Open & Endovascular Aortic Surgery
Aortic Aneurysm Treatment
Specialist assessment and treatment of aortic aneurysms, including open surgical repair and endovascular aneurysm repair (EVAR) where clinically appropriate.
Choosing the right approach for the aneurysm and the patient
Aortic aneurysm treatment may involve continued surveillance, open surgical repair or endovascular repair. The appropriate strategy depends on aneurysm anatomy, growth, symptoms and individual operative risk.
Understanding Aneurysm Repair
Reducing the risk of aneurysm rupture
An aortic aneurysm is an abnormal enlargement of the aorta, the main artery carrying blood away from the heart.
Many abdominal aortic aneurysms are discovered before they cause symptoms. Smaller aneurysms may be monitored with imaging, while repair may be considered when the risk associated with the aneurysm becomes greater than the risks of intervention.
Treatment planning considers the size and growth of the aneurysm, whether symptoms are present, the shape and position of the aneurysm, overall health and whether open or endovascular repair is technically suitable.
Aneurysm management may involve
- Ultrasound surveillance
- CT imaging for detailed assessment
- Cardiovascular risk management
- Open surgical aneurysm repair
- Endovascular aneurysm repair (EVAR)
- Ongoing surveillance after EVAR
Not every aneurysm needs an operation
For many people, surveillance is the appropriate management until the expected risk of aneurysm rupture justifies considering repair.
When Repair Is Considered
The decision is based on more than size alone
Aneurysm diameter is an important factor, but treatment decisions also consider growth over time, symptoms, individual anatomy and the risks associated with surgery.
Detailed discussion is particularly important because aneurysm repair is preventative surgery. The potential benefit of reducing rupture risk must be weighed against the immediate and longer-term risks of treatment.
Endovascular Aneurysm Repair
How EVAR works
EVAR treats the aneurysm from within the circulation rather than by directly replacing the aorta through an open abdominal operation.
A stent graft is introduced through arteries, usually from the groin, and positioned within the aorta under imaging guidance.
Once deployed, blood flows through the graft rather than directly through the weakened aneurysm sac.
Arterial Access
The arterial system is accessed through the groin using an endovascular approach.
Stent Graft Positioning
Imaging is used to position the graft accurately within the aorta.
Aneurysm Exclusion
The deployed graft creates a new route for blood through the aneurysmal segment.
Imaging Follow-Up
Surveillance is needed after EVAR to assess the graft and aneurysm over time.
Open Aneurysm Repair
Direct replacement of the diseased aorta
Open aortic aneurysm repair is a major vascular operation in which the aneurysmal section of the aorta is opened and a vascular graft is sewn into place.
Blood then flows through the graft, providing a durable reconstructed pathway through the treated segment.
Open repair involves a greater initial physiological impact and a longer recovery than standard EVAR, but remains an important treatment for suitable patients.
Open repair planning considers
- Aneurysm anatomy
- Overall operative fitness
- Cardiac and respiratory health
- Kidney function
- Previous abdominal surgery
- Expected durability of repair
- Individual treatment preferences
Treatment Planning
Choosing the appropriate repair
The best treatment is not determined simply by which operation is less invasive.
Aneurysm Anatomy
The position, shape and relationship of the aneurysm to important arterial branches influence which techniques are technically possible.
Operative Risk
Cardiac, respiratory, kidney and general health are considered when assessing the risks of open and endovascular treatment.
Long-Term Considerations
Durability, future imaging, the possibility of further intervention and individual circumstances form part of shared treatment planning.
Before Aneurysm Repair
Detailed imaging and clinical assessment come first
Ultrasound is commonly used to measure and monitor abdominal aortic aneurysms. When repair is being considered, CT angiography can provide the detailed anatomical information needed for operative planning.
Assessment also considers overall health and whether the patient is likely to benefit from intervention compared with continued surveillance or conservative management.
