Endovascular Repair for Aortic Aneurysms
Endovascular repair (EVAR) is the preferred treatment for most aortic aneurysms when anatomy is suitable, offering superior perioperative mortality (<1%) and reduced morbidity compared to open repair, though it requires lifelong surveillance and carries higher long-term reintervention rates. 1
Treatment Approach by Anatomic Location
Abdominal Aortic Aneurysm (AAA)
For ruptured AAA with suitable anatomy, endovascular repair is strongly recommended over open repair to reduce perioperative morbidity and mortality (Class I, Level B). 1
For elective AAA repair in patients with suitable anatomy and life expectancy >2 years, EVAR should be considered as the preferred therapy based on shared decision-making (Class IIa, Level B). 1
Size Thresholds for Intervention:
- Standard fusiform AAA: ≥55 mm in men or ≥50 mm in women (Class I, Level A) 1
- Saccular AAA: ≥45 mm warrants consideration for repair (Class IIb, Level C) - notably lower threshold due to increased rupture risk 2
- Rapid growth: ≥5 mm in 6 months or ≥10 mm per year may warrant intervention (Class IIb, Level C) 1
Key Mortality and Morbidity Data:
- EVAR reduces perioperative mortality to <1% compared to open repair 1
- For ruptured AAA, EVAR perioperative mortality is 15.7% vs 49% for open repair 3
- Ventilator-dependent respiratory failure occurs in 5% with EVAR vs 42% with open repair 3
- Hospital length of stay is significantly shorter with EVAR (10 days vs 21 days for ruptured AAA) 3
Descending Thoracic Aortic Aneurysm (DTA)
For unruptured DTA aneurysm when elective repair is indicated and anatomy is suitable, TEVAR is recommended over open repair (Class I, Level B). 1
Size Threshold:
- Elective repair is recommended if diameter ≥55 mm (Class I, Level B) 1
- May consider repair at <55 mm for women, connective tissue disorders, or rapid growth (≥10 mm/year or ≥5 mm/6 months) 1
Important Technical Consideration:
When TEVAR involves planned left subclavian artery (LSA) coverage, revascularize the LSA before TEVAR to reduce risk of spinal cord ischemia and stroke (Class I, Level B). 1
Long-term Survival Nuance:
While TEVAR offers early mortality benefit, long-term survival (10 years) appears better with open repair 1. Therefore, open repair is advisable for young, healthy patients with unsuitable TEVAR anatomy and prolonged life expectancy 1.
Thoracoabdominal Aortic Aneurysm (TAAA)
For unruptured degenerative TAAA, elective repair is recommended when diameter is ≥60 mm (Class I, Level B). 1
Surgical repair should be considered at diameters ≥55 mm if patients present with high-risk features or are at very low risk under care of experienced surgeons in a multidisciplinary aorta team (Class IIa, Level B). 1
For patients with suitable anatomy when elective repair is indicated, endovascular repair using fenestrated and/or branched endografts should be considered in experienced centers (Class IIa, Level B). 1
Complex Anatomy Considerations
For juxta-renal or para-renal AAA, fenestrated or branched stent endografts should be considered to allow perfusion of visceral vessels 1. These devices have shown excellent results and expand treatment possibilities to 60-70% of infrarenal AAA cases 1.
Critical Contraindications
In patients with AAA and limited life expectancy (<2 years), elective AAA repair is not recommended (Class III, Level B). 1
Mandatory Surveillance and Complications
Endoleak Management:
Endoleaks occur in up to one-third of patients and are the most common complication 1, 4.
Type I and Type III endoleaks require immediate correction with new endovascular procedures to prevent rupture 1, 2.
Type II endoleaks are present in about 25% of patients but may spontaneously seal 1.
Surveillance Protocol:
Lifelong imaging surveillance is required following EVAR, with computed tomography considered the gold standard 4. Monitor at 6-12 months, then annually for 5 years for endoleaks, graft migration, and aneurysm sac changes 2, 4.
Chronic anticoagulation constitutes a risk factor for reintervention, late conversion surgery, or mortality 1.
Pre-operative Planning Requirements
Cardiovascular CT (CCT) is the optimal pre-operative imaging modality to assess the entire aorta and determine EVAR feasibility 2, 5.
Duplex ultrasound (DUS) assessment of the femoro-popliteal segment should be considered prior to AAA repair to detect concomitant aneurysms (Class IIa, Level B) 1.
Routine coronary angiography and systematic revascularization in patients with chronic coronary syndromes is not recommended prior to AAA repair (Class III, Level C). 1
Common Pitfalls to Avoid
Do not wait for the standard 55 mm threshold in saccular aneurysms - these have increased rupture risk at smaller diameters and warrant repair at ≥45 mm 2.
Do not delay repair of symptomatic aneurysms regardless of diameter - symptoms indicate impending rupture 2.
Do not perform EVAR without confirming adherence to manufacturer's instructions for use - off-label use increases complication rates 2.
Do not neglect post-EVAR surveillance - secondary reinterventions are required in approximately 19-24% of cases 4.
For obese patients undergoing open repair, consider prophylactic mesh use to reduce incisional hernia risk 1.
Reintervention Rates
EVAR carries higher long-term reintervention risk compared to open repair, though it remains durable at mid-term follow-up 1, 6. Secondary reinterventions are required in 19-24% of cases and typically involve percutaneous techniques such as cuff extension devices, additional endograft components, or embolization for endoleaks 4.