Abdominal Aortic Aneurysm Surgery: Procedure, Risks, and Specialists

An abdominal aortic aneurysm is a pathological enlargement of the abdominal aorta in which the vessel’s diameter permanently increases to more than 3 cm. Doctors also refer to it as a pathological dilation of the abdominal aorta caused by a weakening of the vessel wall.
The abdominal aorta is the largest section of the aorta, which carries blood to the abdominal organs and the legs. If this vessel wall expands uncontrollably, it is referred to as a bulge (aneurysm).

Most abdominal aortic aneurysms remain asymptomatic for a long time and are discovered by chance, for example as an incidental finding during other examinations. The greatest danger lies in the possibility of rupture, which causes severe internal bleeding and is life-threatening in many cases.

Men over the age of 65 are particularly frequently affected, while women, although less likely to develop an abdominal aortic aneurysm, have a significantly higher risk of developing one and of it rupturing.

Sketch of an abdominal aortic aneurysm @ Henrie /AdobeStock

The main cause of an abdominal aortic aneurysm is atherosclerosis—the buildup of fat, calcium, and connective tissue in the arterial wall. These deposits weaken the arterial wall, leading to pathological dilation. Less commonly, genetic factors, inflammation of the vessel wall, or injuries may play a role.

• Age: Abdominal aortic aneurysms are particularly common in men over the age of 65.
• Gender: Women are affected less frequently; they have a lower risk of developing an aneurysm but a higher risk of rupture.
• Smoking: One of the major risk factors, as it further weakens the arterial wall.
• High blood pressure: Increases pressure on the aorta and accelerates its dilation.
• Family history: A genetic predisposition can significantly increase the risk.
• Other risk factors: Diabetes mellitus, elevated blood lipid levels, or existing vascular diseases.

Doctors pay particular attention to so-called high-risk patients who have several of these factors. In such cases, regular monitoring of the abdominal aorta via ultrasound is recommended to detect a growing aneurysm at an early stage.

In most cases, an abdominal aortic aneurysm remains asymptomatic for a long time. Many affected individuals may therefore have no symptoms for years or even their entire lives. Often, the pathological bulge in the abdominal aorta is discovered by chance during an ultrasound or CT scan.

• Abdominal pain that may radiate to the back or flanks
• A pulsating sensation in the abdomen caused by the expansion of the aorta
• Back pain radiating to the back or pelvis
• A feeling of pressure or fullness if the aneurysm is pressing on surrounding organs

The greatest risk is the rupture of the aneurysm. When this occurs, the vessel wall tears, leading to massive internal bleeding.

• Early signs: sudden, severe abdominal pain that often radiates to the back or pelvis
• Additional symptoms: shock with circulatory failure, dizziness, and loss of consciousness
• Prognosis: A rupture is a life-threatening emergency—without immediate surgery, there is an acute risk of death.

Since most abdominal aortic aneurysms remain asymptomatic for a long time, they are often discovered incidentally during other examinations. Early diagnosis is crucial to prevent the risk of rupture in a timely manner.

Ultrasound examination (sonography):

• The method of choice for early detection
• Fast, painless, and can be performed on an outpatient basis
• Allows for measurement of the diameter of the abdominal aorta
• Highly recommended for men over 65, as they are at increased risk

Computed tomography (CT):

• Used when an aneurysm needs to be assessed more closely
• Provides precise information about size, location, and extent
• Important for surgical planning, e.g., for selecting a suitable vascular prosthesis or stent graft

• Men aged 65 and older are eligible for a one-time preventive ultrasound exam
• If there is a family history or other risk factors, doctors recommend regular checkups
• Although women are affected less frequently, they have a higher risk of complications—early detection can be beneficial in these cases as well

In many cases, abdominal aortic aneurysm surgery is a preventive measure to reduce the risk of a life-threatening rupture. In other situations, however, it is an urgent emergency procedure, such as when the aorta has already torn or ruptured.

In addition to traditional open surgery, the minimally invasive method using an endovascular stent graft (EVAR) is now available in many cases. Both procedures have advantages and disadvantages, which doctors evaluate on a case-by-case basis.

The risk of rupture increases exponentially with the diameter of the aneurysm:

• For an aneurysm with a diameter of less than 5 cm, the risk of rupture is less than 3% per year
• For diameters of 5 cm or more, it rises to as high as 50% over the next two years
• For women, surgery is recommended starting at 4.5 cm

Whether surgery is advisable depends not only on the size but also on individual circumstances:

• Younger patients and those without serious comorbidities: surgery is more frequently recommended
• Older patients with pre-existing conditions: close monitoring is often more appropriate
• Rapid increase in size (> 4 mm per year) → urgent indication for surgery
• Signs of a rupture (sudden abdominal pain, shock) → immediate surgery is life-saving

• Severe abdominal pain
• Back pain radiating to the flank or pelvis
• Shock due to massive blood loss → leads to circulatory failure if left untreated

There are two established surgical methods for treating an abdominal aortic aneurysm: traditional open surgery and minimally invasive endovascular aneurysm repair (EVAR) using a stent graft. The choice of method depends on the size, location, and shape of the aneurysm, as well as on individual risk factors.

