EVAR (Endovascular Aneurysm Repair): A Minimally Invasive Solution for Abdominal Aortic Aneurysms

Every year, thousands of people in Indonesia face the serious threat of an abdominal aortic aneurysm (AAA), a condition that can be fatal if it is not treated in time. The good news is that medicine now offers a minimally invasive treatment option called EVAR (Endovascular Aneurysm Repair).

01 / Cardiovascular Therapy

What Is EVAR (Endovascular Aneurysm Repair)?

EVAR (Endovascular Aneurysm Repair) is a minimally invasive medical procedure designed to treat an aortic aneurysm, particularly an abdominal aortic aneurysm (AAA). An abdominal aortic aneurysm occurs when the wall of the main blood vessel in the abdomen (the aorta) weakens and forms a balloon-like bulge. If this bulge ruptures, the consequences can be fatal.

Unlike open surgery, which requires a large incision in the abdomen, EVAR is performed from inside the blood vessels. This procedure uses catheter technology to insert a stent graft, a special fabric tube reinforced with a metal frame, through a small incision in the groin.

Guided by X-ray imaging, the doctor directs the stent graft to the aneurysm inside the aorta. Once it reaches the site, the stent graft is deployed and expands to attach firmly to the healthy aortic wall above and below the aneurysm. The device acts as a new channel for blood flow, so the pressure no longer pushes against the weakened wall and the aneurysm bulge will not grow larger or rupture.

According to a scientific publication, EVAR can deliver good results with a lower risk of complications than open surgery, especially for older patients or those with certain medical conditions.

02 / Cardiovascular Therapy

When Is EVAR Needed?

EVAR (Endovascular Aneurysm Repair) is a treatment option usually recommended for an abdominal aortic aneurysm (AAA) that has reached a certain size or condition considered to carry a high risk of rupture. The decision to perform EVAR is based on a very careful medical evaluation by a vascular surgeon.

1. When the Aneurysm Is Large or Growing Quickly

In general, EVAR is recommended when the aneurysm’s diameter reaches 5 cm or more (the normal size of the aorta is about 2 cm). This size is considered a threshold because the risk of rupture rises sharply. Besides size, the growth rate is also an important consideration. If the aneurysm grows more than 0.5 cm in six months, EVAR is usually recommended because the aneurysm is considered unstable.

2. An Option for Patients at High Risk From Open Surgery

Not all patients can undergo the more invasive open surgery. Older patients, or those with coexisting conditions such as heart disease, lung disease, kidney disease, or severe diabetes, are often considered unsafe for major surgery. In such cases, EVAR becomes a safer alternative because the procedure is minimally invasive and does not require a large incision.

3. Aneurysms That Cause No Symptoms (Silent)

Many cases of AAA show no symptoms until they reach a large size or even rupture. Therefore, these aneurysms are often detected by chance when patients undergo imaging tests such as an abdominal ultrasound or a CT scan for other complaints. If the results show an aneurysm size that meets the EVAR criteria, the doctor will recommend this procedure as a preventive step.

4. Location and Anatomical Characteristics of the Aneurysm

Besides size and growth rate, the position of the aneurysm in the aorta is also very important. Aneurysms located close to the branches of the renal arteries require special attention. The doctor will evaluate what is called the “aortic neck” (the healthy part of the aorta below the kidneys where the stent graft must attach securely). If the patient’s aortic anatomy meets the requirements, EVAR can be an effective and safe option.

Important Note:

The decision to perform EVAR does not depend only on imaging results; it also includes a thorough assessment of the patient’s medical condition, age, risk of complications, and the patient’s preferences after receiving an explanation from the medical team.

