Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Endovascular repair of abdominal aortic aneurysm

Rabih A Chaer, MD
Section Editors
Joseph L Mills, Sr, MD
John F Eidt, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Endovascular aneurysm repair (EVAR) is an important advance in the treatment of abdominal aortic aneurysm (AAA). EVAR is performed by inserting graft components folded and compressed within a delivery sheath through the lumen of an access vessel, usually the common femoral artery. Upon deployment, the endograft expands, contacting the aortic wall proximally and iliac vessels distally to exclude the aortic aneurysm sac from aortic blood flow and pressure (figure 1).

Compared with open AAA repair, EVAR is associated with a significant reduction in perioperative mortality, primarily because EVAR does not require operative exposure of the aorta or aortic clamping. Since the approval of endograft devices for use in the United States, there has been a 600 percent increase in the annual number of EVAR procedures performed, with EVAR accounting for nearly half of AAA repairs. Concurrent with the increased use of EVAR, a decrease in the incidence of ruptured AAA and associated morbidity and mortality has been reported in the United States, likely due to the ability to offer EVAR to patients who would not otherwise be candidates for open surgical repair [1,2].

Endovascular repair of abdominal aortic aneurysm is reviewed here. General issues regarding the management of abdominal aortic aneurysm, and the clinical features and diagnosis of this condition, are presented separately. (See "Management of asymptomatic abdominal aortic aneurysm".)


The abdominal aorta is the most common site of arterial aneurysm. The abdominal aorta is defined as aneurysmal when a localized dilation is identified, and the diameter of the dilated region is increased more than 50 percent relative to normal aortic diameter [3]. The normal diameter of the aorta at the level of the renal arteries is approximately 2.0 cm (range 1.4 to 3.0 cm). An aortic diameter greater than 3.0 cm is considered aneurysmal for most individuals.

Aortoiliac anatomy — The abdominal aorta is a retroperitoneal structure that begins at the hiatus of the diaphragm and extends to its bifurcation into the common iliac arteries at the level of the fourth lumbar vertebra (figure 2). It lies slightly left of the midline to accommodate the inferior vena cava which is in close apposition. The branches of the aorta (superior to inferior) include the left and right inferior phrenic arteries, left and right middle suprarenal arteries, the celiac axis, superior mesenteric artery, left and right renal arteries, possible accessory renal arteries, left and right gonadal arteries, inferior mesenteric artery, left and right common iliac artery, middle sacral artery and the paired lumbar arteries (L1-L4).

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 31, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Dillavou ED, Muluk SC, Makaroun MS. Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. J Vasc Surg 2006; 43:446.
  2. Giles KA, Pomposelli F, Hamdan A, et al. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg 2009; 49:543.
  3. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991; 13:452.
  4. Sandhu RS, Pipinos II. Isolated iliac artery aneurysms. Semin Vasc Surg 2005; 18:209.
  5. Schanzer A, Greenberg RK, Hevelone N, et al. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. Circulation 2011; 123:2848.
  6. Boijsen E. Anomalies and malformations. In: Abrams' Angiography, Baum S (Ed), Little, Brown and Company, Boston 1997. p.1217.
  7. Higashiura W, Kichikawa K, Sakaguchi S, et al. Accuracy of centerline of flow measurement for sizing of the Zenith AAA endovascular graft and predictive factor for risk of inadequate sizing. Cardiovasc Intervent Radiol 2009; 32:441.
  8. Howell M, Villareal R, Krajcer Z. Percutaneous access and closure of femoral artery access sites associated with endoluminal repair of abdominal aortic aneurysms. J Endovasc Ther 2001; 8:68.
  9. Oliveira NFG, Bastos Gonçalves FM, Van Rijn MJ, et al. Standard endovascular aneurysm repair in patients with wide infrarenal aneurysm necks is associated with increased risk of adverse events. J Vasc Surg 2017; 65:1608.
  10. Gargiulo M, Gallitto E, Wattez H, et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg 2017; 66:1065.
  11. Mohan IV, Laheij RJ, Harris PL, EUROSTAR COLLABORATORS. Risk factors for endoleak and the evidence for stent-graft oversizing in patients undergoing endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2001; 21:344.
  12. Abu-Ghaida AM, Clair DG, Greenberg RK, et al. Broadening the applicability of endovascular aneurysm repair: the use of iliac conduits. J Vasc Surg 2002; 36:111.
  13. Ham SW, Chong T, Moos J, et al. Arch and visceral/renal debranching combined with endovascular repair for thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg 2011; 54:30.
  14. Prinssen M, Wixon CL, Buskens E, Blankensteijn JD. Surveillance after endovascular aneurysm repair: diagnostics, complications, and associated costs. Ann Vasc Surg 2004; 18:421.
