Three large RCTs - EVAR1, DREAM and OVER, comparing EVAR with open surgery for AAA - showed significant reductions in perioperative morbidity and mortality with EVAR. Steps for successful EVAR include: Proper case selection, appropriate imaging, planning of procedure, measurement techniques, vascular access, device deployment and endograft surveillance. Anatomic suitability is important for EVAR.

Tortuosity, calcification, stenosis, occlusion or aneurysmal enlargement of iliac arteries can limit device delivery and distal sealing. Vessel length measurement is an essential step and stent-grafts are planned to be of adequate length whilst allowing sufficient overlap of the modular components. IVUS may be a helpful tool for graft selection, deployment and further interrogation during EVAR. EVAR has the advantages of being a minimally invasive technique, reduced major morbidity and mortality and reduced hospitalization stay. EVAR is also an option in ruptured AA.

Limitations of EVAR include: Anatomy of vessels and access vessel morphology being nonconducive, high cost of treatment and deployment accuracy. Endoleaks need to be carefully monitored and managed. Fenestrated endografts, chimney grafts, Nellix endovascular aneurysm sealing system and Cardiatis Multilayer flow modulator are the recent advances in EVAR. Recent triumphs of EVAR - short neck, angulated neck. Unconquered territories - juxta renal, suprarenal and juxta mesenteric aneurysm, exact place of lamination of blood flow and multilayered flow modulator and epigenetics in treating complex abdominal AA. Robotic EVAR would reduce operator, staff and patient radiation and also reduce procedure time with increased success and accuracy.