VASCULAR SURGERY e I
Abdominal aortic
aneurysm repair
Claire Dawkins
Michael G Wyatt
Abstract
Options for abdominal aortic aneurysm (AAA) repair include both open
and endovascular approaches. Patient selection for each of these re-
quires careful consideration relating to patient health, fitness and anat-
omy. This article aims to provide an overview of the essential aspects
of both open surgical repair (OSR) and endovascular AAA repair
(EVAR), focussing upon decision making, the procedures, follow-up
and long-term outcomes. Consideration is also given to more complex
AAA repairs, including fenestrated/branched stent grafts and open
juxta-renal aneurysm repairs. AAA epidemiology, screening, and
work up for repair are covered in the previous article.
Keywords AAA; aneurysm; aortic; endoleak; EVAR; open repair;
stent-graft
Introduction
The aim of elective abdominal aortic aneurysm (AAA) repair is to
prevent future rupture and death. The principle of both open and
endovascular repair is to exclude the sac of the aneurysm from
the high pressure circulation, while maintaining blood flow
through a normal calibre conduit into the common iliac arteries,
and for more complex repairs aortic side branches (i.e. visceral
and renal arteries). In an open surgical repair (OSR) this is ach-
ieved with a graft that is sutured into the normal artery above
and beyond the aneurysmal segment. The aneurysm sac is then
closed around and over the artificial graft. In an endovascular
repair (EVAR), the same outcome is achieved with the use of a
stent-graft, which uses a combination of radial force and fixation
points (sharp metal barbs) to create a blood tight proximal and
distal seal in normal artery either side of the aneurysm.
Following successful EVAR the aneurysm sac is excluded from
the aortic lumen, but remains intact, meaning there is a risk of
late sac growth and rupture.
The development of guidelines for the management of AAA by
the UK National Institute and Health and Care Excellence (NICE)
has resulted in a passionate debate of the clinical and cost effec-
tiveness of each approach. The draft NICE guidelines recom-
mended open repair for intact AAA and endovascular repair for
AAA rupture. NICE’s challenge to the use of EVAR in the elective
setting has been widely debated, the vascular community raised
Claire Dawkins MSc MA MBChir is an ST7 Specialty Trainee in Vascular
Surgery at Freeman Hospital, Newcastle Upon Tyne, UK. Conflicts of
interest: none declared.
Michael G Wyatt MSc MD FRCS FRCSEd FEBVS is a Consultant and
Honorary Reader in Vascular Surgery at Freeman Hospital, Newcastle
Upon Tyne, UK. Conflicts of interest: none declared.
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issues such as an unusually high 30-day mortality rate of 9% seen
in the EVAR 2 trial (see below) and improved results from EVAR
with developments in stent graft technology and refinements of
technique. They also raised a plethora of other issues such as
quality of life factors, patient and surgeon satisfaction and training.
The final NICE AAA guideline, published March 2020, was
changed in support of EVAR in the elective setting only if there is a
contraindication to open repair, such as medical comorbidities or a
hostile abdomen (e.g. extensive previous surgery).1
Evidence for EVAR versus OSR
United Kingdom EVAR research includes two multi-centre ran-
domized control trials undertaken between 1999 and 2003: The
EVAR 1 trial2 compared OSR and EVAR in men with AAA
diameter
5.5 cm who were suitable for both OSR and EVAR.
Similarly designed trials of OSR versus EVAR have been under-
taken worldwide, including DREAM3 (Dutch trial), OVER4 (US
trial), and ACE5 (French trial).
The EVAR 1 trial reported an initial survival benefit with
EVAR when compared with OSR, a clinically and statistically
significant difference in 30 day mortality of 1.7% in the EVAR
group compared with 4.6% in the OSR group (p ¼ 0.02).2
Comparable early survival benefits were seen with EVAR in the
DEAM3 and OVER4 trials. However, this survival benefit is not
sustained, with comparable aneurysm-related mortality at 1e2
years in the DREAM trial,6 at 5 years in the OVER7 trial and 8
years in the EVAR 1 trial.8 There was also a lower rate of re-
intervention in the OSR group compared with the EVAR group,
although perhaps significantly only arterial interventions were
recorded.
Lower perioperative mortality reflects the less invasive nature
of EVAR and is accompanied by lower rates of cardiac and renal
morbidity, a reduced need for critical care unit admission and
shorter length of hospital stay. These benefits have important
implications for patients with comorbidities which preclude open
repair, i.e. a patient who is unfit for an open AAA repair could be
considered for EVAR if the aneurysm anatomy is suitable. The
second UK randomized control trial, EVAR 2,9 investigated EVAR
in patients who were deemed ‘unfit’ for open AAA repair based
on cardiac, respiratory or renal comorbidity (no objective mea-
sures such as cardio-pulmonary exercise testing were utilized).
Patients in the EVAR 2 trial were randomized to EVAR or no
intervention. This trial identified fewer aneurysm related deaths
in the EVAR group, however there was no significant difference
in all-cause mortality between groups.9
The two EVAR trials were performed in people with intact
