Continued improvement in stent-graft design, including branched endografts, will reduce but not eliminate multi-stage procedures. Percutaneous EVAR
Standard EVAR involves a surgical cut-down on either the femoral or iliac arteries, with the creation of a 4–6 cm incision. Like many surgical procedures, EVAR has advanced to a more minimally invasive technique, by accessing the femoral arteries percutaneously In percutaneous EVAR (PEVAR), small, sub-centimeter incisions are made over the femoral artery, and endovascular techniques are used to place the device over a wire. Percutaneous EVAR has been systematically compared to the standard EVAR cut-down femoral artery approach. Moderate quality evidence suggests that there are no differences in short-term mortality, aneurysm sealing, long and short-term complications, or infections at the wound site. Higher quality evidence suggests that there are no differences in post-repair bleeding complications or haematoma between the two approaches. The percutaneous approach may have reduced surgical time. Fenestrated EVAR
In certain circumstances, a specially designed custom-made graft, which has holes, or fenestrations, on the graft body to maintain the patency of the visceral arteries, is used for the procedure, which is called FEVAR (fenestrated endovascular aortic/aneurysm repair). When the aneurysm begins close to the renal arteries, standard EVAR may be contraindicated since there will be an inadequate length of suitable aorta for the endograft attachment. In these cases, a fenestrated endograft may be useful, where the attachment of the endograft to the aorta may be placed above the renal arteries with each fenestration aligned with a renal artery so that blood flow to the kidneys is maintained.
The options for repair include traditional open aortic surgery or endovascular repair.Endovascular procedures aim to reduce the morbidity and mortality of treating arterial disease in a patient population that is increasingly older and less fit than when major open repairs were developed and popularized. Even in the early days, significant risks were accepted in the understanding that the large open operation was the only option. That is not the case in most patients today.Studies that assign aneurysm patients to treatment with EVAR or traditional open surgery have demonstrated fewer early complications with the minimally invasive approach. Some studies have also observed a lower mortality rate with EVAR. The reduction in death, however, does not persist long-term. After a few years, the survival after repair is similar to EVAR or open surgery. This observation may be the result of durability problems with early endograft, with a corresponding need for additional procedures to repair endoleaks and other device-related issues. Newer, improved technology may reduce the need for such secondary procedures. If so, the results of EVAR may improve to the point where long-term survival benefit becomes evident.EVAR is also used for rupture of the abdominal and descending thoracic aorta, and in rare cases used to treat pathology of the ascending aorta. Aortic dissection
Endografts have been used in patients with aortic dissection, noting the extremely complex nature of open surgical repair in these patients. In uncomplicated aortic dissections, no benefit has been demonstrated over medical management alone.