Endovascular Aortic Aneurysm Repair
What is endovascular aortic aneurysm repair?
Endovascular aortic aneurysm repair is a minimally invasive procedure that treats an aortic aneurysm. An aortic aneurysm is a weakened area in the aorta, the main blood vessel that carries blood from your heart. It passes from the heart down through the chest (thoracic cavity) and abdomen (belly). This weakened area can grow, stretch, balloon outward, and burst causing rapid, massive blood loss. Few people survive a ruptured aortic aneurysm.
Endovascular aortic repair uses a flexible tube (catheter) to insert a stent-graft in the aorta. The stent-graft reinforces the aorta and prevents a life-threatening rupture.
Endovascular aneurysm repair has serious risks and potential complications. In addition, endovascular repair is not an option in all cases of aortic aneurysm. You may have other treatment options, including open surgery. If your situation is not an emergency, consider getting a second opinion or ask about all your treatment choices before having an endovascular aortic repair.
Types of endovascular aortic repair
The types of endovascular aortic repair procedures include:
Abdominal endovascular aortic repair (endovascular AAA repair) repairs an aortic aneurysm that occurs in the part of the aorta that runs through the abdomen (belly). An abdominal aortic aneurysm is the most common type of aortic aneurysm. Another term for endovascular aortic aneurysm repair and endovascular AAA repair is EVAR.
Thoracic endovascular aortic repair repairs an aneurysm that occurs in the part of the aorta that runs through the chest. Another term for thoracic endovascular aneurysm repair is TEVAR.
Why is endovascular aortic aneurysm repair performed?
Your doctor may recommend endovascular thoracic or abdominal aortic aneurysm repair if other treatment options that involve less risk of complications—such as medicine to lower your blood pressure—have been ineffective. If your situation is not an emergency, ask your doctor about all your treatment options and consider getting a second opinion.
Your doctor may recommend EVAR or TEVAR for you if:
You cannot tolerate open surgery due to age, serious heart disease, or other conditions.
Your aneurysm has a shape that works well with a catheter stent-graft.
Your abdominal aneurysm is not located too close to the renal (kidney) arteries.
Your doctor may consider endovascular aortic repair if your aneurysm is large (more than five centimeters) and growing rapidly or causing problems, such as interfering with blood flow or starting to dissect, which is when the internal layers of the aortic wall tear.
Symptoms of an abdominal aortic aneurysm include (belly) pain, low back pain, or feeling your heartbeat in your abdomen. Symptoms of a thoracic aortic aneurysm include chest pain, back pain, upper back, neck, or jaw pain, coughing, shortness of breath, or hoarse voice.
Endovascular repair may also be an option for a ruptured aortic aneurysm, depending on its location and structure. It is also attempted for ruptured aneurysms in people who would have a poor prognosis with open aortic aneurysm repair.
Who performs EVAR and TEVAR surgeries?
The following specialists commonly perform endovascular aortic repair:
Interventional cardiologists specialize in diagnosing and treating heart disease using catheter procedures and radiological imaging.
Vascular and interventional radiologists specialize in the treatment of blood vessel and other conditions using catheter-based procedures and imaging techniques.
Vascular surgeons specialize in the surgical treatment of blood vessel diseases.
Cardiac surgeons specialize in the surgical treatment of heart and blood vessel conditions. They repair thoracic aortic aneurysms.
Thoracic surgeons specialize in the surgical treatment of diseases of the chest, including the blood vessels, heart, lungs, and esophagus.
How is endovascular aortic aneurysm repair performed?
You will have endovascular aortic repair in a hospital using minimally invasive surgery techniques and X-ray guidance. This involves inserting a catheter and guide wire through an artery in your groin or leg. Your doctor then guides the catheter guide wire to the aortic aneurysm in the abdomen or chest. The catheter tip has a deflated synthetic stent-graft. This device expands like a spring once the catheter is in place. The stent-graft reinforces the walls of your aorta. Your blood now flows through the graft.
Your surgeon will perform your endovascular procedure using either general anesthesia or regional anesthesia.
General anesthesia is a combination of intravenous (IV) medications and gases that put you in a deep sleep.
- Regional anesthesia is a nerve block. It involves injecting an anesthetic around certain nerves to numb a large area of the body. You will likely have sedation with regional anesthesia to keep you relaxed and comfortable.
What to expect the day of your procedure
The day of your surgery, you can generally expect these events:
Your nurse will ensure all preoperative tests are in order, answer any questions you have, and will make sure you understand and sign the consent form.
A member of the endovascular procedure team will take you to the surgical suite.
The anesthesiologist or nurse anesthetist will ask you about your medical history and explain the type of anesthesia you will have.
A team member starts an IV and the anesthesiologist starts your anesthesia.
The surgeon or vascular interventionist places the stent-graft, removes the guide wire and catheter, and closes the groin incision.
The surgical team will monitor your vital signs and other critical body functions. This occurs throughout the surgery and recovery until you are alert, breathing effectively, and your vital signs are stable.