AAA. EVAR versus open repair in ruptured AAA has been
compared in the UK-based multi-centre randomized IMPROVE
trial.10 This trial reported that at 1 year, all-cause mortality was
no different between the two groups, but the EVAR group had
shorter length of hospital stay, a higher self-reported quality of
life and a lower cost.
Infrarenal aneurysm morphology
There are several key aspects to consider when reviewing a
contrast enhanced computerized tomogram (CTA) of an AAA
and considering a patient’s suitability for OSR or EVAR. This is
done using fine (1 mm) scanning slices to create a multiple-
289 Ó 2021 Published by Elsevier Ltd.
 VASCULAR SURGERY e I
planar reconstruction of the aneurysm anatomy. Ideally, this
includes a centreline reconstruction to determine if the patient’s
aortic morphology is suitable for treatment with EVAR, and allow
selection of the required stent graft components:
Renal anatomy
The renal arteries are the proximal landmark for both OSR and
EVAR. It is important to establish their position, if they are
multiple and their size. Occasionally, a lower pole renal artery
will arise from the aneurysm sac. For open repair of a juxta-renal
aneurysm, the relationship of the renal arteries to the superior
mesenteric artery is important.
Aneurysm neck
The aneurysm neck is the segment of aorta between the lower
renal artery and proximal aneurysm sac (Figure 1). By conven-
tion, a juxta-renal aneurysm is one in which this segment is too
short for the safe application of a infra-renal aortic clamp. When
considering whether the neck of an aneurysm is suitable for an
infra-renal (‘standard’) EVAR and the type of OSR there are
several important factors which must be fulfilled in order to
achieve and maintain a sufficient seal. A short neck of the AAA
will compromise generation of the radial forces between the
proximal aortic stent graft and the aortic wall, which increases
the risk of slippage e ‘migration’ e of the stent-graft (migration
over time shortening the neck). The length of the neck measured
from the lowest renal artery to the shoulder of the aneurysm
needs to be a minimum of 10 mm for standard stent-graft
placement, although most manufacturers recommend 15 mm
(in what are termed the ‘instructions for use (IFU)’ of the aortic
stent graft’), to achieve a sufficient area of contact between the
neck and the graft for a durable seal. In addition to its length, the
shape of the neck is important, with the ideal neck consisting of
straight parallel walls (i.e. normal healthy aortic wall). When the
neck is conical, barrel shaped or reversed conical (i.e. diseased or
pre-aneurysmal) the stent graft may not achieve continuous
contact with the aortic wall, resulting in a greater risk of dilata-
tion over time (pre-aneurysmal necks are in any case already pre-
disposed to dilate). Thrombus or areas of calcification can also
cause issues creating a seal, or risk embolizing thrombus into
other vessels, particularly the renal arteries. Finally, a sharply
angulated neck can cause difficulties creating a sealing zone,
with the majority of stent grafts designed for neck angles of less
than 60 . When considering treating angulated anatomy with
EVAR it is safer to select patient who have longer necks.
Similar considerations need to be made with patients being
considered for OSR. The neck of the aneurysm requires a suffi-
cient length to clamp, ideally below the renal arteries, allowing
enough of a cuff of healthy vessel to anastomose the graft onto.
This area also needs to be relatively free of calcium and
thrombus to allow clamping without risk of embolization into the
renal arteries.
Iliac arteries
Similar attention needs to be given to the iliac arteries, ensuring
there is either a sufficient length of sealing zone in relatively
straight vessels which are aneurysm free or have an area of
healthy vessel suitable for clamping and anastomosis. Assess-
ment for EVAR must include iliac diameter and tortuosity,
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ensuring they are large enough to accommodate the stent graft
and sufficiently free of calcification to enable access into the
vessel and the passage of the graft. Iliac arteries that are partic-
ularly tortuous make the passage of the stent graft more difficult,
and arteries that are particularly calcified and tortuous, or those
that contain mural thrombus, can prohibit an EVAR being used
due to the high risk of vessel damage or failure to pass the de-
livery system through.
The internal iliac arteries should be considered, as covering or
tying off of both of these can create problems such as buttock
claudication or bowel ischaemia, particularly when the inferior
mesenteric artery (IMA) will also be lost. If the aneurysm extends
down to or past the internal iliac arteries, requiring the graft or
stent graft to extend past them then consideration should be
given to re-implant or stent at least one internal iliac artery with
an iliac branch device, or open surgical revascularization,
although this is beyond the scope of this article.
Common femoral arteries
Finally the common femoral need to be checked for access for
placement of the stent graft, or in the case of open repair with
aorto-bi-femoral bypass the sites of the distal anastomoses.
Increasingly, closure devices (ProglideÔ, Abbot Medical) are
