Thoracic Endovascular Aortic Repair (TEVAR)

Thoracic endovascular aortic repair or TEVAR is performed to correct an aneurysm in the aorta.

Aorta is the largest artery that transfers oxygenated blood from the heart to different parts of the body. It passes from the heart to the abdomen through the chest. From the abdomen, the blood vessels divide further and supply blood to the legs. The aorta has thick walls to resist the pressure of the blood against its walls. However, in some conditions, these walls may become weakened or damaged and swell or bulge like a balloon due to the pressure of blood. Such a condition is called an aneurysm.

If left untreated, such a bulged artery may burst. Therefore, TEVAR surgery is performed to treat the condition. In this procedure, a stent-graft, a metal tube (stent) covered with fabric (graft), is inserted inside the bulged artery. The graft is a collapsed, narrow tube that expands and attaches itself to the walls inside the aorta. The blood flow in the aortic aneurysm is prevented by forming a seal between the stent graft and wall. Once the blood flow is stopped, the aneurysm will shrink, preventing bursting.

Your doctor will recommend this surgery if you have a thoracic aortic aneurysm (in the chest area) with a diameter of ≥5 cm. Some symptoms of this condition include:

• Difficulty in breathing 
• Shortness of breath 
• Hoarseness (roughness in the voice)
• Swelling in the arms, neck, or face
• Pain or difficulty in swallowing 
• Throbbing or pulsating in the abdomen
• Feeling of fullness even without eating excessively
• Pain in the neck, shoulder, jaw, chest, back or abdomen

Besides this, you may also undergo this surgery in the following conditions:

• A traumatic aortic transection (ruptured aorta due to a trauma)
• Type B aortic dissection (tear in the last part of the thoracic aorta)
• Penetrating aortic ulcer (formation of ulcers that penetrate the aortic wall)
• Thoracoabdominal aortic aneurysm (aneurysm that spreads from chest to abdomen area)

This surgery is contraindicated in the following conditions:

• If a person's anatomy is not favourable to surgery, for example, abnormalities in the structure of the aorta 
• Infection in the area of surgery

You will need the following preparations before this surgery:

• Your healthcare provider will perform a complete physical examination and review your medical history. You will also need to undergo a few diagnostic tests such as:
  • Blood tests
  • Angiography (uses X-rays to see the flow of blood in the vessels)
  • Intravascular ultrasound
  • High-resolution, computed tomography (CT) scan 
  • Transoesophageal echocardiography (to capture ultrasound images of the heart from inside the food pipe)
  • Magnetic resonance imaging or MRI
• Notify your doctor if you are:
  • Pregnant or could be pregnant 
  • Allergic to any medicines or surgical components like latex, tape, iodine, or contrast dyes
  • Have bleeding disorders 
• Share a list with your doctor of all the medicines you take, including over-the-counter medications, herbs, vitamins, and supplements. 
• You will have to stop consuming blood thinners (aspirin, ibuprofen, or warfarin) before this surgery. 
• Your healthcare provider may prescribe medications to lower your blood pressure, relax your blood vessels, and decrease the risk of your aneurysm bursting until this surgery is performed. 
• You will need to fast (no food or drink) from the midnight before the surgery. 
• Smoking cessation before the surgery can help in faster recovery after the operation. 
• Ask for a family member or friend to drive you to the hospital and also bring you back.
• You will have to sign an approval form to grant your permission for the procedure.

After admitting to the hospital, 

• You will be given a hospital gown to wear.
• In the operating room, you will be asked to lie on your back over the operating table.
• The medical team will start an intravenous (IV) line in your arm or hand to supply medicines.
• You will be given general anaesthesia to keep you relaxed and pain-free during the surgery. In some cases, epidural anaesthesia is administered to only numb the area to be operated.
• The medical team will monitor your vital functions, including breathing, oxygen levels, heart rate, and blood pressure.
• A tube will be inserted into your bladder to drain urine.
• Once you fall asleep, a breathing tube will be inserted inside your lungs through the throat, and a ventilator will be connected to assist in breathing during the surgery.

The surgery will be done in the following way:

• The surgeon will make an incision (cut) in your groin, near the inner side of both thighs, to access the femoral arteries and insert a needle inside your femoral artery through this incision. 
• Using this needle, the surgeon will insert a guidewire and slide it up to the aneurysm site under the guidance of an X-ray imaging scan. 
• Next, the surgeon will remove the needle and pass a catheter (tube) called a sheath above the wire. 
• He/she will use an aortogram to check the position of the aneurysm in your aorta and the blood vessels associated with it. 
• The surgeon will attach a stent graft at the end of the sheath and inserted it inside your femoral artery. He/she will move the stent-graft slowly up to the aneurysm, where the metal frame (spring) of the stent will expand and attach to your aortic walls. 
• Once the stent is implanted, the surgeon will check for any leakage inside the aneurysm site.
• If no leakage is found, the surgeon will remove the guidewire and catheter.
• Finally, he/she will close the cuts on your groin using dissolvable stitches and apply a bandage over the area.

The duration of this surgery may vary based on your condition. After the surgery, you will be shifted to the recovery area. During your hospital stay, 

• You will continue to have the breathing tube inside your mouth. Once you are awake and can breathe normally, the nurse will replace the tube with an oxygen mask over your nose and mouth. You will be given painkillers through an IV. 
• The drainage tube for urine will be removed during your stay in the recovery area. 
• Your vital functions will be continuously monitored. 
• Your diet will initially include liquid food and would gradually be updated to solid foods once you start eating normally.
• You will be asked to walk around in the hospital to keep yourself active after the surgery. 
• The physiotherapist may teach you a few breathing exercises and ask you to practise it every day for quick recovery.

You will be discharged three to four days after the surgery. Before leaving from the hospital, your doctor will perform an X-ray to check for the correct position of the stent inside your aorta.

Once you are home, you need to take care of the following things:

• Bathing or showering:
  • Avoid bathing in a bathtub for at least first five days after the surgery.
  • Pat dry your incision site after showering. 
• Medications:
  • The surgeon may prescribe statins to reduce your blood cholesterol levels after the surgery. 
  • You may also have to take blood thinners to avoid the risk of blood clots post-surgery. 
• Activities:
  • Avoid lifting heavy objects.
  • Continue doing breathing exercises.
  • Keep yourself active by regularly walking. 
  • You will require a minimum of three months to restart your daily activities. 
• Travelling: 
  • Avoid driving for up to two weeks after the surgery. 
  • Ask your doctor before travelling by plane after the procedure.

When to see the doctor?

Visit or call your doctor if you experience the following symptoms:

• Fever 
• Chills 
• Swelling in the abdomen or legs 
• Inability to move your legs 
• Bleeding, pain, or redness around the catheter incision site 
• Swelling at the catheter site
• Blood in stools 
• Less or dark-coloured urine 
• Yellow or green discharge from the incision site 
• Blood in cough 
• Weakness
• Chest pain 
• Shortness of breath

This surgery is known to carry the following risks:

• Bleeding 
• Paralysis 
• Stroke 
• Leakage around the stent-graft 
• Allergy to anaesthesia 
• Heart attack 
• Injury to the blood vessels 
• Displacement of the graft 
• Visceral ischemia (the insufficient supply of blood to the organs inside the abdomen)
• Kidney damage 
• Infection 
• More bulging of the aneurysm 
• Stent graft failure
• Blood clots 
• Damage to the organs

Your follow-up will be scheduled three months and one year after the surgery wherein a CT scan will be performed to assure the position of the stent inside the aorta wall.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.