Endovascular Aneurysm Repair

Introduction

If you have been told you have an aortic aneurysm and your doctor has discussed endovascular aneurysm repair, also known as EVAR, this guide will help you understand what lies ahead. An aortic aneurysm is a bulge in the wall of the aorta, the body’s main artery. EVAR is a way of repairing that bulge from the inside of the artery, using small incisions in the groin rather than a large cut in the abdomen or chest.

This article explains what EVAR is, why it is performed, who it is suitable for, what alternatives exist, what happens during the procedure, what recovery typically looks like, and what long-term follow-up involves. It is written for adults who already have a diagnosis and are now planning treatment, and for the family members who are supporting them.

An aneurysm is a weakened, ballooned-out section of an artery wall. The aorta runs from the heart down through the chest and abdomen, branching to supply blood to the rest of the body. When the wall of the aorta weakens, blood pressure inside it can push the wall outward, forming an aneurysm. If an aneurysm grows beyond a certain size, the risk that it will burst, or rupture, rises sharply. A ruptured aortic aneurysm is a life-threatening emergency.

Endovascular aneurysm repair, or EVAR, is a way of treating an aneurysm without opening the abdomen or chest. The word “endovascular” means “inside the blood vessel.” The surgeon makes small cuts in the groin to reach the femoral arteries, threads thin tubes called catheters up to the aneurysm, and places a stent-graft inside the aorta. A stent-graft is a fabric tube reinforced with a metal mesh frame. Once it is in position, it expands and seals against the healthy artery wall above and below the aneurysm. Blood then flows through the stent-graft instead of pushing against the weakened wall.

The aneurysm itself is not removed. Instead, it is excluded from the flow of blood. Over time, the sac of the aneurysm typically shrinks or stays stable, because it is no longer under arterial pressure.

EVAR is most often used for aneurysms of the abdominal aorta — the section that runs through the belly. A related procedure called TEVAR (thoracic endovascular aneurysm repair) uses similar techniques for aneurysms in the chest. More complex aneurysms that involve the branches feeding the kidneys or intestines may be treated with specialised stent-grafts known as fenestrated (FEVAR) or branched (BEVAR) devices.

Why Is EVAR Performed?

EVAR is performed to reduce the risk that an aortic aneurysm will rupture. The decision to repair an aneurysm depends largely on its size, its rate of growth, and whether it is causing symptoms.

Major vascular societies, including the Society for Vascular Surgery (SVS) and the European Society for Vascular Surgery (ESVS), generally recommend repair when:

• An abdominal aortic aneurysm reaches around 5.5 cm in diameter in men, or around 5.0 cm in women
• The aneurysm is growing rapidly (commonly defined as more than 0.5 cm in six months, or 1 cm in a year)
• The aneurysm is causing symptoms such as abdominal or back pain
• The aneurysm is leaking or has ruptured (emergency repair)

For thoracic aortic aneurysms, the size thresholds for repair are different and depend on the location and underlying cause. Your surgeon will explain the threshold that applies to your specific case.

Below these size thresholds, the risk of rupture is generally lower than the risks of surgery, and aneurysms are watched with regular imaging instead. This is sometimes called surveillance or watchful waiting.

Who Is a Candidate for EVAR?

Not every aneurysm can be treated with EVAR. Whether you are a candidate depends mainly on two things: your overall health and the anatomy of your aorta and the arteries leading to it.

Anatomical suitability

For a stent-graft to seal properly, there needs to be a section of relatively healthy aorta above and below the aneurysm, called the neck. The arteries in the groin (femoral and iliac arteries) also need to be wide enough and straight enough to allow the delivery system to pass through. Your surgeon uses a detailed CT scan to measure all of these dimensions and decide whether a stent-graft can be placed safely.

If the aneurysm extends close to the arteries supplying the kidneys, intestines, or spinal cord, a standard stent-graft will not work. In these cases, fenestrated or branched stent-grafts — which have openings or side branches custom-made to match the patient’s anatomy — may be an option at specialised centres.

Medical suitability

EVAR puts less stress on the body than open repair, which makes it especially valuable for patients who are older or who have heart, lung, or kidney conditions that would make a large open surgery risky. At the same time, EVAR is not risk-free, and very frail patients still need careful assessment.

Your vascular team will usually want to know about:

• Heart disease, including any history of heart attack, heart failure, or rhythm problems
• Lung conditions such as COPD
• Kidney function, because the contrast dye used during the procedure passes through the kidneys
• Diabetes and blood sugar control
• Smoking history, since continued smoking weakens artery walls
• Other vascular disease, including peripheral artery disease or carotid disease
• Medications, especially blood thinners

The choice between EVAR and open repair is rarely automatic. Major society guidelines describe EVAR as the preferred first-line option when the anatomy is suitable, particularly for older patients and those with significant other health conditions. For younger patients with long life expectancy and straightforward anatomy, open repair may be discussed as an alternative because it has a longer track record of durability and does not require the same level of lifelong imaging surveillance.

