Clinical Challenges in Vascular Surgery: The Risk & Reality of EVAR Complications

Jul 10, 2025

Delve into the chaotic world of vascular surgery as the team navigates a complex case of an 18cm abdominal aortic aneurysm with a Type 1B endoleak. Explore the decision-making process during critical interventions, from ICU resuscitation to multidisciplinary planning. Discover treatment strategies such as endovascular temporization versus open repair, while grappling with ethical considerations for high-risk patients. The discussion uncovers the delicate balance between immediate action and long-term outcomes in life-threatening scenarios.

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ADVICE

Immediate Stabilization And Team Notification

Admit unstable or complex EVAR-failure patients to ICU and start antibiotics and blood cultures immediately.
Optimize hemodynamics, involve cardiology/EP, and gather senior surgical input before definitive intervention.

INSIGHT

Endovascular As A Bridge In High-Risk Patients

In very high-risk patients an initial endovascular temporizing strategy can reduce perioperative stress compared with immediate open explantation.
This approach buys time to resuscitate and plan a staged definitive operation with multidisciplinary input.

ADVICE

Technical Steps For Type 1B Endoleak Control

When treating a Type 1B endoleak with large sac, extend the limb and coil hypogastric artery as needed to exclude the leak endovascularly.
Address concurrent femoral pseudoaneurysms with covered stents to secure access and control bleeding.

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It’s 2 a.m. The on-call resident’s voice is shaky.
The CT shows an 18cm abdominal aortic aneurysm with a Type 1B endoleak.
There’s gas in the sac, fluid in the belly, and the patient has a defibrillator on both sides of his chest.
Is it a rupture? A graft infection? An aortoenteric fistula? All of the above?
You’re the vascular surgeon, what do you do?

This episode dives deep into decision-making when EVAR fails, when infection strikes, and when the patient might not survive a definitive repair. Let’s talk about what happens when clinical textbooks meet real-world chaos.

Hosts:
· Christian Hadeed -PGY 4 General Surgery, Brookdale Hospital Medical Center
· Paul Haser -Division chief, Vascular Surgery, Brookdale Hospital Medical Center
· Andrew Harrington, Vascular surgery, Brookdale Hospital Medical Center
· Lucio Flores, Vascular surgery, Brookdale Hospital Medical Center

Learning objectives:
· Understand the clinical implications and management of late EVAR complications, including Type 1B endoleak and aortoenteric fistula.
· Explore the decision-making process in critically ill patients with multiple comorbidities and infected aortic grafts.
· Compare endovascular vs open surgical approaches in the setting of infected AAA, and when each is appropriate.
· Recognize the role of multidisciplinary collaboration in complex vascular cases.
· Discuss the ethical considerations and goals-of-care planning in high-risk, potentially terminal vascular patients.
· Highlight the importance of long-term surveillance after EVAR and the consequences of noncompliance.

References

· Karl Sörelius et al.Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular Repair.Circulation. 2016;134(22):1822–1832.
PubMed: https://pubmed.ncbi.nlm.nih.gov/27799273/ pubmed.ncbi.nlm.nih.gov+15pubmed.ncbi.nlm.nih.gov+15researchgate.net+15

· PARTNERS Trial (OVER Trial).Outcomes Following Endovascular vs Open Repair of Abdominal Aortic Aneurysm: A Randomized Trial.JAMA. 2009;302(14):1535–1542.
PubMed: https://pubmed.ncbi.nlm.nih.gov/19826022/ pubmed.ncbi.nlm.nih.gov+6pubmed.ncbi.nlm.nih.gov+6jamanetwork.com+6

· B.T. Müller et al.Mycotic Aneurysms of the Thoracic and Abdominal Aorta and Iliac Arteries: Experience with Anatomic and Extra-anatomic Repair in 33 Cases.J Vasc Surg. 2001;33(1):106–113.
PubMed: https://pubmed.ncbi.nlm.nih.gov/11137930/ sciencedirect.com+5pubmed.ncbi.nlm.nih.gov+5periodicos.capes.gov.br+5

· Chung‑Dann Kan et al.Outcome after Endovascular Stent Graft Treatment for Mycotic Aortic Aneurysm: A Systematic Review.J Vasc Surg. 2007 Nov;46(5):906–912.
PubMed: https://pubmed.ncbi.nlm.nih.gov/17905558/ researchgate.net+15pubmed.ncbi.nlm.nih.gov+15pubmed.ncbi.nlm.nih.gov+15

· Hamid Gavali et al.Outcome of Radical Surgical Treatment of Abdominal Aortic Graft and Endograft Infections Comparing Extra‑anatomic Bypass with In Situ Reconstruction: A Nationwide Multicentre Study.Eur J Vasc Endovasc Surg. 2021;62(6):918–926.
PubMed: https://pubmed.ncbi.nlm.nih.gov/34782231/ pubmed.ncbi.nlm.nih.gov+6pubmed.ncbi.nlm.nih.gov+6diva-portal.org+6

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