Urška Bregar Boltin1, Jernej Grmek2, Marko Miklič3, Nina Ostaševski Fernandez4,
Matija Kozak5
One Year Patient Follow-Up Results after
Endovascular Abdominal Aortic Aneurysm
Repair at University Medical Centre Ljubljana
ABSTRACT
KEY WORDS: EVAR, endoleaks
BACKGROUNDS. Endovascular abdominal aortic aneurysm repair (EVAR) is commonly
used to treat abdominal aortic aneurysms (AAA). In our department, the outcomes
following EVAR after 30 days, one year and later have been monitored systematically
in all patients since 2023. METHODS. All the patients after EVAR, which were hospitalized
at our department from January 2023 until May 2024, have been included in our analy-
sis. Our aim is to follow the outcomes in patients after EVAR during hospitalization, after
30 days, one year and later. RESULTS. This analysis included 107 patients after EVAR
(elective and urgent) since the first of January 2023, of these 87 were men and 20 were
women (mean age 74.4 ± 5.2). The mean AAA diameter was 58 ± 7 mm. We analysed the
duration of hospitalization in elective and urgent patients (5.6 ± 2.9 days and 16.2 ± 8.2
days, respectively). 50% of patients after EVAR had a haematoma on the puncture site.
69 patients already had CT angiography after EVAR by the end of April 2024; there were
23 endoleaks detected (type 2 in 21 patients, type 1 in one patient and type 3 in one patient).
DISCUSSION. Since January 2023 and up until now, 107 patients have been treated with
EVAR at our centre. The presence of endoleaks type 1, 2 and 3 and other complications
are comparable with the data from other registries.
1 Dr. Urška Bregar Boltin, dr. med., Klinični oddelek za žilne bolezni, Univerzitetni klinični center Ljubljana, Zaloška cesta 7,
1000 Ljubljana; urska.bregar@gmail.com
2 Jernej Grmek, dr. med., Klinični oddelek za žilne bolezni, Univerzitetni klinični center Ljubljana, Zaloška cesta 7,
1000 Ljubljana
3 Marko Miklič, dr. med., Klinični oddelek za žilne bolezni, Univerzitetni klinični center Ljubljana, Zaloška cesta 7,
1000 Ljubljana
4 Nina Ostaševski Fernandez, dr. med., Klinični oddelek za žilne bolezni, Univerzitetni klinični center Ljubljana,
Zaloška cesta 7, 1000 Ljubljana
5 Prof. dr. Matija Kozak, dr. med., Klinični oddelek za žilne bolezni, Univerzitetni klinični center Ljubljana, Zaloška
cesta 7, 1000 Ljubljana; Katedra za inteno medicino, Medicinska fakulteta, Univerza v Ljubljani, Zaloška cesta 7,
1000 Ljubljana
5Med Razgl. 2024; 63 Suppl 2: 5–10 • doi: 10.61300/anga11
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6 One Year Patient Follow-Up Results after Endovascular Abdominal Aortic Aneurysm Repair at …
BACKGROUNDS
Endovascular abdominal aortic aneurysm
repair (EVAR) has become a key treatment
option for patients with an abdominal aor-
tic aneurysm (AAA) and at our centre it is
offered to patients eligible for EVAR accor-
ding to the guidelines of the European
Society for Vascular Surgery (ESVS) (1). It
is the preferred option since both short and
mid-term outcomes are as good as or be-
tter than open surgical repair, but mid- and
long-term complications such as endoleaks,
graft infection, graft migration, graft
obstruction or post-EVAR rupture can lead
to endovascular reintervention or conver-
sion to open surgical repair (1, 2).
The University Medical Centre (UMC)
Ljubljana is a high-volume centre, and the
majority of procedures nationwide are per-
formed here. The outcomes in patients
that have been treated with EVAR will be
compared with data from other studies
and registries, which will allow us to eva-
luate the quality and possible deficiencies
of this treatment at our centre. Data on early
and late complications, post-operative com-
puter tomography angiography (CTA) or
ultrasound and follow-up after 30 days, one
year and later are collected.
METHODS
Our data was collected on an observation-
al, non-randomised, prospective »all comer«
basis. All patients, who underwent EVAR
and were hospitalized at our department,
were included. Information on AAA dia-
meter, duration of hospitalization, early
complications during the procedures and
during hospitalization (haematoma, other
early complications), outcomes after 30 days,
one year and later (endoleaks, aneurysm sac
growth, infections, ruptures, other adverse
events, death) were collected and analysed.