03 / Cardiovascular Therapy

The EVAR Procedure: Step by Step

Endovascular Aneurysm Repair (EVAR) is an advanced medical procedure performed using a minimally invasive approach. Here are the general steps of an EVAR procedure:

1. Preparation and Anesthesia: Before the procedure begins, the patient will be asked to fast for several hours. The medical team will check vital signs, kidney function, and any history of other diseases that may affect the procedure. The anesthesia used is usually a local anesthetic in the groin area, although in some cases light sedation may be added to make the patient more comfortable.
2. Catheter Insertion: After the groin area has been cleaned and numbed, the surgeon makes a small incision (about 1 cm) to access a large blood vessel called the femoral artery. Through this incision, a catheter (a small, flexible tube) is inserted and guided toward the widened section of the aorta (the aneurysm). This process is guided by real-time images from a fluoroscopy machine (a special X-ray) to make sure the catheter moves precisely to the aneurysm.
3. Stent Graft Placement: A stent graft is a special tube made of durable fabric and reinforced with a metal frame. Through the catheter, the stent is moved until it reaches the aneurysm. Once it is in the correct position, the stent is opened or expanded to attach to the aortic wall. The goal is to divert blood flow so that it no longer puts direct pressure on the weakened aortic wall. Functions of the stent graft:
   • Allowing blood to flow normally.
   • Reducing pressure on the weak aortic wall.
   • Preventing the aneurysm from rupturing.
4. Confirming the Stent Position: To make sure the stent graft is placed accurately, the doctor uses imaging guidance such as fluoroscopy (real-time X-ray) with the help of a contrast agent. If the position is not quite right, the stent can be moved or adjusted until it is optimal.
5. Closing the Incision: After the stent graft is fully in place and the catheter is removed, the small incision in the groin is closed. Because the procedure is minimally invasive, large stitches are usually not needed. The wound is then covered with a sterile bandage.
6. Post-Procedure Monitoring: After the procedure, the patient is taken to the recovery room for intensive observation. During the first 1 to 2 days, blood pressure, heart rate, and organ function are closely monitored. Most patients can start eating, sitting, and walking lightly within a short time. The average hospital stay is about 2 to 3 days, depending on each patient’s condition.

The EVAR procedure can help reduce the risk of aneurysm rupture. However, regular follow-up evaluations with a CT scan or ultrasound are still needed to make sure the stent stays in the right position and functions optimally.

04 / Cardiovascular Therapy

Advantages of EVAR Over Open Surgery

Endovascular Aneurysm Repair (EVAR) is one of the innovations in modern vascular surgery that offers many benefits, especially compared with traditional open surgery. Here are some of the main advantages of EVAR that have made this procedure an increasingly common choice for patients and doctors:

1. A Minimally Invasive Procedure

One of the main advantages of EVAR is that it is minimally invasive. This means the doctor does not need to make a large incision in the abdomen as in open surgery. A small incision of about 1 to 2 cm in the groin is enough to serve as the entry point to the femoral artery. This makes the trauma to the body much lighter, and patients feel less pain after the procedure.

2. Faster Recovery

Because EVAR does not involve major surgery, the recovery process is much shorter. According to data from the Society for Vascular Surgery, most patients who undergo EVAR can go home from the hospital in just 1 to 2 days. Many patients can return to light activities within two weeks, much faster than after open surgery, which usually requires a recovery time of 6 to 8 weeks.

A number of studies also show that EVAR patients generally return to normal activities sooner than open surgery patients.

3. Lower Risk of Complications

EVAR also generally carries a lower risk of complications than open surgery. EVAR causes less blood loss during the procedure, less postoperative pain, and a shorter operating time. In addition, the risks of wound infection, heart problems, and post-anesthesia complications are also lower, especially in older patients or those with coexisting conditions such as diabetes or heart disease.

4. Can Be Performed Without General Anesthesia

Many EVAR cases can be performed with only local or regional anesthesia, without the need for general anesthesia. This is a major benefit for patients at high risk from general anesthesia, for example those with lung or heart problems. With local anesthesia, the patient remains awake during the procedure but does not feel pain.

Direct Comparison of EVAR vs. Open Surgery

Parameter	EVAR	Open Surgery
Incision	1 to 2 cm (groin)	15 to 20 cm (abdomen)
Hospital stay	1 to 3 days	5 to 10 days
Infection risk	Lower	Higher
Anesthesia	Local / sedation	General

With a smaller incision and faster recovery, EVAR can be an option for treating abdominal aortic aneurysm (AAA), especially for patients who are unable to undergo major surgery. However, the final decision must still be based on a thorough assessment by a vascular surgeon, taking into account the patient’s physical condition and anatomy.