used to achieve ultrasound-guided percutaneous arterial access
for EVAR (despite the absence of clinical or cost effectiveness
evidence for this approach). For successful percutaneous closure
the common femoral artery should be of adequate size with little
or no anterior wall disease.
Other considerations
The position of the left renal vein also should be noted particu-
larly with open repair of juxta-renal or aneurysms with short
anatomical necks (10% of veins have a retro-aortic course
placing them at risk from aortic clamp damage). The patency of
lumbar arteries and the IMA is important in OSR as these will
need to be controlled upon entering the aneurysm sac. Rarely, a
fistula is seen where the aneurysm has eroded into the inferior
vena cava. After EVAR, as there is potential for type 2 endoleaks
(see below) from lumbar arteries and the IMA, this is more
common with large aneurysm sacs that contain little or no
thrombus.
Open surgical repair or endovascular aneurysm repair?
It is now widely accepted that patients who are fit for OSR
(i.e. patients at low or moderate predicted risk of perioperative
morbidity and mortality) should be offered this as the
long-term benefits favour this approach, unless there are other
reasons not to, such as a hostile abdomen or considered patient
choice. Patients with a high or very high predicted perioperative
risk may be considered for EVAR, as long as their aneurysm
morphology is suitable. In some people, conservative manage-
ment (i.e. ‘do nothing’ or ‘turndown’) is the most appropriate
course of action. This decision is a balance of predicted life ex-
pectancy (including risk of AAA rupture), anatomical suitability
and patient choice. In patients with more complex aneurysm
morphology a fenestrated or branched endovascular repair
(FEVAR or BEVAR) or more complex open repair may be
appropriate. In all cases choice of treatment is an individualized
290 Ó 2021 Published by Elsevier Ltd.
 VASCULAR SURGERY e I
Figure 1 Three-dimensional CT reconstruction of an abdominal aortic
aneurysm (AAA), showing the infra-renal neck which will provide the
proximal sealing zone or the site of clamping and proximal
anastomosis.
decision for each patient, shared with their surgeon and wider
multi-disciplinary aortic team (MDT). The pathways for decision
making and optimization for aortic surgery have been discussed
in the preceding chapter.
Open surgical repair
Open surgical repair of an AAA requires a cohesive team
approach. Close coordination with the anaesthetic team espe-
cially is vital for the safety of the patient, particularly when
clamping or unclamping the abdominal aorta. Preparation is
vital, ensuring that:
 blood is available (valid cross match or available packed
red cells)
 cell salvage
 sufficient large bore venous access established
 a urinary catheter
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 appropriate warming (e.g. underbody warming blanket
and warmed fluids)
 prophylactic antibiotics.
Often arterial and central venous lines are used for close
monitoring and an epidural for early postoperative pain relief is
placed.
The approach to an infra-renal AAA is generally through an
anterior midline or transverse incision. If access is required to the
supra-renal aorta, a left-sided retroperitoneal approach can give
better exposure. A diagnostic laparotomy is traditionally per-
formed to ensure no other significant pathology, although with
more extensive CT imaging this is often considered unnecessary.
Retractors and packs are used to clear the operative field,
particularly of the small bowel which can be tucked inside the
right hand side of the abdomen or eviscerated into a bowel bag
outside the patient’s abdomen. Clear dissection of the aortic neck
is vital to be able to perform a sound proximal anastomosis.
Occasionally, this requires ligation and division of the left renal
vein to prevent accidental damage when retracted; this should be
towards the IVC side of the exposed vein, to optimize the
availability of collateral veins (gonadal and adrenal veins) to the
left kidney.
A space should be cleared either side of the aortic neck down
to the vertebrae to enable a clamp to be freely applied. Dissection
of the iliacs should be undertaken to expose disease-free seg-
ments of the vessels for clamping and distal anastomoses. Care
should be taken to avoid injury to the adjacent IVC and iliac
veins and to preserve the autonomic ‘nerves of the night’. Five
thousand units of IV heparin should be given and allowed to
circulate prior to clamping the aortic neck, ideally below the
lowest renal artery, and the iliac arteries. On opening the aneu-
rysm sac, the enclosed chronic thrombus should be scooped out
to reveal any source of bleeding within, usually back bleeding
from lumbar arteries, the median sacral artery and the IMA. At
times these may have been identified and controlled prior to
opening the sac, particularly the IMA, but usually there are
several vessels that require suturing to control bleeding. The
opening of the aneurysm sac should be opened like a book at the
proximal and distal end to enable a good view of the anasto-
moses sites.
A Dacron or PTFE tube or trouser graft should be selected of
the appropriate size and type (‘tube’ or ‘bifurcated’) to fit the
anatomy of the aneurysm. Anastomoses are performed with
double-ended monofilament non-absorbable sutures, paying