Our follow-up included a CTA and a cli-
nical examination after EVAR at recom-
mended intervals. All patients after EVAR
were included, be it elective or urgent, but
there were no patients with a ruptured
AAA.
RESULTS
From January 2023 until May 2024, a total
of 107 patients underwent EVAR and were
admitted before the procedure and hospi-
talized at our department, of that 87 were
men (82%) and 20 were women (18%). The
average patient age was 74.4 ± 5.2 years. 96
operations were elective and 11 patients
required urgent EVAR due to a symptomatic
AAA (90% versus 10%). There were no
patients with ruptured AAAs after EVAR
since they were admitted to other depart-
ments. The AAA diameter was 58 ± 7 mm;
56±6mm in elective patients, and 70±14mm
in urgent patients. AAA diameter advanced
with patient age (figure 1). The hospital-
ization duration was different for elective
and urgent patients; 5.6 ± 2.9 days (me-
dian 4 days) for elective patients, and
16.2 ± 8.2 days (median 16 days) for urgent
patients. 50% of patients had a haematoma
on the puncture site, but only one patient
required surgical revision of the pseudo-
aneurysm. In the first 30 days after EVAR,
two patients returned because of compli-
cations on puncture sites – the first patient
was re-admitted due to bleeding from the
wound after EVAR and required addition-
al procedures; the second patient needed
additional procedures and antibiotic treat-
ment due to an infection of the puncture
site.
Patients with a detected type 1 endoleak
(1 patient) and type 3 endoleak (1 patient)
at procedure were treated immediately
during the procedures.
One patient was re-admitted after one
week due to a type B aortic dissection, which
was managed conservatively. One patient
was admitted after a couple of months
due to graft aortitis and was treated with
long-term antibiotics. One patient died six
months after the procedure, her death was
not aneurysm-related.
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So far, 69 patients have had the first
CTA after EVAR at intervals, recommend-
ed by an interventional radiologist or a spe-
cialist of vascular medicine (one to six
months after EVAR). A type 2 endoleak was
detected in 21 patients (31%) with a stable
aneurysm sac or detected aneurysm growth
(three patients), one of them was already
referred for the embolization of lumbal
arteries, others will all be closely monitored.
Two patients with a detected type 1 and type
3 endoleak on follow-up CTA had addition-
al procedures. Patient characteristic, hos-
pitalization duration and outcomes are
presented in table 1.
DISCUSSION
The one-year follow-up of patients after
EVAR has shown promising outcomes
regarding early complications, the presence
of endoleaks and aneurysm-related deaths
in comparison with data from other reg-
istries (2, 3).
7Med Razgl. 2024; 63 Suppl 2:
There were no patients included with
ruptured AAAs, 10% patients with AAA
were admitted due to symptoms (stomach
or back pain), which could not be attributed
to other causes. The management and hos-
pitalization of these patients were longer
than for elective patients, as they needed
more diagnostics and had to wait for the
procedure in the hospital. Elective patients
were admitted one day before the planned
procedure. AAA diameter in urgent patients
was larger compared to elective patients.
In literature, there is not much data com-
paring outcomes after EVAR in elective and
urgent patients without a ruptured AAA.
This distinction is taken in consideration
mainly due to analysis purposes.
The most frequent complication during
hospitalization is a haematoma on the
puncture site, which can be managed con-
servatively in most cases. Only one patient
needed a surgical revision of the pseudo-
aneurysm. Two patients were re-admitted
0
10
20
30
40
40
45
50
50
55
60
60
65
70
70
75
up to 69 70 – 79 80 – 89 > 90
Average AAA diameterAge of patients
N
u
m
b
e
r 
o
f 
p
a
ti
e
n
ts
D
ia
m
e
te
r
m
m
(
)
Distribution by decades
Figure 1. Comparison of abdominal aortic aneurysm (AAA) diameter and patient age.
Angioloski 2024_Mr10_2.qxd  19.9.2024  8:46  Page 7
in the first 30 days after EVAR due to
either bleeding or wound infection (1.8%).
In general, local wound complications
include groin hematoma, infection, or lym-
phocele, the incidence is 1 to 10%. Arterial
thrombosis, dissection, or pseudoaneurysm
formation can occur in up to 3% of EVAR
procedures (4). Half of our patients had
a haematoma on the puncture site, but we
included all haematoma with a diameter of
over 5 cm and which do not necessarily
require further management.
