Endovascular Aneurysm Repair

Endovascular Aneurysm Repair (EVAR) is a minimally-invasive procedure to repair an aneurysm in your aorta (the biggest artery in your body). If left untreated, the aneurysm can leak or burst to cause immediate death.

If you experience the following signs of a ruptured aortic aneurysm, seek medical attention at once:

• Sudden, severe pain
• An extreme drop in blood pressure
• Signs of shock, like passing out or dizziness, weakness

Aortic Aneurysm

An aortic aneurysm occurs when a section of the aorta, the body’s main and biggest artery, weakens and bulges. See figure below.

The aorta transports oxygen-rich blood from the heart to other arteries that distribute blood to all the parts of the body.

An overstretched and weakened aortic wall (aneurysm) can leak, or worst case, burst. If the aneurysm bursts, it can lead to severe bleeding that can immediately cause death.

An aneurysm can develop in any section of the aorta.

If the aneurysm develops in the belly area it is called Abdominal Aortic Aneurysm or AAA, see figure below.

If the aneurysm develops in the upper body it is called Thoracic Aortic Aneurysm, see figure below. The thoracic aortic aneurysm is also called ascending or descending aortic aneurysm.

Causes, Symptoms and Risk Factors

Causes of Aortic Aneurysms

Under normal circumstances, the aortic wall is extremely stretchy. It can stretch and then shrink back as required to adjust to blood flow. The following medical conditions can lead to aortic wall weakening:

• High blood pressure
• Atherosclerosis
• Aging (natural wear and tear of blood vessels)

Aneurysm Symptoms

Nearly all aortic aneurysms do not produce symptoms. Usually, a doctor discovers them when conducting exams or tests done for other reasons. Individuals who have symptoms complain of pain and discomfort in the chest, belly, or back. These symptoms may come and go or stay constant.

Over time, the aneurysm can rupture and lead to severe bleeding and pain. A person can die within minutes to hours.

Another problem arising from an aortic aneurysm is blood clots. Usually, blood flow slows in the aneurysm leading to clot formation. If the blood clot in the chest area travels to the brain and blocks an artery, it can cause a stroke. Blood clots forming in the belly area can block blood flow to the legs.

Risk Factors

The top risk factors for an aortic aneurysm are:

• 65 year old and above
• Male
• A smoker
• High blood pressure
• Family history

When to See a Physician

See your doctor ASAP if you have:

• A pulsating mass in your abdomen
• Abrupt weakness in the lower extremities on one side of the body
• Chest pain you have not felt before
• A cold foot or a black or blue painful toe for no apparent reason

Medical Exams and Tests

Aortic aneurysms are frequently exposed in an X-ray, ultrasound, or echocardiogram performed for other reasons.

Once in a while, an abdominal aneurysm is felt during a regular physical exam. If your doctor suspects an aneurysm, he will have you undergo further tests and exams to confirm his suspicion because it is important to:

• Locate the aneurysm
• Determine its size
• Learn how fast it is growing
• Determine if other blood vessels are involved
• Examine if there are blood clots or inflammation

Exams and tests to help determine the location, size and growth rate of an aneurysm include:

• Abdominal ultrasound
• Computed tomography (CT) and Magnetic Resonance Angiogram (MRA)
• Echocardiogram
• Angiogram

An essential objective of these tests is to calculate the risk of a possible aneurysm rupture and to compare the risk of rupture to the risks of surgery. For example, an abdominal ultrasound can closely monitor any change in the size of the aneurysm and help evaluate the risk for rupture.

Aortic Aneurysm Treatment

Aortic aneurysms that are producing symptoms or enlarging fast are viewed as a significant risk for rupture. Repair is normally advised if either of these factors occur.

In men, the repair is normally advisable for AAA that are 5.5 cm or larger in diameter, causing symptoms, or are rapidly growing. In women, the repair is often advisable for smaller aneurysms.

Repair of thoracic aortic aneurysms is generally advisable once they hit 5.5 cm to 6.0 cm in diameter.