close attention to take good strong bites of the aorta and iliacs,
using pledgets to reinforce sutures if the quality of the aortic
tissue is of concern. The top anastomosis should be tested prior
to undertaking the distal anastomoses to ensure good access to
the circumference of the anastomosis to tighten sutures or place
rescue sutures as required. The distal anastomoses may be sin-
gular to the distal aorta, or double down to the iliac or femoral
vessels depending upon the extent of the aneurysm. The internal
iliacs should be preserved where possible and certainly at least
one should have the blood flow maintained, with the option of
re-implanting one if the aneurysm extends past both internal iliac
arteries.
Release of the limbs should be undertaken one at a time, with
appropriate discussion with the anaesthetist to ensure the drop in
blood pressure associated with re-perfusion of a limb is managed
291 Ó 2021 Published by Elsevier Ltd.
 VASCULAR SURGERY e I
Figure 2 The modular components of a bifurcated aortic stent-graft
showing a main-body (left) and stent-graft limb (right).
Figure 3 Bare metal suprar-enal fixation of a stent-graft; the barbs
allow improved wall anchorage to resist the force of distal stent graft
migration.
appropriately and time is given for the patient to stabilize prior to
releasing the second leg. Graduated pressure on the graft can be
utilized to decrease the speed of the blood pressure drop when
limbs are released. When releasing a limb pressure may be
placed over the common femoral artery to encourage any
embolic material to travel into the internal iliac system in pref-
erence to the patient’s legs. Once the aneurysm repair is
completed, the aneurysm sac and the posterior peritoneum
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should be closed over the graft in order to protect it. A careful
count of swabs and instruments should be performed prior to
closing to ensure all packs have been removed and the bowel
should be replaced. Take care when emptying the small bowel
out of the bowel bag as it will have collected fluid from the bowel
during the procedure, which is far better remaining in the bag
rather than on the floor or down your front! The laparotomy
should be closed according to Jenkins rule (stitches 1 cm apart
and 1 cm from the wound edge).
The foot pulses should be checked following the procedure to
ensure blood flow has been maintained and these should be
marked for the benefit of the recovery team who will be moni-
toring these. Most patients can be woken up in the operating
theatre prior to transfer to a high dependency area for moni-
toring. Occasionally, patients will be kept anaesthetized to allow
correction of acidosis and to warm prior to extubating. Once
awake an epidural catheter, placed preoperatively, can provide
effective pain relief. Usual length of hospital stay is 5e7 days.
EVAR
Endovascular stent grafts are packaged as individual components
on a delivery system. The majority of EVARs consist of a main
body and limbs (Figure 2), which are various lengths and di-
ameters. The appropriate components are selected based on the
preoperative CT angiogram to fit the anatomy of the aneurysm.
The stents themselves are made up of a nitinol or stainless steel
self-expanding metal frames with an impermeable fabric (Dacron
or PTFE) covering. The nitinol frame creates a radial force
against the wall of the artery to prevent slippage from the sealing
zone while the fabric covering creates the conduit. Some stents
have small metal barbs at the top of the graft or on a bare metal
frame above the top of the fabric to resist distal migration. On the
main body the proximal bare stent may extent above the renal
artery origins, this is called supra-renal fixation (Figure 3). Each
component is packed within a low profile (small diameter) de-
livery system with a smooth hydrophilic coating to assist with
ease of delivery.
Insertion of the stent-graft can be under general, regional or
local anaesthetic. Access via the common femoral arteries can be
percutaneous with ultrasound guidance, using endovascular
closure devices. In more complex access, direct cutdown may be
the favoured option. Stiff endovascular wires are used to cross
the aneurysm and the delivery system containing the main body
is advanced into the neck of the aneurysm. It is vital at this point
to obtain an angiogram with a good view of the visceral vessels
in order to deploy the stent-graft fabric directly below the lowest
renal artery. The ipsilateral limb of the main body can then be
extended to obtain a distal sealing zone after undertaking an iliac
angiogram and measuring the remaining distance from the flow
divider (the ‘crotch’ of the stent-graft) to the internal iliac artery.
The contralateral limb requires cannulation via the contralateral
common femoral access site and, once checks have been made to
ensure the wire is definitely in the main body (this can be done
by spinning a catheter within the neck of the main body, inflating
a balloon or performing an angiogram), the distance from the
flow-divider to the internal iliac artery can be measured and the
contralateral limb extended to complete the aneurysm repair. A
completion angiogram is performed to check the patency of the
292 Ó 2021 Published by Elsevier Ltd.
 VASCULAR SURGERY e I

