EVAR stands for endovascular aneurysm repair, a minimally invasive procedure used to treat an abdominal aortic aneurysm (AAA), which is a dangerous bulge in the body’s largest artery. Instead of opening the abdomen to repair the weakened section of the aorta, a surgeon threads a fabric-lined tube called a stent graft through a small incision in the groin and positions it inside the aneurysm to reinforce the artery wall and prevent rupture.
How the Procedure Works
The aorta runs from your heart down through your chest and abdomen before splitting into two arteries that supply your legs. When a section of the abdominal aorta weakens and balloons outward, it creates an aneurysm. If that bulge ruptures, the internal bleeding is often fatal. EVAR prevents this by placing a reinforced sleeve inside the damaged section so blood flows through the stent graft rather than pressing against the weakened wall.
During the procedure, a vascular surgeon makes a small cut near one or both groins to access the femoral arteries. A compressed stent graft is loaded onto a thin delivery catheter and guided up through the artery into the aorta under X-ray imaging. Once positioned at the aneurysm site, the stent graft is gradually released. The metal frame expands and locks against the healthy artery wall above and below the aneurysm, sealing off the bulging section from blood flow. The whole process typically takes one to three hours under general or regional anesthesia.
Who Qualifies for EVAR
Not every aortic aneurysm needs repair. Treatment is generally recommended when the aneurysm reaches 5 centimeters or more in diameter, or when it grows rapidly (more than 0.5 cm in six months). Aneurysms that cause symptoms like back or abdominal pain need repair regardless of size.
Beyond size, your anatomy determines whether EVAR will work. The stent graft needs a healthy “landing zone” of at least 1.5 cm of normal artery below the kidney arteries to create a proper seal at the top, and at least 2.5 cm of healthy artery at the bottom. The angle where the graft attaches should be less than 45 degrees, and the arteries in your groin need to be wide enough (at least 6 to 8 mm) and straight enough for the delivery catheter to pass through.
About 10% of patients don’t meet these requirements because their aneurysm sits too close to the arteries supplying the kidneys. For these cases, a modified version called fenestrated EVAR (FEVAR) uses a custom stent graft with small openings that allow blood to continue flowing to the kidney arteries while still sealing the aneurysm.
EVAR Compared to Open Surgery
The alternative to EVAR is open surgical repair, where a surgeon makes a large incision in the abdomen, clamps the aorta, and sews in a synthetic graft directly. It’s a major operation with a longer recovery, but it has been performed successfully for decades.
The short-term advantage of EVAR is clear. A large randomized trial published in the New England Journal of Medicine found that 30-day mortality after EVAR was 1.8%, compared to 4.3% for open repair. That means EVAR cuts the early death risk by roughly two-thirds. Hospital stays are shorter, blood loss is lower, and patients get back on their feet faster.
The long-term picture is more nuanced. The same trial found no significant difference in overall survival between the two groups over time. EVAR patients face an ongoing need for imaging surveillance to check for complications, whereas open repair, once healed, rarely needs further monitoring. Your surgeon will weigh your age, overall health, and anatomy when recommending one approach over the other.
What Recovery Looks Like
Most people spend one to three days in the hospital after EVAR, compared to a week or more for open repair. You’ll likely have soreness at the groin incision sites, but the pain is significantly less than with abdominal surgery.
For the first two days after the procedure, you should avoid driving, yard work, and sports. For two weeks, avoid lifting anything heavier than 10 pounds. Most people return to normal daily activities within a few weeks, though your surgeon may adjust these timelines based on how your recovery progresses.
Endoleaks: The Main Complication
The most important risk specific to EVAR is an endoleak, which occurs when blood continues to flow into the aneurysm sac despite the stent graft being in place. There are five types, and they vary widely in severity.
- Type 1: Blood leaks around the top or bottom of the stent graft where it meets the artery wall. This means the seal has failed, and the aneurysm is still pressurized. Type 1 endoleaks are serious and usually require prompt treatment.
- Type 2: The most common type. Small branch arteries feed blood back into the aneurysm sac. These are often harmless and resolve on their own within six months. Treatment is only needed if the aneurysm grows by more than 5 mm.
- Type 3: Overlapping sections of the stent graft separate, allowing blood to flow into the sac. Like Type 1, this carries a rupture risk and needs prompt repair.
- Type 4: Blood seeps through the pores of the graft fabric itself. This is rare and typically resolves without intervention.
- Type 5: Also called endotension. The aneurysm sac grows even though no leak is visible on imaging. The cause isn’t always clear.
Types 1 and 3 are the most dangerous because they expose the weakened aneurysm wall to full blood pressure, creating a real rupture risk. Treatment options range from placing an additional stent graft inside the existing one to, in rare cases, converting to open surgery.
Long-Term Monitoring After EVAR
Unlike open repair, EVAR requires regular follow-up imaging for the rest of your life. The stent graft is a mechanical device sitting inside a living artery, and over time it can shift, develop leaks, or lose its seal. Most vascular surgeons schedule a CT scan within the first month, then at regular intervals (often yearly) to check for endoleaks, graft migration, or aneurysm growth. Some centers use ultrasound for routine checks to reduce your cumulative radiation exposure from repeated CT scans.
This ongoing surveillance is one of the key trade-offs of choosing EVAR. The procedure is easier to get through initially, but it comes with a long-term commitment to monitoring that open repair does not require.