Alternatives to EVAR

Before settling on EVAR, it is worth understanding the other paths your doctor may discuss.

Surveillance (watchful waiting)

For aneurysms below the size thresholds for repair, the standard approach is regular monitoring with ultrasound or CT scanning. The intervals depend on the size of the aneurysm; smaller aneurysms may be checked once a year, while those approaching the threshold may be checked every three to six months. Surveillance allows repair to be planned at the safest time, before the risk of rupture rises.

Medical management

Whether or not you are heading for surgery, controlling the factors that weaken artery walls is an important part of care. This typically includes:

• Tight blood pressure control
• Stopping smoking, which is the single most impactful change for many patients
• Treatment of high cholesterol, often with a statin
• Management of diabetes
• Antiplatelet medication such as low-dose aspirin in selected cases

Medical therapy does not shrink an existing aneurysm, but it slows the broader process of vascular disease and supports both surveillance and any future surgery.

Open surgical repair

Open repair is the traditional way of treating an aortic aneurysm. The surgeon makes a long incision in the abdomen (or chest, for thoracic aneurysms), clamps the aorta, opens the aneurysm, and sews in a fabric graft to replace the weakened section. The aneurysm wall is then closed around the new graft.

Compared to EVAR, open repair involves:

• A larger incision and longer operating time
• A longer hospital stay, often a week or more
• A longer recovery period at home, typically several weeks to a few months
• Higher risk of complications in the early period after surgery

However, once an open repair has healed, it is generally very durable, and patients do not require the same intensive long-term imaging follow-up that EVAR demands. For these reasons, current guidelines describe open repair as a reasonable choice for fitter patients with longer life expectancy, and as the standard option when anatomy is not suitable for EVAR.

Surgical and Procedural Approaches

EVAR itself comes in several forms, depending on where the aneurysm is located and how it relates to the branches of the aorta.

Standard infrarenal EVAR

This is the most common form. It is used for aneurysms of the abdominal aorta that sit below the arteries supplying the kidneys. A bifurcated stent-graft — one that splits into two limbs — is placed so that the main body sits in the aorta and the two limbs extend down into the iliac arteries. This is the form of EVAR most patients will encounter when their surgeon first mentions the procedure.

Fenestrated EVAR (FEVAR)

When the aneurysm extends close to or involves the arteries that supply the kidneys, a standard stent-graft cannot seal without blocking these vessels. A fenestrated stent-graft has small custom-made openings (fenestrations) that line up with each branch artery. Small covered stents are then placed through these openings into the branch vessels to maintain blood flow. FEVAR requires careful preoperative planning and is generally performed at specialised centres.

Branched EVAR (BEVAR)

For more extensive aneurysms, including those that involve the thoraco-abdominal aorta, branched stent-grafts have actual side branches that are connected to the visceral arteries. BEVAR is technically demanding and reserved for complex cases.

Thoracic EVAR (TEVAR)

TEVAR is the same general technique applied to aneurysms in the chest portion of the aorta. It is also used for some aortic dissections and traumatic aortic injuries. The stent-grafts and access strategies differ from those used in the abdomen, and the considerations around spinal cord blood supply are particularly important.

Percutaneous versus open femoral access

Traditionally, the femoral arteries in the groin were exposed through small cut-down incisions. Today, in many cases, access can be achieved percutaneously — through a needle puncture, with the artery later closed using a closure device. Percutaneous access tends to result in smaller wounds and faster early recovery. The choice depends on the size of the delivery system, the condition of the femoral arteries, and the surgeon’s judgement.

Preparing for EVAR

Preparation for EVAR usually unfolds over several weeks. Once a decision to proceed has been made, you can expect:

Imaging and measurements

A detailed CT angiogram is the cornerstone of planning. It is used to measure the aneurysm, the neck of healthy aorta above and below it, the angles of the arteries, and the size of the femoral and iliac vessels. These measurements are used to select or custom-make the stent-graft.

Medical assessment

You may have heart tests such as an ECG, echocardiogram, or stress test, lung function tests if you have respiratory disease, and blood tests including kidney function. The team will optimise blood pressure, blood sugar, and any other conditions in the weeks before surgery.

Medications

Your team will give you specific instructions about which medications to continue and which to pause. Blood thinners and some diabetes medications often need to be adjusted around the procedure. Statins and blood pressure medications are usually continued.

