Aortic Aneurysm Repair

EVAR (Endovascular Aneurysm Repair) is a minimally invasive approach where a stent-graft is delivered through small groin incisions using catheter-based techniques under fluoroscopic guidance. Open repair involves a larger abdominal or chest incision to directly replace the damaged aortic section with a synthetic graft. EVAR offers shorter hospital stays (2-5 days vs 7-10 days), lower 30-day mortality (0.5-1.5% vs 3-5% for AAA), and faster recovery, but requires suitable anatomy and lifelong CT surveillance for endoleaks. Open repair provides more durable long-term results with lower reintervention rates (5-8% vs 15-25% at 5 years) and is preferred for younger patients with longer life expectancy.

Elective repair is recommended when an abdominal aortic aneurysm (AAA) reaches 5.5 cm in men or 5.0 cm in women, or when a thoracic aortic aneurysm reaches 5.5 cm (4.5 cm with connective tissue disorders like Marfan syndrome). Repair is also indicated for rapid growth exceeding 0.5 cm per year regardless of absolute size, symptomatic aneurysms causing back or abdominal pain, and saccular aneurysms of any size due to higher rupture risk. These thresholds are based on the 2022 ACC/AHA and 2018 SVS guidelines.

Recovery varies significantly by approach. For EVAR, patients typically walk within 6-12 hours, are discharged in 2-5 days, return to sedentary work in 1-2 weeks, and resume full activities by 4-6 weeks. For open abdominal repair, ICU stay is 2-5 days, total hospitalization is 7-10 days, walking with assistance begins by day 4-5, sedentary work resumes at 4-6 weeks, and full activities return at 10-12 weeks. Open thoracic repair requires 4-6 weeks minimum before flying.

An endoleak is blood flow outside the stent-graft but within the aneurysm sac, occurring in 15-25% of EVAR patients. Type II endoleaks (from branch vessels like lumbar arteries) are most common and are observed if the aneurysm sac remains stable; coil embolization is performed if the sac grows. Type I endoleaks (at attachment sites) and Type III (graft defects) require urgent intervention with extension cuffs or relining. Lifelong CT surveillance is required to monitor for endoleaks, though stable patients may transition to duplex ultrasound after 2 years to reduce radiation exposure.

EVAR candidacy depends primarily on aortic anatomy. Ideal candidates have an adequate infrarenal neck length of at least 15 mm, neck diameter of 32 mm or less, and angulation of 60 degrees or less. EVAR is particularly favored for elderly patients over 75, those with significant cardiac or pulmonary comorbidities, and patients with life expectancy under 10 years. It is generally not recommended for patients with connective tissue disorders (Marfan, Ehlers-Danlos), hostile neck anatomy, or those who cannot comply with lifelong surveillance imaging.

No. Ruptured or rapidly expanding symptomatic aneurysms require immediate local treatment and are not suitable for medical tourism. Rupture carries mortality rates exceeding 80% untreated, and even emergency surgical repair has 30-60% mortality. Only elective repair of monitored aneurysms meeting established size criteria should be planned for treatment abroad. Patients should have their aneurysm actively monitored by a local vascular specialist while planning elective repair.

EVAR requires lifelong imaging surveillance: CT angiography at 1 month, 6 months, and 12 months post-procedure, then annually thereafter. After 2 or more years of stable results, patients may transition to duplex ultrasound to reduce radiation exposure. Surveillance monitors for endoleaks, aneurysm sac growth, graft migration, and limb patency. Additionally, 5-10% of patients develop new aneurysms at other aortic sites over 10 years, so annual imaging should assess the entire aorta.

Five-year overall survival is equivalent at 65-75% for both approaches, reflecting the high cardiovascular comorbidity burden in these patients. However, EVAR has higher 5-year aneurysm-related mortality (2-4% vs 1-2%), higher reintervention rates (15-25% vs 5-8% at 5 years), but lower 30-day perioperative mortality (0.5-1.5% vs 3-5%). Open repair provides superior long-term durability with greater than 99% freedom from rupture at 5 years versus 98-99% for EVAR. The choice between approaches involves balancing perioperative risk against long-term durability.

For EVAR, plan a minimum total stay of 2-3 weeks: 2-3 days pre-operative assessment, 2-5 days hospitalization, and 7-10 days local recovery with daily clinic visits. For open abdominal repair, plan 4-6 weeks minimum: 3-5 days pre-operative workup, 7-10 days hospitalization, and 14-21 days local recovery. Flying restrictions apply: minimum 10-14 days post-EVAR and 3-4 weeks post-open repair. A travel companion is recommended for EVAR and required for open repair on the first flight home.