• In conventional or open surgery, the abdominal cavity is surgically opened.
• The aorta is clamped above and below the aneurysm, the diseased segment of the vessel is removed, and it is replaced with a vascular prosthesis.
• Advantage: a durable and stable repair.
• Disadvantage: major surgical procedure with a longer recovery period; hospital stay often 7–10 days.

• A minimally invasive procedure in which a catheter is inserted through the femoral arteries.
• A stent graft is advanced into the aorta and positioned there so that the aneurysm is excluded from the inside.
• Advantage: significantly smaller incisions, shorter hospital stay (usually 3–5 days), less strain on high-risk patients.
• Disadvantage: Not technically feasible in all cases; regular follow-up CT scans are required.

The procedure for abdominal aortic aneurysm surgery depends heavily on the chosen method and the size of the aneurysm. Depending on the size and location, doctors decide whether the patient will undergo open surgery or if a catheter-based procedure is possible. In some cases, the minimally invasive approach is not possible, so open surgery remains necessary. The procedure is performed at a specialized tertiary care hospital. Whether open or endovascular surgery is performed depends on the size and location of the aneurysm

1. Incision is made in the abdominal cavity at a tertiary care hospital.

2. The affected artery (abdominal aorta) is clamped above and below the aneurysm.

3. The diseased section of the vessel is removed and replaced by suturing in a graft.

4. The vascular graft takes over the function of the aorta and prevents it from rupturing again.

Open surgery is considered particularly reliable, but it is a major surgical procedure.

1. A catheter is advanced into the aorta through the femoral arteries.

2. A stent graft is placed at the affected site and seals off the aneurysm from the inside.

3. This relieves pressure on the vessel wall without requiring the aneurysm to be removed.

4. The procedure is often suitable for high-risk patients or older adults, but—particularly for technical reasons—it is not applicable in all anatomical situations.

Immediately after the surgery, the patient is monitored in the intensive care unit to check blood pressure, heart function, and blood flow to the legs.

• For open surgery, the hospital stay is typically 7–10 days, including a brief stay in the intensive care unit.
• For EVAR, the hospital stay is often only 3–5 days.
• In both cases, post-procedure monitoring in the intensive care unit lasts at least 24 hours.

If an aneurysm is detected early and is found to be approximately 5 cm or larger, doctors often recommend preventive surgery—even before a rupture occurs. In women, surgery is often performed as early as 4.5 cm in diameter, since the risk of rupture is higher than in men, even though women have a lower risk of developing an aneurysm.

In some cases, blood clots are found inside the aneurysm during surgery. These can further impair blood flow and are removed during the procedure or bypassed using a vascular prosthesis.

Like any major surgery, abdominal aortic aneurysm surgery is not without risks. The type of procedure—whether open surgery or endovascular stent graft placement—influences which complications may occur and how high the risk is.

• Bleeding during or after the procedure
• Infections in the incision site or at the implanted vascular prosthesis
• Thrombosis and embolism if blood clots form
• Disruption of bowel or kidney function due to a temporary interruption in blood flow
• Prolonged healing period due to the large surgical incision

• Leaks (endoleaks): Blood continues to flow into the aneurysm
• Displacement or kinking of the stent → repeat procedure required
• Need for regular CT follow-up, as the risk of late complications is higher
• Rare: Infections or injuries to the femoral arteries

• Cardiovascular complications such as heart attack or stroke (especially in high-risk patients)
• Anesthesia risks—depending on age, comorbidities, and overall health
• Swelling or bruising in the surgical area
• Despite all advances: A rupture during or after surgery is possible in rare cases

• The risk of surgery must always be weighed against the risk of a rupture.
• For large or rapidly growing aneurysms, the benefits of preventive surgery outweigh the risks in most cases.
• The decision is made on a case-by-case basis at the hospital by specialized vascular surgeons.

After abdominal aortic aneurysm surgery, careful follow-up care is crucial for detecting complications early and supporting the healing process. Postoperative monitoring lasts at least 24 hours in the intensive care unit. The total hospital stay is 7–14 days for open surgery and 3–5 days for EVAR.

• Immediately after surgery, patients are monitored in the intensive care unit.
• The stay in the intensive care unit usually lasts 1–2 days, depending on the extent of the procedure and the patient’s overall condition.
• In particular, cardiovascular function, kidney function, and blood flow through the vascular prosthesis are monitored.

• After intensive monitoring, patients are transferred to a regular ward.
• The total hospital stay for open surgery is between 7 and 14 days.
• For endovascular stent graft (EVAR) procedures, the hospital stay is usually significantly shorter (3–5 days).
• The goal is gradual mobilization, pain management, and monitoring of wound healing.

• After open surgery, regular ultrasound examinations of the aorta are necessary to check the position and function of the implanted vascular prosthesis.
• After an EVAR, regular CT scans are also required, as endoleaks or stent displacement may occur.
• Patients should consistently manage risk factors such as high blood pressure, smoking, or elevated blood lipid levels to reduce the risk of recurrent vascular problems.

