EVAR & TEVAR

Before the 2000s, Aortic Surgery was among the largest and most complicated surgeries in Cardiovascular and Thoracic Surgery. However, thanks to technological advances, Aortic surgeries can now be easily performed using closed methods. Aortic aneurysm is one of the most dangerous diseases. An aortic aneurysm can either burst (rupture) and cause external bleeding or show tearing inwardly in the form of dissection. Both scenarios pose a significant risk of death. To protect against these complications, aneurysms that reach a certain size are surgically treated.

In open surgery, either the chest is completely opened, or the abdominal region is completely opened, and the aneurysmal aorta (dilated Aorta) is removed, replaced with an “artificial” vessel.

There is also the mentioned “closed” Aortic Surgery, which is performed on an angiography table or under “hybrid” operating room conditions. In this method, instead of open surgical techniques, endovascular repair can be performed using wires and catheters inserted through the groin without making an incision into the abdomen or chest. The method involves placing an artificial vessel onto a catheter (thin plastic tube), advancing it through the femoral artery into the diseased part of the aorta in the abdomen, and placing the artificial vessel by deploying it inside the patient’s vessel. This way, an aneurysm can be treated from the inside without making another incision from the groin. The aneurysm containing the artificial vessel carrying the blood gradually diminishes over time and is treated. This procedure must be performed under X-ray guidance and sterile operating room conditions. The procedure generally takes about 1-2 hours, and it can even be performed under local anesthesia. The hospital stay is 1-2 days, and there may not be a need to stay in the intensive care unit (Figure 2). However, there is a possibility of returning to open surgery in case of any complication (stent migration, blockage of the kidney or another major vessel, bleeding, etc.). Although this probability is low, it varies depending on the anatomical structure and the experience of the team. The procedure must be performed in a clinic where such situations can be easily treated and under the supervision of a Cardiovascular Surgeon.

In addition, patients need to be monitored at specific intervals. The aneurysm sac around the artificial vessel may start to be reperfused even years later. Repeat endovascular intervention or surgery may be necessary to treat this problem, known as “endoleak.” Not every aneurysm can be treated with endovascular methods. Open surgical repair is still the most reliable method for some aneurysms.

The Aorta inside the chest consists of 3 parts: the Ascending Aorta, Arch Aorta, and Descending Aorta. These aneurysms can silently grow without any symptoms. Sometimes they are incidentally diagnosed during examinations with back pain symptoms. When the diameter reaches 5.5 cm and above, the ascending aorta poses a vital risk for the patient. Because if its wall becomes thin and tears, the blood spreads into the heart cavity, compressing and stopping the heart within a few seconds. Therefore, treatment is mandatory. For the ascending aorta, surgery is inevitable, and endovascular (closed) treatments are not suitable. However, it can be replaced with a small incision of 3-4 cm (See Ascending Aorta and Aortic Valve Replacement Closed Method). The descending aorta in the back is suitable for endovascular treatment. In other words, it can be replaced with the TEVAR method without opening the chest cage.