  15. Oderich GS, Ricotta J, Hofer J, et al. Surgeon-Modified Fenestrated and Branched Stent Grafts for High Risk Patients with Juxtarenal, Paravisceral and Thoracoabdominal Aortic Aneurysms: Comparison with Open Abdominal Debranching in a Single Center. J Vasc Surg 2009; 49:S48.
  16. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
  17. http://content.onlinejacc.org/cgi/reprint/47/6/e1.pdf (Accessed on March 23, 2010).
  18. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2.
  19. Volodos NL, Karpovich IP, Troyan VI, et al. Clinical experience of the use of self-fixing synthetic prostheses for remote endoprosthetics of the thoracic and the abdominal aorta and iliac arteries through the femoral artery and as intraoperative endoprosthesis for aorta reconstruction. Vasa Suppl 1991; 33:93.
  20. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991; 5:491.
  21. Schwarze ML, Shen Y, Hemmerich J, Dale W. Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg 2009; 50:722.
  22. Greenberg RK, Sternbergh WC 3rd, Makaroun M, et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms. J Vasc Surg 2009; 50:730.
  23. Greenberg RK, Qureshi M. Fenestrated and branched devices in the pipeline. J Vasc Surg 2010; 52:15S.
  24. Ohrlander T, Sonesson B, Ivancev K, et al. The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones. J Endovasc Ther 2008; 15:427.
  25. Coscas R, Kobeiter H, Desgranges P, Becquemin JP. Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms. J Vasc Surg 2011; 53:1520.
  26. Patel HJ, Upchurch GR Jr, Eliason JL, et al. Hybrid debranching with endovascular repair for thoracoabdominal aneurysms: a comparison with open repair. Ann Thorac Surg 2010; 89:1475.
  27. Epstein D, Sculpher MJ, Powell JT, et al. Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials. Br J Surg 2014; 101:623.
  28. Min SI, Min SK, Ahn S, et al. Comparison of costs of endovascular repair versus open surgical repair for abdominal aortic aneurysm in Korea. J Korean Med Sci 2012; 27:416.
  29. Brown LC, Powell JT, Thompson SG, et al. The UK EndoVascular Aneurysm Repair (EVAR) trials: randomised trials of EVAR versus standard therapy. Health Technol Assess 2012; 16:1.
  30. Morimae H, Maekawa T, Tamai H, et al. Cost disparity between open repair and endovascular aneurysm repair for abdominal aortic aneurysm: a single-institute experience in Japan. Surg Today 2012; 42:121.
  31. Hayes PD, Sadat U, Walsh SR, et al. Cost-effectiveness analysis of endovascular versus open surgical repair of acute abdominal aortic aneurysms based on worldwide experience. J Endovasc Ther 2010; 17:174.
  32. Blackhouse G, Hopkins R, Bowen JM, et al. A cost-effectiveness model comparing endovascular repair to open surgical repair of abdominal aortic aneurysms in Canada. Value Health 2009; 12:245.
  33. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005; 365:2179.
  34. Fotis T, Tsoumakidou G, Katostaras T, et al. Cost and effectiveness comparison of endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysm: a single-center experience. J Vasc Nurs 2008; 26:15.
  35. Matsumura JS, Stroupe KT, Lederle FA, et al. Costs of repair of abdominal aortic aneurysm with different devices in a multicenter randomized trial. J Vasc Surg 2015; 61:59.
  36. Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg 2002; 35:1048.
  37. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1.
  38. de Maistre E, Terriat B, Lesne-Padieu AS, et al. High incidence of venous thrombosis after surgery for abdominal aortic aneurysm. J Vasc Surg 2009; 49:596.
  39. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
  40. Nejim B, Arhuidese I, Rizwan M, et al. Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure. J Vasc Surg 2017; 65:1080.
  41. de la Motte L, Kehlet H, Vogt K, et al. Preoperative methylprednisolone enhances recovery after endovascular aortic repair: a randomized, double-blind, placebo-controlled clinical trial. Ann Surg 2014; 260:540.
  42. Ruppert V, Leurs LJ, Steckmeier B, et al. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair: an analysis based on EUROSTAR data. J Vasc Surg 2006; 44:16.
  43. Parra JR, Crabtree T, McLafferty RB, et al. Anesthesia technique and outcomes of endovascular aneurysm repair. Ann Vasc Surg 2005; 19:123.
  44. Verhoeven EL, Prins TR, van den Dungen JJ, et al. Endovascular repair of acute AAAs under local anesthesia with bifurcated endografts: a feasibility study. J Endovasc Ther 2002; 9:729.
