EVAR and TEVAR: stent-graft repair of aortic aneurysms explained

What an aortic aneurysm is

The aorta is the body's main artery. An aneurysm is a swelling of its wall. Most cause no symptoms until they grow large, and the danger is rupture, which is often fatal. Abdominal aortic aneurysms are the commonest, especially in older men who smoke or have high blood pressure. Aneurysms in the chest (thoracic aorta) may be linked to high blood pressure, connective tissue disease or ageing. Small aneurysms are watched with scans, and repair is advised when the risk of rupture outweighs the risk of the operation ^{[1, 3]}.

When repair is advised

For abdominal aneurysms, the 2024 European guideline recommends repair at 5.5 cm in men and considers repair from 5.0 cm in women, or sooner if the aneurysm grows quickly or causes pain ^[1]. Thoracic aneurysm thresholds, and the treatment of aortic dissection and traumatic injury, are set out in the 2022 ACC/AHA aortic disease guideline and depend on the part of the aorta involved ^[3]. A size alone is not the whole story, and your doctors weigh your health and the shape of the aneurysm.

How EVAR and TEVAR work

A stent graft is a collapsible tube of fabric supported by a metal frame.

• A CT angiogram first measures the aorta, the length and angle of the neck above the aneurysm and the iliac arteries needed for access.
• Through small cuts or punctures in the groins, the folded stent graft is passed up the artery under X-ray guidance.
• It is positioned across the aneurysm and opened, sealing both ends against healthy aorta. Blood then flows through the graft, and the aneurysm sac is no longer under pressure.
• For aneurysms close to the kidney or chest branches, specially made or branched grafts may be needed.
• Most patients stay a few days, and CT scans follow at set intervals.

EVAR compared with open repair

Both are established, and the right choice depends on your anatomy, age, fitness and preference.

What the long-term trial data show

The UK EVAR-1 trial randomised 1,252 patients with large aneurysms. Over up to 15 years, total death rates were similar between groups. EVAR had lower mortality in the first 6 months (aneurysm-related hazard ratio 0.47), but beyond 8 years open repair had lower aneurysm-related mortality (hazard ratio 5.82 for EVAR), mainly from late rupture of the aneurysm sac, which caused 13 deaths (7%) in the EVAR group against 2 (1%) in the open repair group ^[2]. Devices and surveillance have improved since the trial started, but the lesson stands: a stent graft needs lifelong follow-up.

Risks and follow-up

Risks include bleeding or damage at the groin access, kidney injury from contrast dye, leaks around the graft (endoleaks), graft movement or blockage, and rare spinal cord injury or stroke with thoracic repair ^[3]. Surveillance with CT scans or ultrasound at set intervals picks up leaks and sac growth early, so they can be treated, often by a second catheter procedure, before they threaten the aorta.

Where it is done, and your next step

Aortic repair is done in hospitals with an aortic team and intensive care. Bring your CT angiogram, and your consultation reviews whether stent-graft repair is an option, which approach suits your anatomy, and where it is best done.

Cost and insurance

Health insurance can cover these procedures, subject to your policy terms. The cost depends on the hospital, the devices used and the length of stay, and is explained once the plan is made after consultation and a review of your scans. Cashless treatment can be arranged with major Indian health insurers and TPAs, and credit treatment is available for CGHS and Singareni beneficiaries. Eligibility is confirmed after a policy check.