Endovascular Aneurysm Repair (EVAR)

What conditions does it treat?

EVAR is mainly used to treat an abdominal aortic aneurysm (AAA), a bulge in the part of the aorta that runs through your tummy. A related procedure, sometimes called TEVAR, treats aneurysms in the chest.

Your surgeon may recommend EVAR if you have:

• an aneurysm around 5.5cm across or larger, since the risk of it bursting starts to outweigh the risk of surgery at this size
• an aneurysm that’s growing quickly, or one that’s causing pain or tenderness
• healthy blood vessel tissue of a suitable size and shape near the aneurysm, for the graft to attach to
• a reason you wouldn’t be suitable for open surgery with a larger incision.

What are the benefits of EVAR?

Compared with open surgery, EVAR can offer:

• fewer days spent in hospital
• less blood loss during the operation
• less discomfort while you recover
• a quicker return to your daily activities
• a lower chance of a heart attack or dying around the time of the operation
• a shorter procedure overall, usually with just small punctures rather than a large cut.

Are there different types of EVAR?

There’s more than one way to carry out endovascular aneurysm repair, depending on where your aneurysm is and the shape of the blood vessels around it.

Standard EVAR

A tube-shaped stent graft is used for aneurysms that begin below the arteries supplying your kidneys, where there’s enough healthy aorta for the graft to attach to securely.

Fenestrated EVAR (FEVAR)

If your aneurysm is close to the arteries branching off to your kidneys or other organs, your surgeon may use a specially made stent graft with small openings, so blood can still flow into these branch arteries once the graft is in place.

Thoracic EVAR (TEVAR)

This treats aneurysms in your chest rather than your tummy. It works on the same principle, though your surgeon will choose the technique best suited to where your aneurysm is.

Your surgeon may also reach your arteries either through a small surgical cut, or with a needle puncture alone, depending on your circumstances.

What happens before the procedure?

Before your operation, you’ll have detailed scans, usually a CT scan with contrast dye (a CT angiogram), so your surgeon can measure your aneurysm precisely and check the size, shape and condition of the blood vessels that lead to it, including those in your groin and pelvis. You’ll also have blood tests.

Not every aneurysm is suitable for this type of repair. Your surgeon will check whether there’s enough healthy blood vessel near the aneurysm for the graft to attach to securely, and whether your groin and pelvic arteries are wide and straight enough for the instruments to pass through safely.

What happens during the procedure?

1. You lie on your back on the operating table, and your anaesthetist monitors your heart rate, blood pressure, breathing and oxygen levels throughout.
2. You’re given a general anaesthetic, so you’re asleep throughout, or sometimes a regional anaesthetic (an epidural in your back) with medicine to help you relax, so you’re numb but comfortable.
3. Your surgeon makes a small cut in each groin, or uses a needle puncture, to reach your femoral arteries.
4. A guidewire is passed into the artery and advanced towards the aneurysm under X-ray guidance, followed by a sheath that creates a pathway for the instruments.
5. Contrast dye is injected so your surgeon can clearly see the aneurysm and the surrounding blood vessels on the X-ray images.
6. The stent graft, folded down small, is guided up into the aorta and positioned at the aneurysm.
7. The graft is expanded and attached to the wall of your aorta, creating a new, sealed channel for blood to flow through.
8. Further X-ray images check for any leaks around the graft before your surgeon removes the instruments.
9. The cuts in your groin are closed, and a dressing is applied.

The procedure is usually carried out under general anaesthetic, though a regional anaesthetic is sometimes used instead.

What does recovery look like?

In hospital

You may need to stay in hospital for 2 to 3 days to monitor your recovery. Your consultant will let you know. Once your anaesthetic has worn off, you can usually eat and drink normally, and nurses will help you get up and start walking as soon as it’s safe to do so.

At home

Once you’re home, you may tire easily and need pain medication for a few days. You shouldn’t drive until you’ve stopped taking these. Most people return to work within a month.

Avoid heavy lifting for 4–6 weeks after your operation. Gradually build back up to your normal activity.

You’ll need regular scans, usually CT scans, for the rest of your life to check the graft is working properly and the aneurysm hasn’t changed. Your surgeon will typically see you again within a month of your operation to begin this monitoring.

What are the risks and complications?

EVAR is generally a safe procedure with a high success rate, though as with any operation, there are risks to consider.

Risks around the time of the operation

• bleeding, or a blood clot forming in your leg veins (deep vein thrombosis)
• a heart attack, heart failure, or an irregular heartbeat
• kidney problems, including kidney failure
• infection at the wound site
• reduced blood flow to your bowel or other organs if a branch artery is affected
• damage to a blood vessel during the procedure.

Risks related to the stent graft itself

• an endoleak, where blood continues to leak slowly into the area around the graft rather than flowing only through it. This is fairly common, affecting around 30–40% of people, though many cases are low risk and settle on their own without needing treatment
• the graft slipping out of position, or its limbs narrowing or kinking
• infection of the graft itself, which is uncommon but serious, affecting around 1–5% of people with any aortic graft
• the aneurysm continuing to enlarge, or, rarely, rupturing, even some years after your operation.

Because of these risks, you’ll need regular scans for the rest of your life to check the graft is working as it should. Your surgeon will explain how each of these risks applies to you.