Assessment may include
- Review of previous ultrasound measurements
- CT angiography
- Assessment of aneurysm growth
- Blood tests and kidney function
- Cardiac and respiratory assessment
- Medication review
- Discussion of open repair and EVAR
- Individual benefit and risk assessment
After Treatment
Recovery and surveillance
Follow-up differs between open aneurysm repair and EVAR.
After Open Repair
Open surgery involves a more substantial initial recovery. Hospital monitoring, wound care, gradual mobilisation and rehabilitation form part of the postoperative period, with recovery progressing according to the individual.
After EVAR
Initial recovery is generally less extensive than after open surgery, but EVAR requires continued imaging surveillance to check the position and integrity of the graft and assess the aneurysm sac over time.
Treatment Considerations
Aneurysm repair is major vascular treatment
The potential complications vary between open surgery and EVAR. Individual risks are discussed carefully before treatment.
Bleeding
Significant bleeding can occur during or after aneurysm repair and may require further treatment.
Cardiovascular Complications
Aortic surgery places stress on the cardiovascular system, making careful pre-operative assessment important.
Kidney Complications
Kidney function may be affected by major surgery, changes in circulation or contrast used during endovascular treatment.
Limb Circulation
Complications affecting blood flow to the legs can occasionally occur during aortic repair.
Endoleak After EVAR
Blood can occasionally continue to enter the aneurysm sac around or through an endovascular graft, requiring surveillance or further treatment.
Further Intervention
Some patients, particularly after EVAR, may require additional procedures during longer-term follow-up.
Aortic Vascular Surgery
Open and endovascular aneurysm expertise
Mr Shanka Benaragama is a Consultant Vascular and Endovascular Surgeon at Royal Free London and University College London Hospitals.
His practice includes the management of aortic aneurysms using both open surgical and endovascular techniques, with treatment selected according to anatomy and individual clinical circumstances.
Aortic aneurysm care includes
- Specialist aneurysm assessment
- Review of surveillance imaging
- CT-based treatment planning
- Open aortic aneurysm repair
- Endovascular aneurysm repair (EVAR)
- Long-term vascular follow-up
Aortic Aneurysm Emergency
A ruptured aneurysm is a medical emergency
Call 999 immediately for sudden severe abdominal or back pain, particularly if associated with collapse, fainting, severe weakness or feeling acutely unwell. Do not wait for a routine private consultation if an aneurysm rupture is suspected.
Frequently Asked Questions
Aortic aneurysm treatment questions
Does every abdominal aortic aneurysm need surgery?
No. Many aneurysms are monitored with regular imaging. Repair is considered when the expected risk associated with the aneurysm justifies the risks of intervention.
What is EVAR?
Endovascular aneurysm repair, or EVAR, places a stent graft inside the aorta through the arterial system. The graft allows blood to pass through a new channel while excluding the aneurysm sac.
What happens during open aneurysm repair?
The aneurysmal section of aorta is surgically exposed and a vascular graft is sewn into place to provide a reconstructed pathway for blood flow.
Is EVAR always better than open surgery?
No. EVAR is less invasive initially, but it is not suitable for every aneurysm and requires long-term surveillance. Open repair remains an important option for suitable patients.
How is suitability for EVAR assessed?
Detailed CT imaging is used to assess the shape of the aneurysm, the aorta above and below it, and the arteries used to access the aorta. General health and operative risk are also considered.
Why do I need scans after EVAR?
Imaging follow-up checks the endovascular graft, assesses the aneurysm sac and looks for complications that may require further monitoring or treatment.
What is an endoleak?
An endoleak means that blood continues to flow into part of the aneurysm sac after EVAR. Some endoleaks only require surveillance, while others may need additional treatment.
How do you choose between open surgery and EVAR?
The choice depends on aneurysm anatomy, overall health, operative risk, expected durability, the need for future surveillance and individual circumstances.
Aortic Aneurysm Consultation
Request a specialist vascular consultation
If an aortic aneurysm has been identified on a scan, is being monitored, or you have been advised that open repair or EVAR may be required, please contact the practice for a specialist vascular opinion.
Email to Request a Consultation → benaragama.admin@lips.org.uk