Figure 4 Angiography of an aortic stent-graft. (a) intra-operative image, during deployment of the left limb, showing aneurysm sac (blue arrow) and
lumbar arteries (white arrows). (b) Postoperative image (completion angiogram) showing supra-renal bare stent (green arrow), renal arteries (red
arrows), branches of the superior mesenteric artery (blue bracket) and stent-graft in the aorta and common iliac arteries (white arrow).

Figure 5 Fenestrated stent-graft showing a renal artery fenestration
and a ‘scallop’ for the superior mesenteric artery. Another renal
fenestration is present, but out of view, on the opposite side of the
stent-graft. Reproduced by kind permission from Cook MedicalÒ.
renal and internal iliac arteries and to confirm that the aneurysm
has been excluded (Figure 4).
Newer endovascular developments
Juxta-renal aneurysms lack the anatomical neck required for a
robust proximal seal with a standard ‘off the shelf’ aortic stent
graft. To overcome this limitation, stent-grafts have been devel-
oped that take advantage of a normal calibre supra-renal aorta.
An adequate sealing zone can be created by using a stent-graft
which has fenestrations or windows which ‘land’ at the origins
of the renal arteries and the major mesenteric vessels, with stents
placed from the graft into the visceral vessels (Figure 5).
Branched endografts, with down-facing branches in place of
fenestrations, are typically used to repair thoracoabdominal an-
eurysms (Figure 6) due to the wide diameter of the aorta at the
visceral and renal level. The proximal stent graft landing zone is
usually in a normal calibre segment of the thoracic aorta with
branches that flare out at an angle to facilitate endovascular
placement of a bridging stent between the main-body of the
stent-graft and the origin of the corresponding visceral or renal
artery. Occasionally a stent graft with a combination of branches
and fenestrations best fits the aneurysm anatomy.
The three major disadvantages of fenestrated and branched
stents is that they carry an increased risk of complications as
compared to standard EVAR:
 Higher risk of visceral ischaemia, renal failure, spinal cord
ischaemia, and of cardiac or respiratory complications.
 Must be custom made to the precise anatomy of the
aneurysm being treated; time scale for manufacture in-
troduces a delay of at least 6e8 weeks.
 One in four risk of requiring reintervention, as compared
to the one in five risk after standard EVAR.
Patients with ruptured complex aneurysms or those large
enough to be at high risk of rupture will not wait for the
manufacturing process. Some such anatomies can be treated in
selected centers using with an off-the-shelf branched stent graft
(T-Branch, Cook Medical). In other centers, this has led to
physician-modified stents, where an ‘off-the-shelf’ stent is
directly modified by the radiologist/surgeon performing the stent
procedure. The stent can be partially deployed from its delivery
device, modified with both fenestrations and/or branches, then

