Open surgical vs endovascular repair of abdominal aortic aneurysm (EVAR) at The Cleveland Clinic

Endovascular vs Open Repair for Abdominal Aortic Aneurysm: What Patients Need to Know

Abdominal aortic aneurysm (AAA) is a common and serious condition, but it is also highly treatable when found early and managed correctly.

At the Cleveland clinic in Cleveland, Ohio, a multidisciplinary team of physicians is able to assess and deliver high quality care of aortic disease including Type A, Type B and abdominal aortic aneurysm pathology. Lee Kirksey and colleagues have published work looking at the impact of high volume centers on creating regional centers of excellence which serve as a hub of aortic care delivery

Many patients ask:
“If I have an aneurysm, will I need surgery—and if so, will it be open surgery or endovascular?”

This guide explains what an aneurysm is, when repair is recommended, how doctors choose between treatment options, and what recovery looks like.

What Is an Abdominal Aortic Aneurysm (AAA)?

The aorta is the largest blood vessel in the body. It carries blood from the heart to the abdomen, legs, and feet.

An abdominal aortic aneurysm is a ballooning or enlargement of the aorta in the abdomen. Over time, the artery wall weakens and stretches.

Most aneurysms cause no symptoms. Many are found during imaging for other reasons or through screening ultrasound.

The main danger is rupture, which is life-threatening. That is why careful monitoring and timely repair are so important.

When Do Doctors Recommend Repair? (The Threshold for Surgery)

Not every aneurysm needs surgery. Many small aneurysms are safely monitored.

In general, national guidelines recommend repair when:

• The aneurysm reaches 5.5 centimeters (about 2 inches) in men

• The aneurysm grows quickly over time

• The patient develops pain or symptoms

• The aneurysm ruptures (this is an emergency)

The goal is to repair the aneurysm before rupture, but not too early, when surgery may carry unnecessary risk.

Open vs Endovascular Repair: How Is the Decision Made?

There are two main ways to repair an AAA:

1) Endovascular Aneurysm Repair (EVAR)

This is a minimally invasive procedure.

• A stent graft is placed inside the aneurysm through small incisions in the groin.

• The graft reinforces the artery and prevents rupture.

• No large abdominal incision is needed.

2) Open Surgical Repair

This is a traditional open surgery.

• A surgeon makes an incision in the abdomen.

• The weakened part of the aorta is replaced with a durable synthetic graft.

• This repair is very durable and often lasts for decades.

How Doctors Choose Between EVAR and Open Repair

The best option depends on three main factors:

1) Anatomy of the aneurysm

• Some aneurysms have shapes that are ideal for EVAR.

• Others are too complex and require open repair or advanced endovascular techniques.

2) Patient health and age

• EVAR may be preferred for older or higher-risk patients.

• Open surgery may be better for younger, healthier patients who need a long-lasting repair.

3) Patient preferences and lifestyle

• Recovery time, follow-up needs, and personal goals matter.

A personalized approach ensures the best long-term outcome for each patient.

What Is Recovery Like After Surgery?

Recovery After Endovascular Repair (EVAR)

• Hospital stay: Often 1–2 days

• Return to normal activity: Usually 1–2 weeks

• Pain: Mild to moderate

• Follow-up: Lifelong imaging (CT or ultrasound) to monitor the graft

Recovery After Open Repair

• Hospital stay: Typically 5–10 days

• Return to normal activity: 6–12 weeks

• Pain: More significant at first, improves over time

• Follow-up: Usually less frequent imaging once healed

Outcomes: How Do Open and Endovascular Repair Compare?

Short-Term Outcomes (First 30 Days)

• EVAR generally has lower early risk and faster recovery.

• Open repair has a higher initial recovery burden but is very durable.

Long-Term Outcomes (Years Later)

• Open repair often requires fewer re-interventions over time.

• EVAR patients may need additional procedures or imaging surveillance, especially over many years.

Both approaches are safe and effective when performed at experienced centers with careful patient selection.

