Overview

If you have an abdominal aortic aneurysm you might need an endovascular aneurysm repair (EVAR). 

Abdominal aortic aneurysm (AAA)

The aorta is the largest artery in the body. It carries blood away from the heart to the rest of the body. The abdominal aorta is in the tummy (abdomen). An abdominal aortic aneurysm is a swelling (aneurysm) of the aorta.

An aneurysm happens when the wall of the aorta weakens, and the aorta stretches like a balloon. It is not clear what causes this weakness, but smoking and having high blood pressure are thought to increase the risk. 

The abdominal aorta is usually about 2cm wide. An aneurysm can stretch the aorta to make it thinner, until the wall of the aorta cannot stretch any more. If this happens, the aneurysm is at risk of bursting (rupturing), and causing bleeding. If an aneurysm bursts, the chances of survival are low. 

An aneurysm that is 5.5cm or larger might need treatment with surgery to stop it from rupturing. 

A standard EVAR

An EVAR is keyhole surgery to repair an aneurysm. It is used for aneurysms that are below the arteries that carry blood to your kidneys. It is done through a small cut (incision) in your groin, which is the area between your inner thigh and your tummy. 

The aneurysm is repaired using a small, flexible, tube called an endograft. The endograft is made of metal mesh lined with fabric. It is put into the aorta where the aneurysm is, and sealed to the aorta wall. This strengthens the aorta, and lowers the risk of the aneurysm rupturing.

Other types of EVAR

If your aneurysm involves the arteries that take blood to your gut, liver, or kidneys, a standard EVAR might not be the best treatment for you. This is because the endograft would cover the arteries that carry blood to those organs. You might have a different type of EVAR that allows blood to flow to these organs.

• Fenestrated EVAR (FEVAR) uses an endograft with fabric that has carefully placed openings (fenestrations). This allows blood to flow through the openings to the kidneys and other organs.
• Branched EVAR (BEVAR) uses an endograft with side branches. These allow blood to flow to your kidneys and other organs. 
• Thoracic EVAR (TEVAR) is used to treat an aneurysm that is in the upper part of your aorta, in your chest as well as your tummy. This is called the thoracic area.

Your hospital team will decide what type of EVAR you need after looking at your CT scan. The type you have depends on where the aneurysm is. Your team will talk to you about the decision, and why this type of EVAR is best for you. 

Other treatment options

Watchful waiting

Small aneurysms, which are not growing quickly or causing symptoms, do not burst as often. These aneurysms might not need any treatment other than ‘watchful waiting’. This is having regular ultrasound scans to see if the aneurysm has grown, or if it needs any treatment.

Open repair operation

If you do not have an EVAR, you might have an open repair operation. This is the most common treatment for a large aneurysm. It involves an incision across the tummy to replace the aorta with a synthetic tube (graft). 

Benefits of an EVAR

An EVAR or an open repair operation should stop your aneurysm from rupturing. The benefits of an EVAR over an open repair operation are:

• you will not have large cuts in your tummy, and only need stiches in your groin area
• you will have a faster recovery, and shorter time in the hospital
• you will have less pain after surgery

Risks of an EVAR

There is no procedure that is completely safe. Risks are less common during a planned, rather than having an emergency EVAR. Most people have no major problems, but there are possible risks.

• Wound infection at the groin is the most common risk of an EVAR. In most cases this can be treated with antibiotics.
• Groin haematoma is bleeding or bruising under the skin. This can happen where the catheter is put in the groin. It can take 1 or 2 weeks to get better. 
• Damage to blood vessels when you have a catheter put in. This is a very small risk.
• Loss of blood flow to the legs or feet can be caused by blood clot from the aneurysm, which breaks off and travels into smaller arteries. This can block the arteries. You might need more surgery to re-open them.
• Kidney damage can be caused by the contrast dye used. You will have a blood test before an EVAR to check how your kidneys are working. There is more of a risk if you already have kidney disease. You might be given fluids through a drip before and after an EVAR to lower this risk.
• Kidney failure is a risk if the arteries carrying blood to the kidneys are blocked. If this happens, you might need another procedure to unblock the endograft.
• Bleeding where the catheter was put in is a risk, as you might need a blood transfusion.
• Endograft leaks happen if the endograft does not fully seal the aneurysm, and it is still at risk of rupturing. About 1 in 10 people will need more surgery if a leak is found. Your surgeon will check this at your follow-up appointment.
• Graft slipping is when the endograft moves. If this happens, there is a risk of the aneurysm coming back. You will need scans after an EVAR to check the graft is working.
• Loss of function in the lower half of your body (spinal cord injury, or paraplegia) is very rare, but is a risk. Your surgeon will take steps where ever possible to lower the risk.

Your surgeon will talk to you about all possible risks, and how they might affect you. You will be able to ask any questions you have. You will sign a consent form before the operation.

Giving your permission (consent)

We want to involve you in decisions about your care and treatment. If you decide to have the operation, you will be asked to sign a consent form. This states that you understand what is involved and agree to have the treatment. 

Read more about our consent process.

Preparing for having an EVAR

There are a number of ways you can improve your health before your surgery. 

Smoking

If you are a smoker, the most important thing you can do to help yourself is to give up smoking. This will also help to protect all of your arteries, making it less likely that you will have heart attacks or strokes.

Giving up is not easy but there is a smoking cessation service and support groups that can help. Your vascular specialist nurse or GP practice nurse can advise you about these. If you would like to stop smoking, please speak to your nurse or call our stop smoking service phone 020 7188 0995, or call the NHS Smoking Helpline phone 0300 123 1044.

Activity

Gentle exercise, such as walking and cycling, is recommended to help improve your overall level of fitness. Exercise helps your body to produce healthy cholesterol and this helps to protect your arteries against bad cholesterol. Exercising may be difficult if you suffer with claudication, however it is important to keep as active as you can.

Blood pressure

It is very important that you have your blood pressure checked regularly, at least every 6 months. If you have been prescribed medicines for high blood pressure, you must make sure that you take it according to the instructions given.

Diabetes

If you have diabetes, it is important that your blood sugar levels are well controlled.

Blood cholesterol (fatty substance in your blood) levels

You should eat a healthy, balanced diet and try to reduce any excess weight. It is important to reduce the level of cholesterol in your blood. Your vascular nurse can refer you to a dietitian if needed. You might be prescribed medicine to help lower your cholesterol (for example, a statin), and low dose aspirin to help prevent blood clots from forming.

Weight

There are increased risks when having an anaesthetic and the operation if you are overweight, so losing weight and having a healthy diet will help reduce these risks. Your GP may be able to refer you to a dietitian if you need help.