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 VASCULAR SURGERY e I

comorbid patients, with myocardial infarction, respiratory tract

infections and venous thromboembolism being among the most
commonly seen. The previous chapter has a table setting out the
frequency of the major risks for both OSR and EVAR.
As with any vascular intervention, there is risk of bleeding,
either relating to the aneurysm repair or injury to the access
vessels. It is essential to be prepared for this with rapid access to
cross-matched blood, fresh frozen plasma and platelets. The
aortic team should rehearse and be familiar with the massive
transfusion protocol in their hospital. Similarly, for endovascular
procedures the team should rehearse and be prepared for an iliac
artery rupture (treated usually with a covered stent graft) or
common femoral artery bleed (usually requires a surgical repair).
The routine use of cell salvage techniques reduce need for stored
blood transfusion, and may improve patient outcomes.
All endovascular AAA repairs carry a specific risk of failure,
late aortic sac rupture, related to a failure to prevent pressuri-
zation of the aneurysm sac, this is called an ‘endoleak’. Endo-
leaks have been classified into five types (Table 1).
When a type 2 endoleak is associated with an aneurysm sac,
growth a type 1 or 3 endoleak should be sought; the enlarged
vessel seen may be an ‘outflow’ rather than ‘inflow’ vessel. Type
4 endoleak related to porosity of the stent graft fabric has been all
but eliminated by newer materials used in manufacture. In the
perioperative setting most endoleaks are of type 1 and type 2.
Most type 1 endoleaks require a further intervention, most type 2
endoleaks and can be observed.
In aortic surgery there is a risk of end organ ischaemia. This
risk relates to the presence of pre-existing disease and the extent
of surgery. The risk is highest for the repair of more complex
aneurysms (i.e. thoracoabdominal). Injury could be as a result of
vessel thrombus, cholesterol embolization, dissection or a mis-
placed graft or suture. The risk is particularly high for the visceral
vessels, including the renal arteries leading to renal failure and to
the coeliac artery and superior mesenteric artery (SMA) resulting
in bowel ischaemia, requiring resection and stoma formation.
The iliac arteries and peripheral circulation can also be affected,

