Endovascular Aneurysm Repair (EVAR)
Updated On: July 22, 2026
Anesthetic Approaches
The patient, not the procedure - the operation is minimally invasive but the population is not: these are vasculopaths with concurrent CAD, COPD, CKD, and hypertension, and most perioperative deaths after EVAR are cardiac. The preoperative cardiac evaluation and medication review carry more weight than the intraoperative plan for an uncomplicated case.
Technique choice - GA, MAC with surgeon's local at the groins, and neuraxial are all described; percutaneous cases increasingly run under MAC. Whatever the technique, deployment needs a still patient - movement or a cough while the graft is unsheathed can misplace it. If neuraxial is chosen, place it before heparinization and follow current ASRA guidance on the timing.
Arterial line - pre-induction: beat-to-beat pressure is needed both for this population's lability and for the deployment itself.
Deployment hypotension - during main-body unsheathing the surgeon may ask for brief controlled hypotension (SBP roughly 90-100): pulsatile flow hits the partially opened graft like a wind sock and can drag it distal to the renal arteries. Have a short-acting agent ready (nitroglycerin, nicardipine, or a propofol bolus) and restore pressure once it's seated.
Heparin - given at access, typical target ACT 250-300 sec; protamine reversal at closure per surgeon preference.
The quiet case that isn't - typical blood loss is modest, but an iliac injury or acute conversion to open repair is immediate massive hemorrhage from a large vessel. Type and crossmatch, two large-bore IVs, and know the plan for aortic occlusion balloon placement before the case starts.
Contrast and the kidneys - CKD is prevalent in this population and the case runs on iodinated contrast: hydrate, ask the surgeon to minimize dose, and hold nephrotoxins. A bumped creatinine is the most common post-EVAR complication in the renal-impaired.
Completion angiogram - endoleak found here (Type I attachment-site seal failure, Type II retrograde branch flow, Type III junction defect) means re-ballooning or graft extension - the case is not over until the angiogram is clean, so don't lighten early.
Temperature - a long case, exposed patient, cold hybrid room; warm actively from the start.
Emergence - smooth and unhurried; most patients are extubated in the room and go to stepdown rather than ICU.
Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it's going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient's arms.
Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also, consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.
Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram - otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.
Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.
Abdominal aortic aneurysm (AAA) is a degenerative dilation of the infrarenal aorta - smoking, male sex, age, and family history are the dominant risks - and rupture risk climbs with diameter, so elective repair is offered around 5-5.5 cm. EVAR excludes the sac from circulation with a fabric-covered stent graft delivered through the femoral arteries and expanded against healthy aorta above and iliac artery below. No laparotomy and no aortic cross-clamp means a fraction of the physiologic stress of open repair, which is why EVAR now accounts for the majority of AAA repairs - and why the patient population is one of the sickest to walk into an OR: the same disease that dilates the aorta gives them CAD, COPD, CKD, and hypertension.
Access - bilateral common femoral artery access, percutaneous with preclose suture devices or by open cutdown.
Wires and sheaths - advanced under fluoroscopy; systemic heparin once access is established.
Main body deployment - endograft positioned just below the renal arteries and unsheathed; the contralateral limb gate is cannulated and iliac limbs extended.
Seal - balloon molding of the proximal and distal seal zones; completion angiogram to confirm sac exclusion and check for endoleak.
Closure - preclose sutures tightened or the arteriotomy repaired open.
Ruptured AAA presenting for emergency EVAR is a different operation with the same name: keep the patient awake and permissively hypotensive (SBP 80-90, mentating) until the team is scrubbed, draped, and ready for immediate aortic control - induction drops the sympathetic tone that is tamponading the retroperitoneum, and the pressure can vanish with the first dose.