Lifestyle preparation

Stopping smoking before surgery, even for a few weeks, reduces complications. Gentle daily activity, good nutrition, and treatment of any active infections also help. If you drink alcohol heavily, your team will advise on a safe approach to reducing intake.

The day before

You will be asked not to eat for a set number of hours before the procedure, and to drink only clear fluids up to a specified time. You will be told which morning medications to take with a sip of water.

What Happens During the Procedure

EVAR is usually performed in a hybrid operating theatre or vascular suite equipped with high-quality X-ray imaging.

Anaesthesia

EVAR can be performed under general anaesthesia, regional anaesthesia (such as a spinal or epidural), or, in some cases, local anaesthesia with sedation. The choice depends on your overall health, the complexity of the procedure, and the team’s practice.

Access

The surgeon either makes small cuts over each groin or uses needle punctures to access the femoral arteries. Long, thin wires and catheters are then passed up into the aorta under live X-ray (fluoroscopy) guidance. A contrast dye is injected to map the aorta and the aneurysm.

Stent-graft deployment

The main body of the stent-graft is delivered in a collapsed form inside a long sheath. It is positioned carefully above the aneurysm and then released, expanding to seal against the artery wall. Additional limbs are added to extend the graft into the iliac arteries. In fenestrated and branched repairs, additional smaller stents are placed into the kidney and intestinal arteries.

Final check

A final injection of contrast dye is used to confirm that blood is flowing through the stent-graft, that the branches of the aorta are still supplied, and that there is no significant leak into the aneurysm sac. The delivery devices are removed, and the access sites in the groin are closed with sutures or closure devices.

Duration

A standard infrarenal EVAR typically takes between two and four hours. Complex fenestrated or branched repairs can take considerably longer.

Recovery and Healing

In hospital

After the procedure, you will be observed in a recovery area or, for complex cases, in an intensive care or high-dependency unit. Vital signs, pulses in the legs, urine output, and the groin wounds are watched closely. Most patients are encouraged to sit up and start walking the day after surgery.

Hospital stays for straightforward EVAR are commonly two to four days, although some patients are discharged sooner and others stay longer depending on their other health conditions.

At home in the first weeks

Most people feel tired for the first one to two weeks. Mild bruising and discomfort in the groin is common. Typical guidance during early recovery includes:

• Avoiding heavy lifting (usually more than 4–5 kg) for about four to six weeks
• Keeping the groin wounds clean and dry, and watching for redness, swelling, drainage, or fever
• Walking daily, with gradually increasing distance
• Avoiding driving until cleared by your team, often for one to two weeks
• Resuming sexual activity when comfortable, usually within a few weeks

Follow-up imaging

EVAR requires ongoing imaging to confirm that the stent-graft remains in position and that no new leaks have developed. A common pattern is a CT scan or ultrasound at one month, then at six or twelve months, and then yearly. Your team will set the schedule that fits your case.

Risks and Complications

EVAR is generally safer in the early period than open repair, but it carries its own set of risks, some of which are specific to the stent-graft.

Early complications

• Bleeding or bruising at the groin access sites
• Damage to the femoral or iliac arteries from the delivery system
• Kidney injury from the contrast dye, especially in patients with pre-existing kidney disease
• Heart complications such as heart attack or rhythm problems, particularly in patients with underlying cardiac disease
• Stroke, more commonly associated with thoracic EVAR
• Spinal cord ischaemia, a rare but serious complication mainly seen in thoracic and thoraco-abdominal repairs, which can cause leg weakness
• Infection of the wound or, very rarely, of the stent-graft itself

Endoleaks

• Type I: leak at the top or bottom seal of the graft
• Type II: backflow from small side branches of the aorta into the sac (the most common type)
• Type III: leak between components of the graft
• Type IV: seepage through the fabric of the graft
• Type V: ongoing expansion of the sac without a clearly visible leak

Some endoleaks, particularly Type II, may simply be observed if the aneurysm is not growing. Others, especially Types I and III, usually need treatment to prevent the aneurysm from re-pressurising. This is one of the main reasons EVAR requires long-term imaging follow-up.

Stent-graft migration and structural issues

Over years, the stent-graft can shift position, develop kinks, or, very rarely, fracture. Regular imaging is designed to catch these issues early.

Re-intervention

A proportion of EVAR patients require a further procedure at some point — usually a minor endovascular intervention to address an endoleak, extend a limb, or treat a stenosis. This is more common with EVAR than with open repair, which is part of the trade-off for the easier initial recovery.

Life After EVAR

Once you have recovered from the procedure itself, the focus shifts to two things: protecting the repair and protecting the rest of your cardiovascular system.

