What are the surgical steps of an Endovascular Aneurysm Repair (EVAR)?

From the Guidelines

Endovascular Aneurysm Repair (EVAR) is a minimally invasive procedure that involves several key surgical steps to treat abdominal aortic aneurysms, including obtaining vascular access, advancing guidewires, deploying the stent graft, and performing completion angiography. The procedure begins with obtaining vascular access through the femoral arteries via small groin incisions, as described in the 2014 ESC guidelines on the diagnosis and treatment of aortic diseases 1. After administering heparin for anticoagulation, guidewires are advanced through the access sites under fluoroscopic guidance.

Key Steps in EVAR

• Obtaining vascular access through the femoral arteries via small groin incisions
• Advancing guidewires through the access sites under fluoroscopic guidance
• Deploying the stent graft at the planned deployment site below the renal arteries
• Cannulating the contralateral limb using a catheter from the opposite femoral access
• Deploying the iliac limb extensions to complete the graft
• Performing completion angiography to confirm proper positioning, seal, and exclusion of the aneurysm without endoleaks

The main body of the stent graft is then inserted through one femoral artery and positioned at the planned deployment site below the renal arteries. Following precise positioning, the main body is deployed, and the contralateral limb is cannulated using a catheter from the opposite femoral access. The iliac limb extensions are then deployed to complete the graft. Completion angiography is performed to confirm proper positioning, seal, and exclusion of the aneurysm without endoleaks, as recommended by the 2014 ESC guidelines 1. The procedure concludes with closure of the arteriotomy sites using either sutures or closure devices, followed by closure of the groin incisions.

Post-Operative Care

• Lifelong surveillance with imaging to monitor for potential complications such as endoleaks, graft migration, or aneurysm expansion
• Regular follow-up appointments to assess the patient's condition and adjust treatment as needed
• Education on the importance of adhering to the recommended surveillance schedule and reporting any symptoms or concerns to the healthcare provider

Post-operatively, patients require lifelong surveillance with imaging to monitor for potential complications such as endoleaks, graft migration, or aneurysm expansion, as highlighted in the 2005 Annals of Internal Medicine study 1. This approach offers advantages over open repair including reduced blood loss, shorter hospital stays, and faster recovery, though it requires appropriate anatomical features including adequate proximal and distal landing zones for successful implementation.

From the Research

Surgical Steps of Endovascular Aneurysm Repair (EVAR)

• The traditional approach in EVAR involves surgical exposure of the femoral arteries with bilateral groin incisions 2
• Through the groin access, and under fluoroscopy, a special insertion sheath introducer is used to position a stent graft in the desired location with the patient in general or epidural anesthesia 2
• The procedure can be performed using a percutaneous approach, which is a minimally invasive technique that may reduce groin wound complication rates and improve recovery time 3
• The percutaneous approach involves the use of a closure device to seal the femoral artery access site, rather than a surgical cut-down 3
• The choice of approach depends on the unique anatomy of each patient and the presence of any complications such as bleeding, stenosis, ischemia, or femoral artery injury 2
• The surgical steps may also involve the use of a chimney graft, which is a stent placed parallel to the aortic stent-graft to preserve flow to a vital aortic branch 4
• The type of groin incision used can also vary, with transverse and vertical incisions being compared in terms of their effectiveness and safety 5
• A minimalist approach to EVAR, using local anesthesia and a smaller incision, may also be used to reduce complications and costs 6

Approaches to Femoral Artery Access

• Percutaneous approach: a minimally invasive technique that uses a closure device to seal the femoral artery access site 3
• Surgical cut-down approach: a traditional approach that involves surgical exposure of the femoral arteries with bilateral groin incisions 2
• Transverse groin incision: a surgical technique that involves making a cut parallel to the groin crease 5
• Vertical groin incision: a surgical technique that involves making a cut across the groin crease 5

Considerations for EVAR

• Patient anatomy and the presence of any complications such as bleeding, stenosis, ischemia, or femoral artery injury 2
• The choice of approach and the type of groin incision used 2, 3, 5
• The use of a chimney graft to preserve flow to a vital aortic branch 4
• The use of local anesthesia and a minimalist approach to reduce complications and costs 6