Deciding whether to have surgery

Whether surgery is a good idea, and when it should be done, depend on two questions:

  • How high is the risk that the aneurysm will suddenly rupture within the next few years?
  • What risks does preventive surgery involve?

Risk of a sudden rupture

A rupture is a life-threatening medical emergency that requires immediate surgery at the hospital. About half of all men who have a sudden rupture die shortly afterwards. These are the main factors that make a rupture more likely:

  • The aneurysm is larger than 5.5 cm (2.16 inches) in diameter.
  • The aneurysm has grown quickly: more than 0.5 cm (about 0.2 inches) in six months or more than 1 cm (about 0.4 inches) in one year.
  • The aneurysm is causing symptoms such as pain in the back, stomach, or sides.

Risks of preventive surgery

Surgery on an aneurysm can lead to serious complications, especially lung complications and damage to the heart. The implanted piece of artificial blood vessel may become infected. The surgery may even lead to death, for example due to circulatory collapse. The risk of complications is determined by various factors. One of these is the patient’s general health. For instance, the surgery is riskier for people who have cardiovascular disease. Sometimes further surgery is needed shortly after surgery or at a later date.

Because of this, doctors estimate the patient’s risk of complications. Reasons not to have preventive surgery include the following:

  • The person has other serious conditions, such as heart disease.
  • Their general health is so poor that a procedure seems to be too risky, for example due to old age and associated problems.

Surgery is considered if the risk of the aneurysm unexpectedly rupturing in the next few years seems to outweigh the risks associated with the surgery.

What surgical techniques are used?

Two techniques can be used to operate on an aneurysm:

  • Open surgery through an abdominal incision (cut)
  • Endovascular surgery through a small cut in the groin
Illustration: Surgical techniques for abdominal aortic aneurysm

In Germany, about 20 out of 100 patients have open surgery and 80 out of 100 have endovascular surgery.

Open surgery

In open surgery, the aneurysm is removed and replaced with an artificial blood vessel (tube made of a synthetic material).

This is done under general anesthesia. First, a cut is made in the abdominal wall. The doctors interrupt the flow of blood in the aorta by clamping it above and below the aneurysm. They cut the aneurysm open and implant the artificial artery (graft) there. It is sewn into place. Then the doctors wrap the vessel wall of the opened aneurysm around the graft and it together tightly. After that, the clamps are removed and the blood is allowed to flow again.

Illustration: Open surgery: The aneurysm is replaced with an artificial vessel (graft)

The procedure lasts about three hours. After surgery, patients are taken to the intensive care unit and stay at the hospital for an average of 11 to 14 days. But it can take several weeks or months until you are ready to get back to your normal everyday life.

Open surgery is often not suitable for people who also have other serious medical conditions, for instance affecting the cardiovascular system, the airways or the kidneys. The procedure is too risky then. Check-ups are scheduled after surgery.

Endovascular surgery

In endovascular surgery, a thin is inserted into the femoral artery through a small cut in the groin. The is guided through this artery to the aneurysm so that the stent graft can be implanted there. The stent graft is made of metal mesh with a synthetic coating. Once the aneurysm is reached, the stent graft is expanded using a balloon at the tip of the and then attached to the aorta. The is then pulled out. The blood flows through the stent. This puts less pressure on the vessel wall, lowering the risk of the aneurysm getting bigger or rupturing.

Illustration: Endovascular surgery with stent graft

This procedure can be done using general, regional or local anesthesia. Patients stay at the hospital for an average of 6 to 8 days afterwards. It can take several weeks to recover fully.

After the operation, the stent graft is checked to make sure that it is in the right position, doesn't leak and is not bent. Life-long check-ups are recommended: the first is scheduled one month later, and after that they take place every 3 to 6 months, and every 12 months starting the second year after surgery. The check-ups often involve radiation because (CT) is used to check the stent graft.

Endovascular surgery isn’t always possible. It depends on certain characteristics of the aorta and where exactly the other blood vessels branch off. A suitable stent graft has to be available too. Although endovascular surgery is less invasive than open surgery, it doesn’t offer any improved chances of survival over the long term. Compared to open surgery, it is also more likely to be followed by further surgery and more check-ups. The type of surgery you choose will also depend on what you yourself think of the advantages and disadvantages of both techniques.