What are the risks and potential complications of the endovascular approach?
Endovascular aortic repair involves risks and possible complications, which can develop during surgery or recovery. You can improve your chances of a successful outcome by choosing a surgeon who performs endovascular aneurysm repair on a regular basis and has a good success rate.
General risks of surgery
General risks of surgery include:
Anesthesia problems such as an allergic reaction
Bleeding, which can lead to shock and require blood transfusion
Risks specific to endovascular aortic aneurysm repair
Potential complications of endovascular aortic repair include:
Blockage of the graft
Blood leaking from the graft
Blood vessel damage
Cancer from radiation exposure. Endovascular repair exposes patients to ionizing radiation because the surgeon uses X-rays to guide the stent-graft to the repair site. Patients also need annual imaging tests like a CT scan to monitor the aorta and the graft. Because radiation-induced cancer usually takes many years to develop, the risk may be more of a concern for younger patients undergoing endovascular repair.
Movement of the graft, which can lead to regrowth of the aneurysm
Reducing your risk of complications
You can reduce the risk of certain complications by following your treatment plan and:
Following activity, dietary and lifestyle restrictions and recommendations during your recovery
Limiting the amount of radiation exposure from medical tests or treatments (except for aneurysm and graft monitoring and in emergency situations)
Notifying your doctor immediately of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage
Taking your medications exactly as directed and notifying your doctor about side effects
Telling all members of your care team if you have any allergies
How do I prepare for endovascular aortic aneurysm repair?
If your surgery is scheduled and you have time to prepare, the steps you take before surgery can improve your chances of a successful outcome. You can prepare for endovascular aortic repair by:
Answering all questions about your medical history and medicines you take. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins.
Losing excess weight before the surgery through a healthy diet and exercise plan.
- Not eating or drinking before surgery as directed by the surgical team.
Your surgery may be cancelled if you eat or drink too close to the start of surgery. This is because you can choke on stomach contents during anesthesia.
Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and help the healing process.
Taking or stopping medications exactly as directed. This may include not taking aspirin, ibuprofen (Advil, Motrin), and blood thinners.
Questions to ask your doctor
Being well informed about endovascular aortic aneurysm repair is an important part of preparing for the procedure and knowing what to expect afterwards. Below is a list of questions to ask your doctor. The answers should help you understand the operation, why it’s a good option for you, and what to plan for recovery,
Why do I need endovascular aortic repair? Are there any other options for treating my condition?
How many EVARs do you perform in a month, on average?
How often do your patients encounter complications? Do you have outcomes data to share?
How long will the surgery take? When can I go home?
What restrictions will I have after the surgery? When can I return to work and other activities?
What kind of assistance will I need at home?
What medications will I need before and after the surgery? How should I take my usual medications?
How will you treat my pain?
When should follow-up with you?
How should I contact you? Ask for numbers to call during and after regular hours.
Contact your doctor with concerns and questions before surgery and between appointments.
What can I expect after endovascular aneurysm repair?
Knowing what to expect makes it easier to plan for recovery after endovascular aortic repair.
How long will it take to recover?
A typical hospital stay for endovascular aortic repair is two to three days. You will stay briefly in the recovery room after surgery until your vital signs are stable. You may or may not need to stay in an intensive care unit (ICU) after recovery. Many people move from the recovery room to a hospital room outside the ICU. Your room has equipment to monitor your heart rhythm and vital signs.
For endovascular repair, you will notice tenderness at the catheter incision site. You may also feel discomfort in your abdomen or chest, depending on the location of the stent-graft. Your doctor will treat your pain so you are comfortable and get enough rest. Tell your doctor or care team if your pain gets worse or changes because it may be a sign of a complication.
When you wake up, you may have a breathing tube in your mouth. You will not be able to talk if you have a breathing tube. Your team usually removes it within a short period of time. You may also have a sore throat, which is usually temporary.
Full recovery takes two weeks or more, depending on your general health, age, and other factors.
When should I call my doctor?
It is important to keep all your follow-up appointments after endovascular aortic repair. Contact your doctor for questions and concerns between appointments. Call your doctor right away or seek immediate medical care if you have:
Bloating or pain in your abdomen or belly
Coughing up blood or yellow or green mucus
Inability to urinate or have a bowel movement
Pain not controlled by your pain medication
Uncontrolled or heavy bleeding
Unexpected drainage, pus, redness or swelling at the catheter incision site (in your groin)
How might endovascular aortic repair affect my everyday life?
Many people return to an active normal life after endovascular aortic repair. However, it will not prevent another area of your aorta from developing an aneurysm.
You can make changes to your everyday life to reduce the risk of another aneurysm. These include:
Eating a heart-healthy diet
Getting regular exercise
Maintaining a healthy weight
Practicing stress management techniques
You will also have long-term follow-up visits and imaging tests to check that your graft is functioning well. You may also need additional surgery in the future to maintain or repair the graft.