Endovascular Repair for Aortic Aneurysms

Treatment Approach by Anatomic Location

The European Society of Cardiology recommends endovascular repair (EVAR) as the preferred treatment for most aortic aneurysms when anatomy is suitable, offering superior perioperative mortality (<1%) and reduced morbidity compared to open repair 1, 2
For ruptured AAA with suitable anatomy, endovascular repair is strongly recommended over open repair to reduce perioperative morbidity and mortality (Class I, Level B) 1, 2
For elective AAA repair in patients with suitable anatomy and life expectancy >2 years, EVAR should be considered as the preferred therapy based on shared decision-making (Class IIa, Level B) 1, 2
Standard fusiform AAA: ≥55 mm in men or ≥50 mm in women is the recommended size threshold for intervention (Class I, Level A) 1, 2
Rapid growth: ≥5 mm in 6 months or ≥10 mm per year may warrant intervention (Class IIb, Level C) 1, 2

For juxta-renal or para-renal AAA, fenestrated or branched stent endografts should be considered to allow perfusion of visceral vessels 1, 2, 4

In patients with AAA and limited life expectancy (<2 years), elective AAA repair is not recommended (Class III, Level B) 1, 2

Endoleaks occur in up to one-third of patients and are the most common complication 1, 2
Type I and Type III endoleaks require immediate correction with new endovascular procedures to prevent rupture 1, 2, 3
Type II endoleaks are present in about 25% of patients but may spontaneously seal 1, 2

Duplex ultrasound (DUS) assessment of the femoro-popliteal segment should be considered prior to AAA repair to detect concomitant aneurysms (Class IIa, Level B) 1, 2
Routine coronary angiography and systematic revascularization in patients with chronic coronary syndromes is not recommended prior to AAA repair (Class III, Level C) 1, 2

Do not wait for the standard 55 mm threshold in saccular aneurysms - these have increased rupture risk at smaller diameters and warrant repair at ≥45 mm 3
For obese patients undergoing open repair, consider prophylactic mesh use to reduce incisional hernia risk 1, 2

EVAR carries higher long-term reintervention risk compared to open repair, though it remains durable at mid-term follow-up 1, 2, 4