Can a surgeon combine a full open abdominal incision with endovascular aneurysm repair (EVAR) for a 78‑year‑old woman with an infrarenal abdominal aortic aneurysm?

Can a Surgeon Combine Open Abdominal Incision with EVAR?

Yes, a surgeon can technically perform both an open abdominal incision and endovascular aneurysm repair (EVAR) in the same procedure, though this hybrid approach is typically reserved for specific clinical scenarios such as managing infected endografts, complex anatomic challenges, or intraoperative complications requiring conversion. 1

Standard Practice: Separate Approaches

The contemporary management of infrarenal AAA involves choosing either open surgical repair or EVAR as distinct treatment strategies, not combining them routinely. 1

• EVAR is performed through small groin incisions (femoral artery access) with stent-graft deployment under fluoroscopic guidance, avoiding laparotomy entirely. 2, 3, 4
• Open repair requires a full midline laparotomy with direct aortic exposure, clamping, and synthetic graft placement. 1
• For a 78-year-old woman with infrarenal AAA and suitable anatomy, EVAR should be considered the preferred approach based on significantly lower 30-day mortality (1.7% vs 4.7% for open repair) and reduced perioperative morbidity. 1, 5

When Hybrid Approaches Are Used

Infected Endograft Management

• Device explantation with open abdominal incision followed by in situ reconstruction represents the primary scenario where open and endovascular techniques intersect, though this involves removing—not placing—an endograft. 1
• Infected EVAR devices require explantation through laparotomy with either extra-anatomic bypass or in situ reconstruction using rifampin-bonded grafts, venous autografts, or cryopreserved allografts. 1

Complex Anatomic Situations

• Adjunctive open procedures may accompany EVAR when iliac access vessels are inadequate, requiring iliac conduit creation or femoral-femoral bypass. 1
• Fenestrated or branched EVAR for juxtarenal or pararenal aneurysms may occasionally require limited open exposure for visceral vessel access, though this remains primarily endovascular. 1

Intraoperative Conversion

• Unplanned conversion from EVAR to open repair occurs in approximately 1-2% of cases due to access failure, deployment complications, or acute rupture during attempted endovascular repair. 1

Decision Algorithm for This 78-Year-Old Woman

Step 1: Obtain CT Angiography

• Assess proximal neck length (≥10-15 mm required), neck diameter (<30 mm), neck angulation, and iliac access adequacy. 1, 5, 2
• More than 50% of patients lack suitable anatomy for standard EVAR; fenestrated EVAR extends options for short necks. 5, 2, 6

Step 2: Assess Life Expectancy and Surveillance Compliance

• EVAR requires mandatory lifelong imaging every 6-12 months; patients with life expectancy <2 years should not receive EVAR. 1, 5, 2
• Women over 75 years have 90-day mortality exceeding 5% with open repair, making EVAR strongly preferred when anatomically feasible. 5

Step 3: Choose Single Modality

• If anatomy is suitable and life expectancy >2 years: proceed with EVAR alone through femoral access without laparotomy. 1, 5, 2
• If anatomy is unsuitable for EVAR or patient cannot comply with surveillance: proceed with open repair alone through midline laparotomy. 1, 2
• Do not plan a combined open-plus-EVAR approach unless specific complications arise intraoperatively requiring conversion. 1

Critical Pitfalls to Avoid

• Performing laparotomy negates the primary advantage of EVAR—reduced perioperative morbidity and mortality—and exposes the patient to the combined risks of both approaches. 1, 3
• Women have four-fold higher rupture risk than men at equivalent AAA sizes, justifying lower repair thresholds (≥50 mm vs ≥55 mm in men). 1, 5, 6
• Reintervention rates are higher after EVAR (5.1%) than open repair (1.7%), requiring patient counseling about long-term surveillance burden. 1, 5, 2
• Endoleaks occur in 10-17% of EVAR patients within 30 days, necessitating protocol-driven imaging follow-up. 1, 5

Preoperative Optimization for Either Approach

• Identify and treat active cardiac conditions (unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease) before elective repair. 1, 5
• Initiate or optimize statin therapy for cardiovascular risk reduction in all patients with atherosclerotic aortic disease. 5, 6
• Ensure strict blood pressure control to slow aneurysm growth and reduce perioperative risk. 5, 6
• Provide smoking cessation counseling, as smoking is the strongest modifiable factor influencing AAA expansion and rupture. 5, 6