Long-term surveillance

Lifelong imaging follow-up is a central part of care after EVAR. The schedule varies between centres but typically involves an early scan to confirm the result, followed by regular scans — usually annually — for the rest of your life. Keeping these appointments matters even if you feel completely well, because changes inside the stent-graft are usually silent.

Cardiovascular health

The same processes that weakened the aorta — high blood pressure, smoking, atherosclerosis — affect the rest of the arteries too. After EVAR, ongoing care typically focuses on:

• Keeping blood pressure within the range your doctor sets
• Stopping smoking permanently
• Managing cholesterol, often with a statin
• Controlling diabetes if present
• Maintaining regular moderate physical activity
• Eating a heart-healthy diet that is low in salt and high in vegetables, fruits, whole grains, and fish
• Taking antiplatelet medication if prescribed

Activity and travel

Once you have fully recovered, most everyday activities — including walking, swimming, cycling, light gardening, work, and travel — are usually possible. Heavy weightlifting and contact sports may be discussed with your team. Air travel is generally safe after recovery, although you may want to wait several weeks after the procedure. If you plan to travel after EVAR, it can help to carry a brief letter from your surgeon describing your stent-graft, particularly because the metal frame may set off airport metal detectors.

When to seek urgent attention

Although serious problems are uncommon after a well-functioning EVAR, you should seek urgent medical care if you experience:

• Sudden severe abdominal, back, flank, or chest pain
• Fainting or near-fainting
• A new pulsating sensation in the abdomen
• Sudden cold, pale, or painful legs
• Fever, redness, swelling, or drainage at the groin wounds in the weeks after surgery

These can be signs of rupture, graft problems, blocked blood flow, or infection, all of which need prompt evaluation.

Frequently Asked Questions

Does EVAR cure the aneurysm?

EVAR does not remove the aneurysm; it excludes it from the circulation. In most cases the sac shrinks or remains stable over time, and the risk of rupture is significantly reduced. However, because the aneurysm is still there and the stent-graft can change over years, lifelong imaging follow-up is required. This is different from open repair, where ongoing surveillance is much less intensive.

How is EVAR different from a stent for a blocked artery?

A coronary or peripheral artery stent is a small mesh tube placed to hold open a narrowed artery. A stent-graft used in EVAR is larger and is covered with fabric, so blood cannot push through the wall of the device. Its job is to reinforce a weakened aorta rather than to open a blockage.

Will I feel the stent-graft inside me?

Most people do not feel the stent-graft once they have healed. It does not move with breathing or activity in a way that is noticeable.

Can I have an MRI scan after EVAR?

Most modern stent-grafts are MRI-compatible, but the specific device used matters. Your surgeon or implant card will indicate what is safe. It is worth keeping a record of the make and model of your stent-graft.

How often will I need follow-up scans?

A common pattern is an early scan within the first month, scans at six and twelve months, and then yearly imaging for life. Your team will tailor the schedule based on your anatomy, the type of graft, and findings over time.

What if my aneurysm is not suitable for EVAR?

If your anatomy is not suitable for a standard stent-graft, options may include fenestrated or branched EVAR at specialised centres, or open surgical repair. Your vascular team will explain which alternatives apply to your case.

Is EVAR an option in an emergency?

In some hospitals, EVAR can be performed for a ruptured aneurysm if the anatomy is suitable and a stent-graft is available. Emergency EVAR has been shown to reduce early mortality compared with emergency open repair in selected patients, but the situation remains very high-risk regardless of approach.

Will I need to take medications for life?

Most patients continue medications to control blood pressure, cholesterol, and other cardiovascular risk factors for life. Antiplatelet drugs such as low-dose aspirin are often prescribed. The exact medication plan depends on your overall vascular health, not just the stent-graft.

Conclusion

Endovascular aneurysm repair has changed the experience of living with an aortic aneurysm for many patients. It offers a way to reinforce a weakened aorta from the inside, with smaller incisions, shorter hospital stays, and faster early recovery than traditional open surgery. For many older patients and those with significant other health conditions, current vascular society guidelines describe it as the preferred first-line approach when anatomy allows.

At the same time, EVAR is part of a longer story. It does not remove the aneurysm, and it requires lifelong imaging to confirm that the stent-graft is still doing its job. Looking after blood pressure, stopping smoking, and managing other cardiovascular risk factors are as important as the procedure itself.

The right choice between surveillance, medical management, EVAR, and open repair depends on the size and shape of your aneurysm, your overall health, and your personal priorities. A careful conversation with a vascular surgeon, supported by detailed imaging and an honest discussion of the trade-offs, is the best foundation for the decision ahead.