When Is Open Surgery Still Needed?

Although EVAR has many advantages, open surgery may be better for:

• Aneurysms with complex anatomy (for example, a very short aortic neck).
• Young patients with a long life expectancy (the stent graft may need to be replaced after 10 to 15 years).

05 / Cardiovascular Therapy

Risks and Side Effects of EVAR

EVAR is known as a relatively safe, minimally invasive procedure for treating abdominal aortic aneurysm (AAA). However, like all medical procedures, EVAR still carries potential risks and side effects.

1. Surgical Complications

Although EVAR is a lighter procedure than open surgery, postoperative complications can still occur. Some of them include:

• Bleeding at the incision site (groin)
• Mild infection of the surgical wound
• Reactions to anesthesia or medications, although rare

However, with an experienced medical team, these risks can be minimized.

2. Endoleak

One complication specific to EVAR is endoleak, a condition in which blood still flows into the aneurysm sac even after the stent graft has been placed. This can happen because the stent does not seal the aneurysm completely.

The incidence of endoleak ranges from 20 to 30% depending on the patient’s anatomy (Source: Society for Vascular Surgery).

Depending on the type, some endoleaks resolve on their own, but others require additional procedures to correct the position or replace the stent graft. Types of endoleak include:

• Type I: Leakage at the ends of the stent (requires prompt treatment)
• Type II: Backflow from small vessels (often not dangerous)
• Type III: Leakage between stent graft components

3. Risk of Blood Clots (Deep Vein Thrombosis / DVT)

After surgery, the risk of blood clots, especially in the leg veins, can increase. If a clot travels to the lungs (pulmonary embolism), it can become a serious condition. Therefore, doctors usually recommend compression stockings, early mobilization, and blood thinners when needed.

4. Organ Damage

Because EVAR uses a contrast agent (usually iodine) for X-ray image guidance, there is a possibility of impaired kidney function, especially in patients with a history of kidney disease.

In addition, because blood flow is briefly disrupted during stent graft placement, there is a small chance of reduced blood supply to organs such as the intestines or legs.

5. Serious Cardiovascular Complications

Although rare, serious complications such as a heart attack or stroke can still occur, especially in patients with a history of heart disease or high blood pressure. For this reason, close monitoring is carried out before, during, and after the procedure.

6. Other Side Effects

Some patients, especially older men, report erectile dysfunction after an EVAR procedure. This may be related to disrupted blood flow to the pelvic area.

In addition, although the death rate from EVAR is low, the aneurysm can still pose a risk if it is not managed properly. Therefore, patients need regular follow-up after EVAR with a CT scan or ultrasound to make sure the stent continues to work well.

EVAR is a very helpful and relatively safe solution for patients with abdominal aortic aneurysm. With professional care, most patients can recover well. However, understanding the risks and attending long-term follow-up remain important so that the results of EVAR last a long time.

06 / Cardiovascular Therapy

Recovery After EVAR

The EVAR procedure is designed to repair an aortic aneurysm in a minimally invasive way, which means recovery is much faster and more comfortable than after open surgery. However, there are still stages to follow so that healing goes optimally and safely.

1. A Short Hospital Stay

After the procedure, patients usually stay in the hospital for only 1 to 3 days.

Once the patient is awake and stable:

• They can drink, eat light meals, and start sitting up or walking slowly in less than 24 hours.
• The medical team will continue to monitor blood pressure, kidney function, and the condition of the wound in the groin.

If there are no complications, patients can go home within 2 to 3 days after the procedure.

2. Pain and Physical Activity

Unlike open surgery, which causes severe pain, pain after EVAR is generally mild and can be managed with low-dose pain relievers.

During recovery:

• Patients are advised not to lift heavy loads or do strenuous physical activity such as exercise, excessive stair climbing, or long-distance driving for 4 to 6 weeks.
• Light walking and gentle stretching are actually recommended to improve blood circulation and prevent clotting.

3. Recovery Time

One of the main advantages of EVAR is a much faster recovery period than conventional surgery.

