Fenestrated endovascular aortic repair (FEVAR) is a minimally invasive procedure used to repair aneurysms in the aorta, in areas near the kidneys, and other organs. A vascular surgeon who has successfully performed this specialised procedure explains more.
Dr Sabatta Tsotetsi, a vascular surgeon at Mediclinic Heart Hospital, recently carried out a successful aortic aneurysm repair using FEVAR. This procedure uses a specially designed tube with small openings to fix an aneurysm (bulge) in the aorta, the main blood vessel in the body. FEVAR is used when the bulge is near where the aorta splits to send blood to the kidneys and other organs. The surgery is performed through small incisions rather than open surgery, which lowers the risk of complications.
Understanding aneurysms
While aneurysms can occur in any blood vessel, they more commonly affect the arteries, especially the aorta and blood vessels in the brain. “An aneurysm is a localised dilatation of an artery, usually more than one and half times its normal size,” Dr Tsotetsi explains.
This occurs due to the weakening of a certain area in the artery, the blood vessel responsible for transporting oxygenated blood away from the heart to the body's tissues and organs. Due to the internal pressure this creates, when there is such a weakness, a ballooning of the affected area inside the artery occurs. This grows and eventually ruptures like a balloon causing a life-threatening emergency.
While the cause of an aneurysm is sometimes unknown, cigarette smoking is a major risk factor due to its adverse impact on the blood vessels, Dr Tsotetsi explains. The risk of aneurysms also increases with age, yet heavy smokers experience more rapid degeneration. Although any gender or race group can be affected, aneurysms more commonly occur in white males above the age of 60 who have a smoking history. One should therefore consider having an abdominal sonar scan after the age of 65 as a proactive health measure if you have smoked, or have a family member (such as a parent or sibling) who previously had an aneurysm.
“Aneurysms commonly occur in the aorta, and more so in the infrarenal abdominal aorta, just below the kidneys,” Dr Tsotetsi says. These aneurysms are repaired by inserting a stent – a tube used to reinforce the weakened area from the inside and prevent the aneurysm from bursting – into the aorta. This minimally invasive procedure is known as an endovascular aneurism repair (EVAR), Dr Tsotetsi explains. This is still the most common procedure used in these cases.
“However, when the aneurysm comes too close to the kidneys, it makes the repair more difficult because there's the risk of kidney blockage when you put in the stent,” he continues. This necessitates a much bigger operation than would have been required had the kidneys not been not involved.
How the FEVAR procedure works
The FEVAR mitigates the need for such a big operation and minimises the risks this involves. “If the aneurysm is slightly higher, there's not enough space below the kidneys to use the traditional approach,” Dr Tsotetsi says.
“We then do a fenestrated endovascular repair (FEVAR). Here, we use a stent with special holes – fenestrations – that allow blood to still flow to the kidneys and other branching arteries.” Based on the patient’s CT scans, this stent is specially manufactured – in Europe or Australia – to suit the patient’s particular anatomy.
During the FEVAR, doctors make a small incision in the groin area, and then, guided by the X-rays, they deliver the stent to the weakened area using wires. “The stent placement needs to be meticulous,” Dr Tsotetsi explains.
“The pre-created fenestrations or holes on the stent must align with the existing blood vessels we’re trying to preserve.” Extensive pre-operative planning is therefore essential. As the procedure is minimally invasive, surgeons do not need to make big incisions, minimising the associated complications, especially in the elderly patients who are commonly affected.
“As the procedure is minimally invasive, the mortality risk is lower,” says Dr Tsotetsi. “Patients usually don't need to be intubated and ventilated after the operation and therefore go home sooner. The patient on whom we recently performed a FEVAR was discharged two days later.”
The danger of untreated aneurysms
If left untreated, aneurysms naturally keep growing and eventually burst with fatal consequences, Dr Tsotetsi explains. “When they burst, patients lose a lot of blood rapidly, and very few make it to the hospital,” he says. “Of those who make it to the hospital, very few of them will survive the operation to repair the aneurysm.”
That’s why early detection and treatment before rupture is vital. “An aneurysm repair must ideally be done before it reaches the size known for rupture,” Dr Tsotetsi explains. “If the aneurysm is small, the risk of rupture is low, but if it’s more than 5.5 centimetres, the risk goes up significantly, and it therefore needs to be repaired to prevent rupture.”
A unique offering at Mediclinic Heart Hospital
To date, Dr Tsotetsi has performed two FEVAR procedures at Mediclinic Heart Hospital on patients in their 70s and both have had good outcomes. Dr Tsotetsi stresses the importance of awareness and continuous education around aneurysms. “It's one of those silent conditions where the day you experience pain might be your last. This is why screening after 60 is so important.”
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