Endovascular aneurysm repair (EVAR)

Overview

Endovascular aneurysm repair (EVAR) is a minimally invasive procedure employed in the treatment of abdominal aortic aneurysms, which are dangerous bulges in the body’s largest artery, responsible for transporting blood from the heart to various parts of the body. EVAR involves the use of small punctures and advanced medical tools to effectively repair these aneurysms within the abdominal aorta, offering a less invasive alternative to traditional surgical methods.

Reasons for undergoing the procedure

Patients with aortic aneurysms may find EVAR beneficial. These aneurysms affect the largest artery in the body, the aorta.

Not all aneurysms require medical intervention. Physicians may recommend EVAR if:

• An individual has a large aneurysm or a smaller one that is growing rapidly.
• Traditional open surgery with a large incision is not an option.
• Healthy blood vessel tissue is located near the aneurysm.

Risks

Like any surgical procedure, there are potential complications associated with this intervention. These complications may include, but are not limited to:

• Damage to nearby blood vessels, organs, or adjacent anatomical structures due to surgical tools.
• Possible impairment of kidney function.
• Reduced blood flow to the lower extremities, leading to limb ischemia caused by blood clots.
• Risk of infection at the surgical site in the groin.
• Formation of a hematoma, which is a large blood-filled bruise in the groin area.
• Occurrence of excessive bleeding during or after the procedure.
• Development of an endoleak, which indicates ongoing blood leakage from the graft into the aneurysm sac, potentially resulting in rupture.
• The possibility of spinal cord injury.
• Patients with allergies or sensitivities to medications, contrast dyes, iodine, shellfish, or latex must inform their attending physician about these sensitivities.

Additional risks may depend on the patient’s specific medical condition. Therefore, it is crucial for patients to have thorough discussions with their healthcare provider to address any concerns before undergoing the procedure.

Before the procedure

Prior to the procedure, your physician will thoroughly explain the process, address any questions you may have, and require you to sign a consent form. You may also undergo a physical examination and diagnostic tests to ensure your health suitability. It’s important to abstain from food for eight hours before the procedure, typically after midnight. Notify your physician if you are pregnant, have allergies, or are sensitive to certain substances, and disclose all medications and supplements you’re taking. If you have a history of bleeding disorders or take blood-thinning medications, your physician may advise you to discontinue them. Smoking should be ceased prior to the procedure for better recovery and overall health. Sedation may be administered for relaxation, and in some cases, the surgical site may need to be shaved. Additional specific preparations may be required based on your medical condition.

During the procedure

Procedures may vary based on individual medical conditions and physician preferences. Below is a concise description of the surgical process:

• Patient positioning: The patient assumes a supine (lying on the back) position on the operating or radiology table.
• Anesthesia and monitoring: An anesthesiologist continuously monitors vital signs such as heart rate, blood pressure, breathing, and blood oxygen levels. General anesthesia with a possible intubation and ventilation or regional anesthesia through an epidural may be administered, depending on the physician’s decision.
• Incision and access: The physician makes incisions in the groins to expose the femoral arteries. A needle is inserted into the femoral artery, and a guidewire is advanced to the aneurysm site. A sheath is then placed over the guidewire.
• Aortogram: Contrast dye is injected to visualize the aneurysm’s position and adjacent blood vessels.
• Intervention: The physician utilizes specialized endovascular instruments and real-time X-ray imaging for guidance. A stent-graft is inserted through the femoral artery and advanced into the aorta at the aneurysm site.
• Stent-graft deployment: The stent-graft, initially in a collapsed state, is expanded in a spring-like fashion and securely attached to the aortic wall.
• Post-intervention aortogram: Another aortogram is conducted to verify the absence of endoleak (blood leakage into the aneurysm sac) from the stent-graft.
• Instrument removal: If no leaks are detected, the surgical instruments are removed.
• Closure and suturing: The incisions are meticulously sutured closed.
• Dressing application: A sterile dressing or bandage is applied to the surgical site.
• Post-operative care: In the case of an open procedure, a gastric tube may be inserted through the mouth or nose for stomach fluid drainage. The patient is then transferred to either the intensive care unit (ICU) or the post-anesthesia care unit (PACU).

After the procedure

After surgery, you may be taken to either the intensive care unit (ICU) or the post-anesthesia care unit (PACU), where you’ll be continuously monitored for your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and oxygen levels. Following a designated period in either unit, you’ll then be transferred to a regular nursing care unit. Pain relief will be provided for incisional pain, possibly through an epidural placed during surgery. As you recover, your activity level will gradually increase, with you getting out of bed and walking for longer periods, and your diet will advance to solid foods as tolerated. Additionally, arrangements will be made for a follow-up visit with your physician.

Outcome

Recovery after the procedure typically takes several days to several months before you start feeling normal again. You should anticipate spending a few days in the hospital. Once the effects of the anesthesia wear off, you can resume eating and drinking. The nursing staff will assist you in getting out of bed and beginning to walk as soon as it is safe to do so.

After returning home, you may experience fatigue and may require pain medication for a few days. It’s important not to drive while you are still taking pain medication. Most people are able to return to work within a month, but you should avoid lifting heavy objects for four to six weeks following the procedure.

Make sure to promptly contact your physician if you experience any of the following symptoms:

• Fever and/or chills
• Redness, swelling, bleeding, or unusual discharge from the incision site
• An increase in pain around the incision site

Your physician may provide you with additional or alternative instructions based on your specific circumstances.