Data from the Society for Vascular Surgery show that:

• Most patients can return to normal activities within 1 to 2 weeks, including walking, light work, and taking care of themselves.
• Activities such as full-time work can usually be resumed within about 1 month, depending on physical condition and type of work.

4. Follow-Up Checkups

After EVAR, routine monitoring is very important to make sure the stent graft stays in the right position and functions well.

Examinations usually include:

• CT scan or Doppler ultrasound every 6 months to 1 year, then periodically depending on the patient’s condition.
• These examinations aim to detect complications such as endoleak (blood leaking into the aneurysm) or stent migration.

Warning signs to watch for:

• Sudden abdominal/back pain
• Leg swelling or numbness
• High fever

About 1 in 10 EVAR patients may need a follow-up procedure to correct the position or replace part of the stent graft in the future. Therefore, adherence to medical follow-ups is very important to prevent serious complications.

07 / Cardiovascular Therapy

Differences Between EVAR and TEVAR: Minimally Invasive Procedures for Different Aneurysm Locations

Technically, EVAR and TEVAR are both minimally invasive and fluoroscopy-based, using a catheter to place a stent graft at the aneurysm site. However, there are significant differences:

1. Aneurysm location:
   • EVAR: for infrarenal aneurysms in the abdomen
   • TEVAR: for aneurysms in the chest (thoracic) region
2. Anatomical challenges: TEVAR often involves more complex areas because they are close to the heart and the large arterial branches in the chest, so it requires more complicated planning and a specific stent structure.
3. Indications and complications: TEVAR is usually used for thoracic aneurysms that pose an immediate serious risk, while EVAR is more often used for unruptured abdominal aneurysms.

According to the Society for Vascular Surgery, TEVAR is now the primary option for aneurysms in the chest because it carries a lower risk of postoperative morbidity and mortality than open surgery on the thoracic aorta.

08 / Cardiovascular Therapy

Conclusion

EVAR is a minimally invasive treatment option for abdominal aortic aneurysm (AAA). Thanks to its minimally invasive approach, EVAR can:

• Effectively prevent aortic rupture through stent graft placement.
• Lower 30-day mortality compared with open surgery.
• Reduce the risk of complications, improving patient safety and comfort.

Quick Action = Saving Lives

Aneurysms generally develop without symptoms until they finally rupture, with a mortality rate of 75 to 90%.

Therefore, it is important to:

• Know the risk factors: smoking, hypertension, advanced age, and a family history of AAA.
• Get imaging tests (ultrasound/CT scan) promptly if symptoms such as sudden chest, abdominal, or back pain appear, or if you belong to a high-risk group.
• Treating an aneurysm before it ruptures is crucial to saving lives and improving the success of EVAR.

09 / Cardiovascular Therapy

Final Thoughts

Heart and blood vessel diseases are often called a “silent killer” because their symptoms are not always felt until the condition is already severe. However, the good news is: with early detection and proper treatment, many cases can be prevented or controlled before they develop into serious complications.

According to the World Health Organization (WHO), most cardiovascular diseases can be prevented through early detection and management of risk factors.

Heart and Blood Vessel Problems Can Be Treated Well

Various cardiovascular disorders, including aortic aneurysms, can be treated effectively when they are recognized and treated early. With technological advances such as Endovascular Aneurysm Repair (EVAR), patients now have a treatment option that is safer, minimally invasive, and has a much faster recovery time than conventional surgery.

According to data from the American Heart Association, early detection of aortic aneurysms can significantly reduce the risk of death. In fact, the success of EVAR procedures has continued to improve over the past two decades, especially thanks to collaboration among multidisciplinary medical teams and the use of modern technology.

Detection and Proactive Action Are Key

If you have risk factors such as:

• A family history of aneurysm or heart disease,
• A smoking habit,
• Chronic hypertension,
• Or you experience unusual sudden abdominal/flank pain,

do not delay seeing a doctor. Early detection is the first step toward protecting your life. Remember, aneurysms often cause no symptoms until a serious complication occurs, such as an aortic tear, which can be fatal.

Do not wait until it is too late.

Have regular heart and blood vessel check-ups. Consult a specialist you trust.

Prevention today is protection for the future!