  45. Haas PC, Krajcer Z, Diethrich EB. Closure of large percutaneous access sites using the Prostar XL Percutaneous Vascular Surgery device. J Endovasc Surg 1999; 6:168.
  46. Papazoglou K, Christu K, Iordanides T, et al. Endovascular abdominal aortic aneurysm repair with percutaneous transfemoral prostheses deployment under local anaesthesia. Initial experience with a new, simple-to-use tubular and bifurcated device in the first 27 cases. Eur J Vasc Endovasc Surg 1999; 17:202.
  47. Torsello GB, Kasprzak B, Klenk E, et al. Endovascular suture versus cutdown for endovascular aneurysm repair: a prospective randomized pilot study. J Vasc Surg 2003; 38:78.
  48. Larzon T, Geijer H, Gruber G, et al. Fascia suturing of large access sites after endovascular treatment of aortic aneurysms and dissections. J Endovasc Ther 2006; 13:152.
  49. Nelson PR, Kracjer Z, Kansal N, et al. A multicenter, randomized, controlled trial of totally percutaneous access versus open femoral exposure for endovascular aortic aneurysm repair (the PEVAR trial). J Vasc Surg 2014; 59:1181.
  50. Gimzewska M, Jackson AI, Yeoh SE, Clarke M. Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair. Cochrane Database Syst Rev 2017; 2:CD010185.
  51. Cao Z, Wu W, Zhao K, et al. Safety and Efficacy of Totally Percutaneous Access Compared With Open Femoral Exposure for Endovascular Aneurysm Repair: A Meta-analysis. J Endovasc Ther 2017; 24:246.
  52. Georgiadis GS, Antoniou GA, Papaioakim M, et al. A meta-analysis of outcome after percutaneous endovascular aortic aneurysm repair using different size sheaths or endograft delivery systems. J Endovasc Ther 2011; 18:445.
  53. Larzon T, Roos H, Gruber G, et al. Editor's choice. A randomized controlled trial of the fascia suture technique compared with a suture-mediated closure device for femoral arterial closure after endovascular aortic repair. Eur J Vasc Endovasc Surg 2015; 49:166.
  54. Jean-Baptiste E, Batt M, Azzaoui R, et al. A comparison of the mid-term results following the use of bifurcated and aorto-uni-iliac devices in the treatment of abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2009; 38:298.
  55. Fernandez JD, Craig JM, Garrett HE Jr, et al. Endovascular management of iliac rupture during endovascular aneurysm repair. J Vasc Surg 2009; 50:1293.
  56. Peterson BG, Matsumura JS. Internal endoconduit: an innovative technique to address unfavorable iliac artery anatomy encountered during thoracic endovascular aortic repair. J Vasc Surg 2008; 47:441.
  57. Görich J, Rilinger N, Sokiranski R, et al. Treatment of leaks after endovascular repair of aortic aneurysms. Radiology 2000; 215:414.
  58. Go MR, Barbato JE, Rhee RY, Makaroun MS. What is the clinical utility of a 6-month computed tomography in the follow-up of endovascular aneurysm repair patients? J Vasc Surg 2008; 47:1181.
  59. Garg T, Baker LC, Mell MW. Postoperative Surveillance and Long-term Outcomes After Endovascular Aneurysm Repair Among Medicare Beneficiaries. JAMA Surg 2015; 150:957.
  60. Zaiem F, Almasri J, Tello M, et al. Surveillance after endovascular aortic repair. J Vasc Surg 2017.
  61. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357:2277.
  62. Katzen B. The Guidant/EVT Ancure device. J Vasc Interv Radiol 2000; 11:62.
  63. Wolf YG, Johnson BL, Hill BB, et al. Duplex ultrasound scanning versus computed tomographic angiography for postoperative evaluation of endovascular abdominal aortic aneurysm repair. J Vasc Surg 2000; 32:1142.
  64. McWilliams RG, Martin J, White D, et al. Detection of endoleak with enhanced ultrasound imaging: comparison with biphasic computed tomography. J Endovasc Ther 2002; 9:170.
  65. Powell JT, Greenhalgh RM. Clinical practice. Small abdominal aortic aneurysms. N Engl J Med 2003; 348:1895.
  66. Sato DT, Goff CD, Gregory RT, et al. Endoleak after aortic stent graft repair: diagnosis by color duplex ultrasound scan versus computed tomography scan. J Vasc Surg 1998; 28:657.
  67. Walsh SR, Tang TY, Boyle JR. Renal consequences of endovascular abdominal aortic aneurysm repair. J Endovasc Ther 2008; 15:73.
  68. Mills JL Sr, Duong ST, Leon LR Jr, et al. Comparison of the effects of open and endovascular aortic aneurysm repair on long-term renal function using chronic kidney disease staging based on glomerular filtration rate. J Vasc Surg 2008; 47:1141.
