Open vs. Endovascular Repair: Which AAA Treatment Is Safer?

If you’re dealing with an Abdominal Aortic Aneurysm (AAA) diagnosis and trying to figure out the next steps, one of the first questions that probably comes to mind is: which AAA treatment gives me the best shot at staying healthy? It’s a fair question, especially when you’re staring down two very different surgical approaches.

Here’s the reality: both open surgery and endovascular repair can successfully fix Abdominal Aortic Aneurysm, but they work in completely different ways. And here’s the thing that catches most people off guard: the “safer” option really depends on your specific situation. Your age, overall health, anatomy and how fast you need treatment all play a role in which approach makes the most sense.

Let’s break down what actually matters when choosing between these two treatments.

Understanding Your Two Main Options

Think of an AAA like a weak spot in a garden hose that’s starting to bulge out. Both surgical approaches fix this problem, but they take different paths.

Open Surgical Repair is the traditional approach surgeons have used since the 1950s. The surgeon makes an incision in your abdomen, clamps off the weakened section of your aorta and sews in a synthetic graft. It typically takes three to four hours, with about a week in the hospital and six to eight weeks recovering at home.

Endovascular Aneurysm Repair (EVAR) is the newer option from the 1990s. Instead of opening your abdomen, the surgeon makes small incisions near your groin and threads a catheter up through your blood vessels to deploy a stent graft. 

Endovascular surgery is a minimally invasive technique that’s changed vascular treatment. The procedure takes about two hours, with one to three days in the hospital and two to four weeks of recovery.

Short-Term Safety: The Numbers

EVAR advantages in the first 30 days:

• Mortality rate of 1.4% to 1.8% compared to 4.2% to 5.2% for open repair
• Less blood loss (under 200ml vs 500-1000ml)
• Smaller incisions mean less surgical trauma
• Less time under general anesthesia
• Lower rates of heart problems, pneumonia and wound infections
• Faster return to normal activities

The numbers clearly favor EVAR for short-term safety. Your body doesn’t work as hard to recover, which matters especially if you have other health conditions.

Long-Term Outlook: A Different Story

Here’s where things get more complicated. For the first three years after surgery, EVAR maintains that early survival advantage. But around the three to four year mark, the curves even out. By eight years, some studies show open repair pulling ahead slightly.

Why does this happen?

• EVAR requires more follow-up procedures (29% of patients vs 15% for open repair)
• Reinterventions happen because of endoleaks (blood leaking around the graft) or stent shifting
• Each additional procedure carries risks and recovery time
• Open surgical grafts are more durable once healed
• EVAR needs yearly monitoring with CT scans or ultrasounds

Open repair’s durability becomes more valuable over time.

Who Benefits Most from Each Approach?

EVAR makes more sense for:

• Older patients (typically over 75) who might struggle with major surgery
• People with serious health conditions affecting the heart, lungs, or kidneys
• Anyone needing faster recovery for work or caregiving
• Patients with anatomy that fits current stent graft designs

Open repair often works better for:

• Younger, healthier patients (under 70) with longer life expectancy
• Complex aneurysm anatomy (short aortic neck, severely angled vessels)
• Those wanting to avoid lifelong monitoring
• Patients are concerned about long-term reintervention risks

Emergency Situations: When AAA Ruptures

Everything changes when an aneurysm ruptures. This is a medical emergency with 80% to 90% mortality rates overall.

EVAR’s advantage in ruptures:

• Cuts 30-day mortality roughly in half (21% vs 37%)
• A faster procedure means less bleeding
• Less stress on a body already in shock
• About half of ruptured cases have suitable anatomy for EVAR

The key factor is timing. When an abdominal aortic aneurysm is detected, repairing it before rupture is vital. Planned repairs have a much higher survival rate than emergency surgery, which is why routine vascular screening is so important. 

During these evaluations, doctors may also assess the carotid arteries through carotid artery screening because vascular disease can affect multiple areas of circulation. Identifying issues early, whether an aneurysm or an arterial blockage, greatly improves the chances of a safe procedure and a strong recovery.

Recovery and Healthy Life

After EVAR, most patients feel pretty good within a couple of weeks. You’ll have soreness at the groin sites, but many people return to light activities within days and work within two to four weeks.

Open surgery recovery is longer and tougher. That abdominal incision needs time to heal. You’ll deal with more pain, fatigue and activity restrictions for at least six to eight weeks. About 10% to 15% of patients experience complications like incisional hernias.

However, once fully healed from open surgery, you typically have fewer restrictions and less worry about your repair failing over time.

Making The Right Decision

Consider these factors:

• Your age and overall health condition
• How quickly do you need to return to normal activities
• Your anatomy and whether it suits EVAR
• Your comfort level with ongoing monitoring
• Long-term durability vs short-term recovery preferences

Sometimes your anatomy decides for you. If your aneurysm has a short neck or severely twisted vessels, standard EVAR might not work. If you’re not healthy enough for major abdominal surgery, EVAR might be your only option.

Choosing the Right Aneurysm Surgery for You

EVAR is clearly safer short term with lower 30-day mortality and faster recovery. If you’re older, have health issues, or need a quicker bounce-back, EVAR often makes the most sense.

Open repair might be safer in the long term, particularly for younger, healthier patients seeking a durable fix without ongoing monitoring. The lower reintervention rates appeal to many people.

For ruptured aneurysms, EVAR generally offers better survival if your anatomy allows it.

The good news? You don’t have to decide alone. At PVC, our skilled vascular surgeons can evaluate your specific aneurysm, review your overall health and help you understand which approach offers the best outcome now and in the years ahead.

What matters most is getting your aneurysm fixed before it becomes an emergency. Both procedures work when done well by experienced hands. The key is choosing the right approach for your particular situation.