What is the recommended treatment for a patient with an aortic aneurysm, considering endovascular aneurysm repair (EVAR) as a first-line option?

Endovascular Aneurysm Repair (EVAR) for Aortic Aneurysms

For abdominal aortic aneurysms (AAA) with suitable anatomy, EVAR is the recommended first-line treatment over open repair, reducing 30-day mortality from approximately 4.7% to 1.7%. 1, 2

Treatment Thresholds by Location

Abdominal Aortic Aneurysm (AAA)

• Elective repair is indicated at ≥55 mm in men or ≥50 mm in women 1, 2
• For saccular AAA morphology, repair at ≥45 mm due to higher rupture risk at smaller diameters 2
• Rapid growth (≥5 mm in 6 months or ≥10 mm per year) warrants intervention regardless of absolute size 2, 3
• For ruptured AAA with suitable anatomy, EVAR is strongly preferred over open repair (Class I, Level B recommendation) to reduce perioperative morbidity and mortality 1, 2, 4

Descending Thoracic Aortic Aneurysm (DTA)

• TEVAR is recommended over open repair when diameter ≥55 mm and anatomy is suitable (Class I, Level B) 1, 2
• Open repair should be reserved for young, healthy patients with unsuitable TEVAR anatomy and life expectancy exceeding 2 years 1
• The early mortality benefit of TEVAR decreases after 1 year, with long-term survival (10 years) potentially favoring open repair in appropriate candidates 1

Thoracoabdominal Aortic Aneurysm (TAAA)

• Elective repair threshold is ≥60 mm for low-moderate surgical risk patients 1, 2
• Consider repair at ≥55 mm for high-risk features or very low-risk patients in experienced centers 1
• Endovascular repair using fenestrated/branched endografts should be considered in experienced centers when anatomy is suitable 1, 2

Critical Patient Selection Criteria

When EVAR is Appropriate

• Life expectancy >2 years is mandatory for elective repair consideration 1, 2, 3
• Suitable anatomy (adequate proximal neck, iliac access vessels) 1, 5
• Patient ability to comply with mandatory long-term imaging surveillance 1, 5

When EVAR Should NOT Be Used

• Do not offer elective repair to patients with life expectancy <2 years (Class III, Level B) regardless of aneurysm size 1, 2, 3
• Unsuitable anatomy that doesn't meet established criteria 1
• Inability to access required imaging modalities for follow-up 1
• Patients who cannot comply with yearly surveillance requirements 1, 5

Perioperative Advantages of EVAR

The superiority of EVAR over open repair is most pronounced in the perioperative period:

• 30-day mortality: 1.6-1.7% for EVAR vs 4.6-4.7% for open repair 6
• Reduced ventilator-dependent respiratory failure: 5% vs 42% 4
• Shorter hospital stay: 10 days vs 21 days 4
• Lower blood loss and no aortic cross-clamping required 7

Important caveat: The early mortality benefit does not translate to long-term survival advantage, as demonstrated in multiple trials 1, 6. This underscores that treatment selection must account for patient-specific factors beyond just short-term outcomes.

Mandatory Surveillance Protocol

Imaging surveillance is non-negotiable after EVAR and must be performed as follows:

• At 1 month: CCT (or CMR) plus DUS/CEUS 1, 2
• At 12 months: CCT (or CMR) plus DUS/CEUS 1, 2
• Annually thereafter: DUS/CEUS if no abnormalities 1, 2
• Every 5 years: Repeat CCT or CMR 1, 2

Complications and Reintervention

Endoleaks

Endoleaks occur in 16-30% of AAA repairs and up to 38% of TEVAR cases 7:

• Type I endoleaks require immediate reintervention to achieve seal 1, 3
• Type III endoleaks require reintervention, primarily by endovascular means 1, 3
• Type II endoleaks occur in ~25% but may spontaneously seal; at 6-12 months, assess for aneurysm sac growth ≥10 mm and consider embolization if feasible 2, 3

Secondary Interventions

• More common after EVAR than open repair: 9.8% vs 5.8% 6
• Overall reintervention rates: 19-24% for endovascular repair 7
• Most reinterventions are endovascular (cuff extensions, additional components, embolization) 7

Complex Anatomy Considerations

For juxta-renal or para-renal AAA, fenestrated or branched stent endografts allow perfusion of visceral vessels and should be considered in experienced centers 1, 3

Preoperative Assessment

• Do NOT perform routine coronary angiography and systematic revascularization in patients with chronic coronary syndromes prior to AAA repair (Class III, Level C) 1, 3
• Consider duplex ultrasound of femoro-popliteal segment to detect concomitant aneurysms (Class IIa, Level B) 3
• For DTA with planned left subclavian artery (LSA) coverage, revascularize the LSA before TEVAR to reduce spinal cord ischemia and stroke risk 1

Common Pitfalls to Avoid

1. Do not apply male size thresholds to women - use ≥50 mm, not ≥55 mm 2, 3
2. Do not wait for standard 55 mm threshold in saccular aneurysms - repair at ≥45 mm 2, 3
3. Do not offer EVAR to patients who cannot comply with surveillance - this negates the benefit and increases risk 1, 5
4. Do not assume EVAR is appropriate for all high-risk patients - the EVAR 2 trial showed no survival benefit in patients too unfit for open repair, with 7.3% 30-day mortality and no improvement in overall mortality 1