• Depending on the method used, the procedure and hospital stay range from a few days to two weeks.
• A brief period of intensive care monitoring is standard practice to rule out any potential early complications.
• Consistent follow-up care with imaging (ultrasound, CT) is essential, as the risk of late complications can never be completely ruled out.

The prognosis after abdominal aortic aneurysm surgery depends heavily on the initial condition, age, and comorbidities. Although women have a lower risk of developing an aneurysm, their risk of rupture is significantly higher than that of men.

• Men over the age of 65 are most commonly affected, which is why screening programs are particularly recommended for this group.
• Women have a lower risk of developing an abdominal aortic aneurysm; however, the risk of rupture is significantly higher than in men for an aneurysm of the same size.
• Major risk factors include smoking, high blood pressure, diabetes mellitus, atherosclerosis, and a family history of the condition.

• Following a successful surgery, life expectancy can be significantly improved, as the risk of rupture is minimized.
• However, regular follow-up care is crucial for the early detection of complications such as blood clots, prosthetic infections, or endoleaks.
• Most patients can resume normal physical activity after recovery, but should watch for warning signs such as pain or swelling in the abdominal area.

• A healthy diet, exercise, and avoiding nicotine reduce the risk of further vascular diseases.
• Doctors recommend maintaining good control of blood lipid levels and blood pressure over the long term.
• Regular ultrasound or CT scans ensure that the implanted prosthesis or stent remains stable.

• After surgery, the prognosis is generally favorable if follow-up care is consistently followed.
• Men are affected more frequently; women have a higher risk of rupture for aneurysms of the same size.
• A healthy lifestyle and close monitoring are crucial for a stable long-term outcome.

Surgery for an abdominal aortic aneurysm may only be performed by experienced vascular surgeons.

• Treatment should take place at a tertiary care hospital or a university vascular center.
• Approval by the Medical Service of the Health Insurance Funds (MDK) is essential to ensure high-quality care.
• Only these facilities have the necessary resources—such as interdisciplinary collaboration (vascular surgery, radiology, cardiology, anesthesia) and intensive care following the procedure.

• Both open surgery and endovascular aneurysm repair (EVAR) using a stent graft are offered at specialized centers.
• Whether a patient can undergo open surgery or receive minimally invasive treatment depends on the size and location of the aneurysm, as well as individual risk factors.
• In some cases, a catheter-based procedure is not possible—in such cases, the aorta must be surgically exposed and replaced by suturing in a prosthesis.

• After abdominal aortic aneurysm surgery, the hospital stay ranges from a few days (for EVAR) to two weeks (for open surgery), depending on the method used.
• Immediately after surgery, the patient is placed in the intensive care unit for post-operative monitoring to assess circulation, kidney function, and the vascular prosthesis.

How risky is abdominal aortic aneurysm surgery?
Abdominal aortic aneurysm surgery is a major surgical procedure. The risk depends on the diameter and size of the aneurysm, any underlying medical conditions, and the surgical method chosen. In cases of an impending rupture, the surgery is life-saving but carries a higher risk of complications. For elective procedures (preventive surgery), the prognosis is significantly better.

What does “repair of abdominal aortic aneurysm” mean?
The medical term “repair of abdominal aortic aneurysm” describes the surgical treatment of an abdominal aortic aneurysm—either as open surgery or as endovascular repair using a stent graft.

What is the life expectancy after aortic aneurysm surgery?
Life expectancy after abdominal aortic aneurysm surgery depends heavily on the patient’s overall health and regular follow-up care. After successful implantation of a vascular prosthesis or stent graft, many patients can return to a normal life expectancy—provided that risk factors such as atherosclerosis or blood clots are treated.

How long does abdominal aortic surgery take?
The duration depends on the method used:

• Open surgery: about 3–5 hours. In this procedure, the aorta is clamped above and below the aneurysm and replaced with a graft.
• Endovascular therapy (EVAR): usually 1–2 hours, as a stent is inserted minimally invasively via the femoral arteries.

How long is the hospital stay after the procedure?
After open surgery, the hospital stay is usually 7–14 days, including a brief period of intensive care monitoring following the procedure. With EVAR, the stay is shorter—often only 3–5 days.

What happens after an aneurysm surgery?
After surgery, regular follow-up examinations using ultrasound or computed tomography are necessary. Particularly with a stent graft, it is important to check that it is properly positioned and that no leaks (endoleaks) occur. Rest during the first few weeks, a gradual increase in physical activity, and lifestyle changes (e.g., quitting smoking, exercise, healthy diet) are crucial for a stable recovery.

What symptoms indicate an abdominal aortic aneurysm?
Most abdominal aortic aneurysms are asymptomatic and are discovered incidentally during medical examinations. Warning signs may include persistent back pain, abdominal pain, or pain radiating to the flank. A sudden onset of pain accompanied by circulatory collapse indicates a rupture and requires immediate surgery.

How is an abdominal aortic aneurysm diagnosed?
The diagnosis of an abdominal aortic aneurysm is initially made via ultrasound. Computed tomography (CT) or MRI is used for a more precise assessment of the diameter and the vessel wall. These procedures determine whether surgery is necessary or whether close monitoring is sufficient.