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Paradigm shifts in abdominal aortic aneurysm management based on vascular registries

Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR.

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Featured

 Abdominal aortic aneurysm: An update

Medical therapy options remain limited and no aneurysm-specific pharmacotherapy is currently available. Recent years have witnessed a significant shift in AAA surgery from open repair to EVAR and expansion of EVAR techniques. General management of cardiovascular risk factors remains key to reducing all-cause mortality for patients with AAA.

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Endovascular Aneurysm Repair (EVAR)

Endovascular aneurysm repair involves inserting a graft within the aneurysm through small groin incisions using X-rays to guide the graft into place. The advantage of this type of repair is that there is no abdominal surgery. This technique is therefore safer than the traditional operation, and you need to spend less time in hospital. A disadvantage is that some patients have to undergo a further operation at a later stage to refine the initial procedure.

NICE Guidelines

Consider aneurysm repair for people with an unruptured abdominal aortic aneurysm (AAA), if it is: symptomatic, asymptomatic, larger than 4.0 cm and has grown by more than 1 cm in 1 year (measured inner-to-inner maximum anterior-posterior aortic diameter on ultrasound), asymptomatic and 5.5 cm or larger (measured inner-to-inner maximum anteriorposterior aortic diameter on ultrasound).

Prevention/detection/management of abdominal aortic aneurysm

Guidelines recommend that patients with infrarenal or juxtarenal AAAs measuring 5.5 cm or larger in diameter should undergo endovascular or open repair to eliminate the risk of rupture (class I indication). Patients with infrarenal or juxtarenal AAAs measuring 4.0 to 5.4 cm in diameter should be monitored by ultrasound or computed tomographic scans every 6 to 12 months to detect expansion (class I indication).

Small Abdominal Aortic Aneurysms: Should We Wait?

The proper management of small abdominal aortic aneurysms (AAAs), namely those under the threshold of 5.5 cm in diameter, has been under investigation for years. Risk of rupture for this group of AAAs is higher than the rest of the population, and specific factors have been associated with increased growth rate of small AAAs.

The Clinical Challenges of Abdominal Aortic Aneurysm: Rapid, Systematic Detection and Outcome-Effective Management

Given equal availability of US and CT, bedside US is the test to obtain in order to answer the question of whether there is an aneurysm. It is nearly 100% sensitive for diagnosing the presence of an AAA, it can be executed in a matter of minutes, and it does not require unstable patients to leave the department.1 While much less accurate than CT in detecting actual rupture, if the patient has the symptoms of rupture and presence of an AAA, this usually is all the information required for the consultant to take the patient to the OR.

When Should an Abdominal Aortic Aneurysm Be Treated?

Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men.

Resources

Physiopedia

Abdominal aortic aneurysms account for three fourths of all aortic aneurysms, and have been reported to occur four times as often as a thoracic aortic aneurysm.