  69. Tomlinson J, McNamara J, Matloubieh J, et al. Intermediate follow-up after endovascular aneurysm repair: can we forgo CT scanning in certain patients? Ann Vasc Surg 2007; 21:663.
  70. AbuRahma AF. Fate of endoleaks detected by CT angiography and missed by color duplex ultrasound in endovascular grafts for abdominal aortic aneurysms. J Endovasc Ther 2006; 13:490.
  71. AbuRahma AF, Welch CA, Mullins BB, Dyer B. Computed tomography versus color duplex ultrasound for surveillance of abdominal aortic stent-grafts. J Endovasc Ther 2005; 12:568.
  72. Sandford RM, Bown MJ, Fishwick G, et al. Duplex ultrasound scanning is reliable in the detection of endoleak following endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2006; 32:537.
  73. Elkouri S, Panneton JM, Andrews JC, et al. Computed tomography and ultrasound in follow-up of patients after endovascular repair of abdominal aortic aneurysm. Ann Vasc Surg 2004; 18:271.
  74. Chaer RA, Gushchin A, Rhee R, et al. Duplex ultrasound as the sole long-term surveillance method post-endovascular aneurysm repair: a safe alternative for stable aneurysms. J Vasc Surg 2009; 49:845.
  75. Dias NV, Ivancev K, Malina M, et al. Direct intra-aneurysm sac pressure measurement using tip-pressure sensors: in vivo and in vitro evaluation. J Vasc Surg 2004; 40:711.
  76. Cantisani V, Ricci P, Grazhdani H, et al. Prospective comparative analysis of colour-Doppler ultrasound, contrast-enhanced ultrasound, computed tomography and magnetic resonance in detecting endoleak after endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2011; 41:186.
  77. Perini P, Sediri I, Midulla M, et al. Single-centre prospective comparison between contrast-enhanced ultrasound and computed tomography angiography after EVAR. Eur J Vasc Endovasc Surg 2011; 42:797.
  78. Mirza TA, Karthikesalingam A, Jackson D, et al. Duplex ultrasound and contrast-enhanced ultrasound versus computed tomography for the detection of endoleak after EVAR: systematic review and bivariate meta-analysis. Eur J Vasc Endovasc Surg 2010; 39:418.
  79. Karthikesalingam A, Al-Jundi W, Jackson D, et al. Systematic review and meta-analysis of duplex ultrasonography, contrast-enhanced ultrasonography or computed tomography for surveillance after endovascular aneurysm repair. Br J Surg 2012; 99:1514.
  80. Gilabert R, Buñesch L, Real MI, et al. Evaluation of abdominal aortic aneurysm after endovascular repair: prospective validation of contrast-enhanced US with a second-generation US contrast agent. Radiology 2012; 264:269.
  81. Iezzi R, Basilico R, Giancristofaro D, et al. Contrast-enhanced ultrasound versus color duplex ultrasound imaging in the follow-up of patients after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2009; 49:552.
  82. Sheehan MK, Barbato J, Compton CN, et al. Effectiveness of coiling in the treatment of endoleaks after endovascular repair. J Vasc Surg 2004; 40:430.
  83. Cynamon J. The role of arteriography in endovascular grafting techniques. In: Endovascular Grafting Techniques, Parodi JC, Veith F, Marin M (Eds), Lippincott Williams and Wilkins, Philadelphia 1999. p.7.
  84. Greenhalgh RM, Brown LC, Kwong GP, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004; 364:843.
  85. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607.
  86. Schermerhorn ML, O'Malley AJ, Jhaveri A, et al. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358:464.
  87. Wilt TJ, Lederle FA, Macdonald R, et al. Comparison of endovascular and open surgical repairs for abdominal aortic aneurysm. Evid Rep Technol Assess (Full Rep) 2006; :1.
  88. Lederle FA, Kane RL, MacDonald R, Wilt TJ. Systematic review: repair of unruptured abdominal aortic aneurysm. Ann Intern Med 2007; 146:735.
  89. Teufelsbauer H, Prusa AM, Wolff K, et al. Endovascular stent grafting versus open surgical operation in patients with infrarenal aortic aneurysms: a propensity score-adjusted analysis. Circulation 2002; 106:782.
  90. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA 2012; 307:1621.
  91. Sweeting MJ, Patel R, Powell JT, et al. Endovascular Repair of Abdominal Aortic Aneurysm in Patients Physically Ineligible for Open Repair: Very Long-term Follow-up in the EVAR-2 Randomized Controlled Trial. Ann Surg 2017; 266:713.
  92. Powell JT, Sweeting MJ, Ulug P, et al. Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years. Br J Surg 2017; 104:166.