If EVAR is not done, you will need routine tests to see if the aneurysm is getting bigger.

Smaller aneurysms (less than 5.5 cm in diameter) that are considered the low risk for rupture are normally treated with medications used to treat high blood pressure, like a beta-blocker.

Before the Procedure

• Your surgeon will explain how the procedure will take place and you may ask any questions that you have about the procedure. You will need to sign a consent form that gives permission to do the procedure. Carefully read the form and ask questions if anything is unclear.
• Your doctor will take a complete medical history and perform a physical exam to make sure you are healthy enough to undergo the procedure. You may additionally undergo blood tests and other diagnostic tests.
• You will be instructed to fast for 8 hours before the procedure, usually after midnight.
• Inform your doctor if you are allergic to any medications. Inform your doctor of every medication and herbal or dietary supplement that you are taking.
• Inform your doctor if you have a history of bleeding disorders.
• Stop smoking now. Nicotine and other substances found in smoke interfere with healing.

During the Procedure

• You will be required to take off any jewelry or other objects that may interfere with the procedure.
• You will be requested to take off your clothing. You will be provided a gown to wear instead.
• You will be requested to empty your bladder before the procedure.
• Your nurse will shave the surgical site should there be too much hair.
• An IV line will be inserted in your arm or hand.

The Procedure

• You will be positioned in your back on the operating table.
• Your anesthesiologist will constantly observe your heart rate, blood pressure, breathing and blood oxygen level during the surgery. By the time you are sedated, a breathing tube is usually inserted by way of your throat into your lungs and you will be plugged into a ventilator, which will breathe for you during the procedure.
• Your surgeon may opt for regional anesthesia as an alternative for general anesthesia. Regional anesthesia is anesthetic introduced in the body through an epidural (in the back) to numb the surgical site. Your surgeon can talk to you during the procedure. Your doctor will decide which type of anesthesia is best for you.
• Your surgeon will create an incision in the skin in each groin and then locate the femoral arteries. By means of fluoroscopy (a kind of X-ray that broadcasts images to an RV-like monitor), your surgeon will insert a guide wire (catheter) through the femoral artery. See figure below.

• The catheters are used to guide and deliver a stent-graft (a tube composed of fabric supported by a metal mesh called a stent) through the blood vessels to the site of the aneurysm.
• The stent-graft is in a collapsed form while being inserted and when it gets to the aneurysm, it will be expanded and attached to the wall of the aorta. As soon as the stent-graft is in place, the blood flows through the graft, avoiding the aneurysm. With time, the aneurysm generally shrinks because the blood pressure is now exerted on the wall of the graft. See Letter B, the figure above.
• Your surgeon will check for leaks using an aortogram and if no leak is confirmed, the instruments are removed.
• Your surgeon will suture the incisions and a sterile dressing will be applied.

After the Procedure

• After the surgery, you will be transferred to the recovery room where your blood pressure, breathing rate, and oxygen level will be monitored closely.
• Once you are awake and your vital signs return to normal, you will be transferred to your own private room in the ward.
• Our nurses will take care of you in the ward and provide you with pain medication for incisional pain if needed.
• Your activity will progressively increase as you get out of bed and walk around for longer times. Your food will be advanced to solid foods as tolerated.
• Your surgeon or nurse will give you a schedule for follow-up visits.

At Home

• By the time you get home, it is very important to keep the surgical site clean and dry. Your nurse will provide you with specific bathing instructions. The sutures will be taken off at a follow-up visit.
• The surgical site may be a little sore for several days and can be relieved by pain medications prescribed by your surgeon.
• Visit your doctor if you experience:
• Fever and/or chills
• Redness, swelling, or bleeding from the surgical site
• Increase in pain in the surgical site

Your surgeon may give you more instructions before you go home. Take the first step and contact us through our no-cost virtual consultation. During this process, we will recommend options that will work best for you. Every client is different, so our virtual consultants and physicians tailor the treatment to match each person’s needs.