Elective Endovascular Aneurysm Repair (EVAR)

Elective Endovascular Aneurysm Repair (EVAR) is a minimally invasive procedure used to treat abdominal aortic aneurysms (AAA) and, in some cases, thoracic aortic aneurysms. This technique involves placing a stent graft inside the aneurysmal segment of the aorta to prevent rupture by reinforcing the weakened artery wall. As an alternative to open surgical repair, elective EVAR offers reduced operative risk, shorter recovery times, and excellent long-term outcomes when performed under controlled, non-emergency conditions.

EVAR can be performed either electively or emergently. However, elective EVAR is far more common and is associated with significantly lower morbidity and mortality rates compared to emergency repair.

• Elective EVAR is planned in advance for patients with asymptomatic but high-risk aneurysms (e.g., large or rapidly expanding).
• Emergency EVAR is conducted when an aneurysm has ruptured or is actively leaking, requiring urgent intervention to prevent fatal internal bleeding.

Elective procedures allow for comprehensive preoperative imaging, patient optimization, and device selection, which are often not possible in emergency scenarios.

FOR PATIENTS REQUIRING EMERGENCY EVAR, IT IS ESSENTIAL TO SEEK IMMEDIATE MEDICAL ATTENTION AT THE NEAREST EMERGENCY FACILITY FOR URGENT CARE.

Why Cuba

In Cuba, elective Endovascular Aneurysm Repair (EVAR) is a carefully coordinated procedure designed to prevent aortic rupture by reinforcing the structural integrity of the aorta before complications arise. This proactive surgical approach reflects the country’s emphasis on preventative care, surgical precision, and patient-centered planning. Candidates for elective EVAR are evaluated in detail to determine the safest course of action, with every aspect—from aortic anatomy to systemic comorbidities—factored into the treatment strategy.

Postoperative care in Cuba follows a structured, multidisciplinary protocol that extends well beyond the initial procedure. Patients are closely monitored through scheduled imaging studies and vascular assessments to ensure stent graft durability and detect any early signs of endoleak or device migration. Rehabilitation support and lifestyle modification programs are integral to long-term care, aiming to preserve vascular health and improve overall outcomes. This comprehensive model reinforces Cuba’s broader commitment to high-quality, accessible vascular surgery delivered with foresight, clinical rigor, and compassionate follow-up.

Conditions Treated by Elective EVAR

Elective EVAR primarily addresses:

• Abdominal Aortic Aneurysms (AAA): The most common indication, especially when the aneurysm exceeds the threshold size or shows rapid expansion.

• Thoracic Aortic Aneurysms (TAA): In select cases where endovascular access is feasible.

• Iliac Artery Aneurysms: Often coexistent with AAAs and treatable via branched or bifurcated grafts.

• Fusiform or saccular aneurysms detected incidentally during imaging studies.

These conditions are typically asymptomatic until complications arise, highlighting the importance of early detection and scheduled intervention.

Cause of These Conditions

Aortic aneurysms result from progressive weakening of the aortic wall, leading to a localized dilation that increases the risk of rupture. Common contributing factors include:

• Atherosclerosis: Chronic inflammation and plaque buildup compromise vascular integrity.
• Hypertension: Persistent high blood pressure places mechanical stress on the aortic wall.
• Smoking: Strongly associated with the development and progression of aneurysms.
• Age and Male Sex: Incidence increases significantly in males over 65.
• Genetic disorders: Such as Marfan syndrome or Ehlers-Danlos syndrome.

Indications for EVAR

Several clinical and radiological criteria guide the decision to proceed with elective Endovascular Aneurysm Repair (EVAR), ensuring that intervention is both timely and appropriate for preventing aneurysm rupture and its associated complications.

• The aneurysm diameter exceeds 5.5 cm in men or 5.0 cm in women.
• There is rapid growth (typically >0.5 cm in 6 months).
• Consistent growth over multiple imaging studies confirms the trend and necessitates timely surgical planning.
• Imaging shows structural abnormalities (e.g., thinning wall, impending rupture).
• Presence of mural thrombus or signs of inflammatory changes may also prompt early repair.
• The aneurysm becomes symptomatic (e.g., back or abdominal pain).
• Symptoms often precede rupture and require urgent evaluation, even if the aneurysm does not meet size criteria.

Risks of Delaying Surgery

• Rupture risk increases significantly with aneurysm size.
• Ruptured aneurysms carry a mortality rate exceeding 80% without intervention.
• Delayed treatment may lead to:

• Hemodynamic collapse
• Severe internal bleeding
• Multi-organ failure
• Death

Elective repair dramatically reduces these risks by intervening before the aneurysm becomes unstable.

Qualification for Elective EVAR

Ideal candidates for elective EVAR include:

• Patients with confirmed aortic aneurysms meeting size or growth criteria.
• Those with suitable vascular anatomy for stent graft deployment (e.g., adequate neck length, minimal calcification, appropriate iliac access).
• Patients at higher surgical risk due to age or comorbidities, making EVAR preferable to open surgery.
• Individuals able to comply with post-procedure imaging surveillance.

A multidisciplinary evaluation involving vascular surgeons, radiologists, and anesthesiologists is essential to determine suitability.

Pre-Surgery Diagnosis

Prior to elective EVAR, comprehensive diagnostic assessment is essential for procedural planning:

• Abdominal ultrasound: Often used for initial aneurysm detection.

• CT angiography (CTA): Gold standard for evaluating aneurysm size, shape, and relationship to nearby arteries.

• MRI angiography (MRA): Alternative for patients with iodine contrast allergy or kidney dysfunction.

• Ankle-Brachial Index (ABI): To assess peripheral circulation if limb involvement is suspected.

• Cardiac and pulmonary evaluation: To assess perioperative risk in older patients or those with comorbidities.

Proper imaging and preoperative planning ensure accurate device sizing, appropriate access strategy, and a safer overall procedure.

Types of EVAR

There are several forms of endovascular aortic repair, tailored to aneurysm location and anatomy:

Standard EVAR

• Involves the placement of a bifurcated stent graft through the femoral arteries.
• The graft seals off the aneurysm and redirects blood flow through the stented lumen.

Fenestrated EVAR (FEVAR)

• Designed for aneurysms near visceral arteries (renal or mesenteric).
• Custom-made grafts with fenestrations (holes) align with major branches.

Branched EVAR (BEVAR)

• Used for complex thoracoabdominal aneurysms involving multiple arteries.
• Branched grafts allow blood flow into vital arteries while excluding the aneurysm.

Iliac Branch Devices (IBDs)

• Used when aneurysms involve the common iliac artery, preserving flow to the internal iliac artery.

Procedure Overview

• Performed under local, regional, or general anesthesia.
• A catheter is inserted via a small incision in the groin (percutaneous or cutdown access).
• The stent graft is deployed into the aneurysmal segment.
• Blood is rerouted through the stent, relieving pressure on the aneurysm wall.

EVAR is a minimally invasive procedure and is typically preferred over open repair when anatomy permits. Benefits include:

• No large abdominal incision
• Reduced blood loss
• Shorter hospital stay
• Faster recovery and lower complication rates
• Lower early mortality compared to open surgery

In cases of unsuitable anatomy, connective tissue disorders, or graft failure, open aortic repair may still be necessary.