Endovascular Repair for Abdominal Aortic Aneurysm

How EVAR works

During the EVAR procedure, the aneurysm is not removed. Instead, a stent-graft is inserted into the aorta to strengthen it. The stent-graft is a high-tech fabric and mesh tube that is expanded inside the aorta and fastened in place to form a stable channel for blood flow.This type of surgery is performed through catheters (thin tubes) inserted into the artery. EVAR does not require surgically opening the chest.The doctor first inserts a catheter into an artery in the groin (upper thigh) and threads it up to the area of the aneurysm. Then, watching on X-ray, the surgeon moves the stent-graft into the aorta to the aneurysm. The stent-graft reinforces the weakened section of the aorta to prevent the aneurysm from rupturing.

Advantages of EVAR

While not every aortic aneurysm is a candidate for EVAR, the procedure offers advantages over open-chest surgery when it is appropriate. The benefits include:

• Lower risk of infection

• Less blood loss

• Quicker recovery and shorter hospital stay

What are the risks of surgery?

As with any major operation general complications can occur including infection in the wound, chest infections or diarrhea.

There is a small risk of the patient having a medical complication such as:

• Heart attack

• Stroke

• Kidney failure

• Chest problem

• Loss of circulation in the legs or bowel

• Infection in the graft used to replace your aorta

What happens during an endovascular aneurysm repair procedure?

1. The patient will receive medications (anesthesia) to help relax or fall asleep.

2. The surgeon uses arteries near the groin, called the femoral arteries, to access the abdominal aortic aneurysm in the belly. Needles are inserted through the skin and underlying soft tissue and into the femoral arteries.

3. The surgeon inserts a catheter (thin tube) that contains a low-profile, expandable stent graft. The catheter is guided through the arteries to reach the aneurysm. Real-time imaging enables the surgeon to control the catheter’s journey.

4. When the catheter reaches the aneurysm, the surgeon opens the stent graft so it expands and becomes a new, stable path for blood to flow. The graft’s wireframe forms a tight seal that keeps the graft in place and prevents blood from entering the aneurysm.

5. Once the procedure is complete, the surgeon removes the catheter.

6. Puncture sites are so small that stitches are not necessary. A bandage covers the wounds as they heal.

For post-operative care:

• Monitor urine output this should be maintained above 30 ml/hr. If falls below this inform surgeon.

• Monitor blood pressure which should be maintained 120-160 mmHg

• Foot observations hourly.

• Document temperature, color, capillary refill and movement of toes/ankle joints and any calf tenderness. Calf tenderness is to be reported to the surgeon immediately.

• Observe groin wounds half hourly for any signs of swelling or bleeding. Inform surgeon if any concerns.

• Ward Care

• The urinary catheter can be removed on the first morning post-op except with fenestrated EVAR which should be discussed with the consultant surgeon.

• Once the catheter is out and the groin wounds assessed for hematoma then the patient should be mobilized and physiotherapy assessment completed together with any OT as necessary.

• Patient should be planned for home on the second post-operative day.

References:

Adventist Health Portland, Northwest Regional Heart and Vascular: Dr. Jeffry Boskind, MD

Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic and cardiovascular risks. US population data. Archives of internal medicine 1993; 153; 598-615.

Instruments and OR needs:

Intruments:

AVF  set

Prep basin

Light handles

OR Needs:

Laparotomy pack

Operative sponge

Gloves (all sizes)

Povidone iodine scrub

Povidone iodine paint

Blade 10, 11, 15

Sterile cotton balls

Cherry balls

Lidocaine 2%

Syringes 10cc, 1cc

Heparin 1000IU

Sheath Fr. 7

BER II catheter

Pigtail catheter

Backup meir wire

Tegaderm Medium