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

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 3

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 3, 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. 3, 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 3, 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 3, 5
• Patients with unsuitable aneurysm morphology for EVAR or failed EVAR require open repair 3