Classification of endovascular aneurysm repair-related

endoleaks

Figure 6 Branched stent-graft showing branches for the renal, supe- Type Feature
rior mesenteric and coeliac arteries. Reproduced by kind permission
from Cook MedicalÒ. 1 Failure of proximal (type 1a) or distal (type 1b)
attachment sites to seal, allowing blood to
leak around the device into the redundant
aortic sac
re-sheathed so that it can be delivered like a pre-fabricated graft. 2 Filling of the sac via collateral vessels (eg
Another option in this circumstance is a ‘chimney’ or ‘snorkel’ inferior mesenteric artery, lumbar arteries,
technique, where grafts run in parallel, the main body through accessory renal arteries, median sacral artery)
the aneurysm with smaller stent grafts from the aorta into the 3 Graft defect: a break in the graft material or
relevant visceral vessels. dislocation of a modular component of
thestent-graft
Complications 4 Graft wall porosity
5 ‘Endotension’ or increasing aneurysm size
Complications of AAA repair are varied. They can be relating to without a visible leak
the aneurysm repair itself, the access and the systemic effect
upon the patient. Systemic complications are more common in Table 1

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 VASCULAR SURGERY e I

with buttock and lower limb claudication which has the potential Careful anaesthetic assessment and anatomical assessment is
to be unsalvageable resulting in amputation. Renal function can required with a multi-disciplinary team (MDT) approach taken
also be affected by a temporary interoperative ischaemic time or towards decision making. It is only by offering the two options in
contrast used in EVAR angiograms. a balanced way, taking account of the evidence basis that we, as
A post implantation syndrome is often seen following the healthcare providers, can offer the optimal treatment for our
aortic instrumentation during EVAR, and junior doctors can face patients. A
this on the wards the night following a procedure. Up to 35% of
patients display an inflammatory response,11 with pyrexia and
raised inflammatory markers, and often confusion. Generally this REFERENCES
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Follow-up (accessed 18 January 2021).
2 The EVAR Trial Participants. Endovascular aneurysm repair versus
Following discharge from hospital after OSR, patients are usually
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1): randomised controlled trial. Lancet 2005; 365: 2179e86.
assess for postoperative complications and ensure their recovery
3 Prinssen M, Verhoeven EL, Buth J, et al. A randomised trial
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rysm. A randomised trial. J Am Med Assoc 2009; 302: 1535e42.
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5 Becquemin JP, Pillet JC, Lescalie F, et al. A randomized
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pain. Occasionally, antibiotics can supress infection as an alter-
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patients. J Vasc Surg 2011; 53: 1167e73.
deep vein. Revision aortic surgery is a major undertaking asso-
6 De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open
ciated with significant morbidity and mortality.
repair of abdominal aortic aneurysm. N Engl J Med 2010; 362:
Follow-up face to face at 4e6 weeks is also usual following
1881e9.
EVAR. As endoleaks can occur in approximately 30% of patients,
7 Lederle FA, Freischlag JA, Kyriakides TC, et al. Long term com-
with rupture rates post-EVAR of 0.9% per annum, life-long sur-
parison of endovascular and open repair of abdominal aortic
veillance is required.12 Prevention of post-EVAR rupture depends
aneurysm. N Engl J Med 2012; 367: 1988e97.
on detection complications and secondary interventions. Examples
8 Patel R, Sweeting MJ, Powell JT, et al. Endovascular versus open
of reinterventions include endoleak embolization, graft re-lining
repair of abdominal aortic aneurysm in 15-years’ follow-up of the
and even graft explant with conversion to OSR. All patients un-