A Message of Reassurance and Hope

Abdominal aortic aneurysm is serious, but it is one of the most treatable vascular conditions when managed correctly. Modern imaging, personalized decision-making, and advanced surgical techniques allow most patients to live full, active lives after repair.

If you have an aneurysm, talk with a vascular specialist about your anatomy, your health, and your goals. The best treatment is the one that fits you—not a one-size-fits-all approach.

Below is a patient-friendly checklist you can place at the end of your blog, use in clinic, or share at community events. It’s written at an 8th–9th grade reading level and designed to help patients understand AAA, treatment options, and how to prepare for decisions.

Abdominal Aortic Aneurysm (AAA) Repair: Patient Checklist

Use this checklist to understand your condition and prepare for conversations with your vascular surgeon.

✅ 1) Do I have risk factors for an abdominal aortic aneurysm?

You may be at higher risk if you have any of the following:

• ☐ Male, age 65 or older

• ☐ Current or former smoker (biggest risk factor)

• ☐ Family history of aneurysm

• ☐ High blood pressure

• ☐ High cholesterol

• ☐ Heart disease or prior heart attack

• ☐ Peripheral artery disease or carotid disease

• ☐ Chronic lung disease (COPD/emphysema)

• ☐ Kidney disease

👉 If you checked one or more boxes: ask your doctor about an abdominal ultrasound screening.

✅ 2) Do I know the size of my aneurysm?

Ask your doctor:

• ☐ What is the size of my aneurysm in centimeters (cm)?

• ☐ How fast is it growing?

• ☐ How often do I need imaging (ultrasound or CT scan)?

In general:

• Repair is often recommended at 5.5 cm in men or sooner if symptoms or rapid growth occur.

✅ 3) Am I a candidate for surgery right now?

Ask your vascular surgeon:

• ☐ Do I need surgery now, or can we safely watch it?

• ☐ What is my risk of rupture if we wait?

• ☐ What is my surgical risk based on my heart, lungs, and kidneys?

✅ 4) If I need surgery, which type is best for me?

Endovascular Repair (EVAR)

Ask:

• ☐ Is my anatomy suitable for EVAR?

• ☐ How often will I need follow-up imaging?

• ☐ What is the chance I may need another procedure later?

Open Surgical Repair

Ask:

• ☐ Am I healthy enough for open surgery?

• ☐ How long is the expected recovery?

• ☐ How durable is the repair over my lifetime?

✅ 5) What should I expect after surgery?

After EVAR

• ☐ Hospital stay: usually 1–2 days

• ☐ Return to normal activity: about 1–2 weeks

• ☐ Lifelong imaging follow-up is needed

After Open Repair

• ☐ Hospital stay: usually 5–10 days

• ☐ Return to normal activity: 6–12 weeks

• ☐ Fewer long-term imaging needs once healed

Ask:

• ☐ When can I drive?

• ☐ When can I return to work?

• ☐ When can I exercise again?

✅ 6) Am I protecting my heart and overall health?

AAA is a sign of whole-body artery disease. Ask about:

• ☐ Cholesterol medicine (statin)

• ☐ Blood pressure control

• ☐ Aspirin or other antiplatelet (if recommended)

• ☐ Smoking cessation support

• ☐ Regular walking and exercise plan

🚨 7) Symptoms that need urgent medical care

Go to the ER or call 911 if you have:

• ☐ Sudden severe back or abdominal pain

• ☐ Dizziness or fainting

• ☐ A pulsating painful mass in the abdomen

• ☐ Symptoms of rupture (this is a life-threatening emergency)

Bottom line for patients

• Many aneurysms can be safely watched.

• Surgery is recommended when the risk of rupture becomes higher than the risk of surgery.

• Endovascular and open repairs are both effective—the best option depends on your anatomy, health, and life expectancy.

• Expert vascular care and early detection can prevent rupture and save lives.

Lee Kirksey MD, MBA