Endovascular surgery for people in poor health

Endovascular surgery is mainly considered for older men if the risks of open surgery are too great – for instance, because they have a serious heart, lung or kidney disease. But endovascular surgery can also cause unnecessary stress in this group of patients. One study involving men whose health didn't allow for open surgery suggests that they don't benefit from endovascular surgery. The same number of men had died within four years, regardless of whether they had endovascular surgery or chose not to have any surgery.

What are the possible complications?

Both open surgery and endovascular surgery can lead to serious complications. Some people also die as a result of this surgery. The risk of dying within 30 days of surgery is higher in people who have open surgery than it is in people who have endovascular surgery. Over the long term, though, the risk of dying is the same regardless of which type of surgery people have.

Surgery can also cause other complications, such as a stroke or lung problems. It may damage the heart muscle or affect the functioning of the kidneys. Sexuality may also be temporarily affected after surgery.

Compared to endovascular surgery, open surgery is typically associated with more blood loss. It also leaves behind a larger scar. Sometimes an incisional hernia develops near the surgical scar and further surgery is needed. Further surgery – usually a smaller procedure using a – may also be needed for other reasons. For example, the artificial artery (graft) may become closed off following open surgery.

And after endovascular surgery, the stent graft may slip or leak. Additional surgery may also be needed if it wasn’t possible to position the stent graft properly. Or if the femoral artery was injured while the was guided along it. Compared to people who have open surgery, people who have endovascular surgery are more likely to need further surgery.

Abdominal aortic aneurysms are more common in men than in women. For this reason, most studies are on the treatment of men only. So the information in the following table applies to men (in overall good health). The table shows the differences between the two types of surgery, and how common the possible complications are.

Table: Comparison of open surgery and endovascular surgery in men with an abdominal aortic aneurysm
  Open surgery Endovascular surgery
Who are these procedures considered for?
  • People in relatively good health
  • People with an abdominal aorta that has certain characteristics
  • The right stent graft must be available
30 days after the surgery: How many men had died? About 4 out of 100 About 1 out of 100
Four years after the surgery: How many men had died?
There was no longer any difference four years after the surgery. In both groups, around 10 out of 100 people had died.
How many men had another surgical procedure?
About 7 out of 100 About 16 out of 100
Several years after the surgery: How many men had lung complications? About 8 out of 100 About 3 out of 100
How many men had kidney complications? About 1 out of 100 About 1 out of 100
How many men had a stroke and survived?
About 3 out of 100 About 3 out of 100

AlOthman O, Bobat S. Comparison of the Short and Long-Term Outcomes of Endovascular Repair and Open Surgical Repair in the Treatment of Unruptured Abdominal Aortic Aneurysms: Meta-Analysis and Systematic Review. Cureus 2020; 12(8): e9683.

Antoniou GA, Antoniou SA, Torella F. Editor's Choice - Endovascular vs. Open Repair for Abdominal Aortic Aneurysm: Systematic Review and Meta-analysis of Updated Peri-operative and Long Term Data of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2020; 59(3): 385-397.

Deutsche Gesellschaft für Gefäßchirurgie (vaskuläre und endovaskuläre Chirurgie) (DGG). S3-Leitlinie zu Screening, Diagnostik, Therapie und Nachsorge des Bauchaortenaneurysmas. AWMF-Registernr.: 004-014l. 2018.

Kent KC. Abdominal Aortic Aneurysms. N Engl J Med 2014; 371(22): 2101-2218.

Paravastu SC, Jayarajasingam R, Cottam R et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev 2014; (1): CD004178.

Parkinson F, Ferguson S, Lewis P et al. Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair. J Vasc Surg 2015; 61(6): 1606-1612.

Schmitz-Rixen T, Steffen M, Böckler D et al. Versorgung des abdominellen Aortenaneurysmas (AAA) 2019. Registerbericht des DIGG der DGG. Gefäßchirurgie 2021; 26: 41-48.

Ulug P, Powell JT, Martinez MA et al. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database Syst Rev 2020; (7): CD001835.

Yokoyama Y, Kuno T, Takagi H. Meta-analysis of phase-specific survival after elective endovascular versus surgical repair of abdominal aortic aneurysm from randomized controlled trials and propensity score-matched studies. J Vasc Surg 2020; 72(4): 1464-1472.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Updated on October 6, 2021

Next planned update: 2024


Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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