UK endovascular aneurysm repair trial 1 (EVAR trial 1): a rando-
dergoing EVAR should be enrolled in postoperative surveillance,
mised controlled trial. Lancet 2016; 388: 2366e74.
with regular imaging. Typical imaging protocols include a post-
9 The EVAR trial participants. Endovascular aneurysm repair and
operative CT scan performed at 1 month and at 12 months, then
outcome in patients unfit for open repair of abdominal aortic
annually thereafter. If a complication such as an endoleak is found
aneurysm (EVAR trial 2): randomised controlled trial. Lancet 2005;
at the 1 month scan, a further scan at 6 months is also recom-
365: 2187e92. 9478.
mended.13 The use of ultrasound and contrast-enhanced ultra-
10 IMPROVE Trial Investigators. Endovascular strategy or open
sound (CEUS) is increasing e CEUS has been shown to have a
repair for ruptured abdominal aortic aneurysm: one-year out-
high sensitivity and specificity for the detection of endoleaks, and
comes from the IMPROVE randomized trial. Eur Heart J 2015; 36:
reduces costs, nephrotoxicity and radiation exposure.14 Trial evi-
2061e9.
dence shows that following EVAR one in five patients will require
11 Arnaoutoglou E, Kouvelos G, Milionis H, et al. Post-implantation
a reintervention during the life-time of the graft. Following com-
syndrome following endovascular abdominal aortic aneurysm
plex EVAR, the need for re-interventions is higher, with one in four
repair; preliminary data. Interactive CardioVasc Thorac Surg 2010;
patients needing reintervention. This difference is due in part to
12: 609e14.
reinterventions to maintain patency or seal into visceral and renal
12 O’Mara JE, Bersin RM. Endovascular management of abdominal
arteries. Aortic stent grafts may also become infected, however,
aortic aneurysms: the year in review. Curr Treat Options Cardio
this is less likely to result in aorto-enteric fistula.
Med 2016; 18: 54.
13 Chaikof EL, Brewster DC, Dalman RI, et al. The care of patients
Summary
with an abdominal aortic aneurysm: the Society for Vascular
EVAR and OSR offer a balanced approach to aortic aneurysm Surgery practice guidelines. J Vasc Surg 2009; 50: S2e49.
repair when the two options are carefully considered and man- 14 Cantisani V, Grazhdani H, Clevert DA, et al. EVAR: benefits of CEUS
agement is tailored to individual patient’s needs and situation. for monitoring stent-graft status. Eur J Radiol 2015; 84: 1658e65.

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 VASCULAR SURGERY e I

Practice Points

C Recent guidance from the National Institute of Clinical and Health

Excellence (NICE) for AAA repair has highlighted concerns
regarding the clinical and cost effectiveness of endovascular
aneurysm repair (EVAR)
C EVAR has a strong evidence base in support of short-term benefit,
with reduced morbidity and mortality as compared to open sur-
gery in patients who are anatomically suitable
C The concern for EVAR is durability given a 0.9% per annum late
risk of rupture and loss of the early survival benefit when
compared with open surgery over the first 8 postoperative years
C Good outcomes from aortic surgery require a cohesive team
approach; preparation is vital
C Stent graft developments allow more complex aneurysm anato-
mies, including thoraco-abdominal aneurysms, to be treated
using minimally invasive techniques
C Complications for major haemorrhage or end organ damage can
occur after aortic surgery. Patients are also at risk of systemic
complications, more so if they have cardiac, respiratory or renal
comorbidities
C Endoleaks are unique to endovascular aneurysm repair. Some can
cause late sac rupture. Life-long imaging surveillance is require
after EVAR to detect and treat endoleaks
C Aneurysm treatment should be individualized, taking into account
the patients’ anatomy, comorbidities, health, needs and
preferences

SURGERY 39:5 296 Ó 2021 Published by Elsevier Ltd.

Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en septiembre 17, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.