month post-procedure 3
• Follow-up imaging at 6-12 months 1, 3
• Annual surveillance for at least 5 years 1, 3
• CT angiography is the gold standard for surveillance 3

Common Pitfalls to Avoid

1. Underestimating the importance of anatomical suitability for EVAR 3
2. Performing EVAR in patients with limited life expectancy (<2 years) 1, 3
3. Failing to detect concomitant femoro-popliteal aneurysms 1, 3
4. Inadequate post-EVAR surveillance leading to missed endoleaks 3
5. Neglecting the higher long-term reintervention rates with EVAR 4

In summary, while endovascular repair offers significant perioperative benefits, the choice between endovascular and open repair should be based on aneurysm location, patient anatomy, life expectancy, and ability to comply with follow-up protocols. For most patients with suitable anatomy, endovascular repair provides better short-term outcomes with reduced perioperative mortality and morbidity.