What is endoaneurysmorrhaphy (endovascular aneurysm repair) and is it the preferred treatment for a 78‑year‑old woman with an infrarenal abdominal aortic aneurysm?

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Last updated: February 22, 2026 • View editorial policy

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What is Endoaneurysmorrhaphy (Endovascular Aneurysm Repair)?

Endoaneurysmorrhaphy, more commonly known as endovascular aneurysm repair (EVAR), is a minimally invasive procedure that uses a stent graft deployed through the femoral arteries to exclude an abdominal aortic aneurysm from circulation, thereby preventing rupture while maintaining blood flow through the graft. 1

Definition and Mechanism

  • EVAR involves inserting a stent graft endovascularly to exclude the aneurysm sac from blood flow while maintaining antegrade flow through the graft, avoiding the need for major abdominal surgery 1
  • The procedure is performed through small groin incisions, accessing the femoral arteries to deliver the stent graft to the aneurysm site 2

Application for a 78-Year-Old Woman with Infrarenal AAA

For a 78-year-old woman with an infrarenal abdominal aortic aneurysm and suitable anatomy, EVAR is the preferred treatment approach if her life expectancy exceeds 2 years. 3

Treatment Decision Algorithm

Step 1: Assess Life Expectancy

  • If life expectancy is less than 2 years, elective AAA repair is not recommended 4, 5
  • If life expectancy exceeds 2 years, proceed to anatomic evaluation 4

Step 2: Obtain Pre-operative Imaging

  • Cardiovascular CT (CCT) is the optimal imaging modality to assess the entire aorta and determine EVAR feasibility 4
  • Imaging must evaluate aneurysm size, extent, rate of growth, and suitability for endovascular repair 6

Step 3: Determine Treatment Based on Anatomy

  • If anatomy is suitable for EVAR: This is the preferred approach, offering perioperative mortality <1% compared to 4.3% with open repair 3, 4
  • If anatomy is unsuitable for EVAR: Open repair remains indicated for patients who are good surgical candidates 3
  • If patient cannot comply with lifelong surveillance: Open repair is reasonable despite being a good surgical candidate 3

Advantages of EVAR Over Open Repair

  • EVAR demonstrates significantly lower procedural mortality (1.8% vs 4.3% for open repair) 3
  • Reduced perioperative morbidity compared to open surgical repair 6, 2, 1
  • Shorter hospitalization and faster recovery 1
  • However, long-term outcomes show clinical equivalence between EVAR and open repair, with similar all-cause mortality (7.5 vs 7.7 deaths per 100 person-years) and aneurysm-related mortality (1.0 vs 1.2 deaths per 100 person-years) at 6-year follow-up 3

Critical Requirement: Lifelong Surveillance

EVAR requires mandatory lifelong imaging surveillance, which is the most significant disadvantage compared to open repair. 6, 4

  • Endoleaks occur in up to one-third of patients and are the most common complication 4, 5
  • Type I and Type III endoleaks require immediate correction to prevent rupture 6, 4, 5
  • Type II endoleaks occur in approximately 25% of patients but may spontaneously seal 5
  • Surveillance imaging should be performed at 6-12 months post-procedure, then annually for 5 years to monitor for endoleaks, graft migration, and aneurysm sac changes 4
  • Reintervention rates are significantly higher with EVAR (5.1%) compared to open repair (1.7%) 3

Common Pitfalls to Avoid

  • Do not assume EVAR is appropriate for high-risk patients with severe cardiac, pulmonary, or renal disease—the effectiveness in this population is uncertain despite historical recommendations 3
  • Do not neglect to confirm the patient can comply with lifelong surveillance requirements before choosing EVAR over open repair 3
  • Do not delay treatment if the aneurysm is symptomatic—symptoms indicate impending rupture regardless of size and warrant urgent repair 4
  • For saccular aneurysms specifically, do not wait for the standard 55 mm threshold—repair is warranted at ≥45 mm due to higher rupture risk 4, 5

Special Considerations for Complex Anatomy

  • For aneurysms with inadequate neck length, fenestrated EVAR (FEVAR) allows perfusion of major visceral arteries through fenestrations in the graft material 6, 5
  • Patients with unsuitable aneurysm morphology for EVAR or failed EVAR require open repair 6

References

1
Research

Endovascular aneurysm repair (EVAR).

International journal of surgery (London, England), 2008

4
Guideline

Treatment of Saccular Infrarenal Abdominal Aortic Aneurysm

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

5
Guideline

Endovascular Repair for Aortic Aneurysms

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.