One patient was re-admitted after one
week due to a type B aortic dissection, which
8 One Year Patient Follow-Up Results after Endovascular Abdominal Aortic Aneurysm Repair at …
Table 1. Patient characteristics, duration of hospitalization and outcomes. EVAR – endovascular abdominal
aortic aneurysm repair, SD – standard deviation, CTA – computer tomography angiography.
Characteristic
Age 74.4 ± 5.2
Sex
male 87 (81%)
female 20 (18%)
All EVAR 107
electivež 96 (90%)
urgent 11 (10%)
Diameter of aneurysm 58 ± 7 mm
elective 56 ± 6 mm
urgent 70 ± 14 mm
Duration of hospitalization
mean value and SD 6.7 ± 4.2 days
median 4 days
min 2 days
max 36 days
Duration of hospitalization – elective
mean value and SD 5.6 ± 2.9 days
median 4 days
Duration of hospitalization – urgent
mean value and SD 16.2 ± 8.2 days
median 16 days
Presence of hematoma
no hematoma 54 (50%)
hematoma 53 (50%)
With control CTA scan 69
no enodoleak 46 (67%)
endoleak type 1 1
endoleak type 2 21 (31%)
endoleak type 3 1
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was a complication of EVAR – a rare but seri-
ous adverse event. There have only been few
reports of similar events in literature (5).
Most cases of type B dissections are uncom-
plicated and can be managed by medical
therapy, including antihypertensive drugs,
which was the case with our patient as well.
One patient was admitted after a cou-
ple of months due to graft aortitis, which
has so far been managed conservatively
with antibiotics. Due to the patient’s age
and psychophysical condition, new invasive
therapies or reinterventions are not re-
commended. EVAR infections show high
mortality rates for every kind of treatment
employed, as patients unsuitable for major
surgery experience the same chance of
survival as patients submitted to an endo-
graft explant (6).
In our cohort study, endoleaks were pre-
sent either at procedure or on the first fol-
low-up CTA. Reinterventions were ne-
cessary for type 1 and type 3 endoleaks,
patients with type 2 endoleaks are currently
under surveillance. Type 2 endoleaks are
most common and the early incidence is
usually reported to be around 25%, but most
resolve spontaneously during the first six
months. Up to 10% of type 2 endoleaks per-
sist and they may cause aneurysm growth,
in which case, treatment should be consider-
ed (7). In our cohort, type 2 endoleaks are
present in 31% of patients. In one patient,
the embolization of lumbal arteries was
already performed, other patients with
a type 2 endoleak and aneurysm sac growth
will be closely monitored.
Limitations
Registries, by nature, are observational
and are not designed in the same manner
as a randomized control trial would be.
Maintaining adherence to follow up in
patient registries is more challenging than
in a trial. Data is collected in real life and
although the compliance with follow up has
been excellent (almost 100%) so far, we
expect a drop in the following years. 
CONCLUSIONS
The outcomes of the one-year follow-up on
patients after EVAR at the UMC Ljubljana
have been positive so far. There has been
no rupture or aneurysm-related deaths
and patients with a type 2 endoleak will be
monitored further. Longer term follow up
is necessary for the assessment and com-
parison of the outcomes in our patients
against existing data from other registries
and trials.
9Med Razgl. 2024; 63 Suppl 2:
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REFERENCES
1. Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. Editor’s choice — European Society for Vascular Surgery
(ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J
Vasc Endovasc Surg. 2024; 67 (2): 192–331. doi: 10.1016/j.ejvs.2023.11.002
2. Teijink JAW, Power AH, Böckler D, et al. Editor’s choice – five year outcomes of the endurant stent graft for
endovascular abdominal aortic aneurysm repair in the ENGAGE Registry. Eur J Vasc Endovasc Surg. 2019; 58
(2): 175–81. doi: 10.1016/j.ejvs.2019.01.008 
3. Malas MB, Freischlag JA. Interpretation of the results of OVER in the context of EVAR trial, DREAM, and the
EUROSTAR registry. Semin Vasc Surg. 2010; 23 (3): 165–9. doi: 10.1053/j.semvascsurg.2010.05.009
4. Maleux G, Koolen M, Heye S. Complications after endovascular aneurysm repair. Semin Intervent Radiol. 2009;
26 (1): 3–9. doi: 10.1055/s-0029-1208377
5. Khanbhai M, Ghosh J, Ashleigh R, et al. Type B aortic dissection after standard endovascular repair of abdominal
aortic aneurysm. BMJ Case Rep. 2013; 2013: bcr2012007209. doi: 10.1136/bcr-2012-007209
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