Management of Asymptomatic Abdominal Aortic Aneurysm - UpToDate

8/1/2017
ManagementofasymptomaticabdominalaorticaneurysmUpToDate
OfficialreprintfromUpToDate
www.uptodate.com2017UpToDate
Managementofasymptomaticabdominalaorticaneurysm
Authors: RonaldLDalman,MD,MatthewMell,MD,FACS
SectionEditors: JosephLMills,Sr,MD,JohnFEidt,MD,EmileRMohlerIII,MD,DenisLClement,MD,PhD
DeputyEditor: KathrynACollins,MD,PhD,FACS
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2016.|Thistopiclastupdated:Nov10,2016.
INTRODUCTIONAbdominalaorticaneurysm(AAA)isacommonandpotentiallylifethreateningcondition.
Withoutrepair,rupturedAAAisnearlyuniformlyfatal.Ofthe50percentofpatientswithrupturedAAAwho
reachthehospitalfortreatment,between30and50percentwilldieinthehospital[1,2].
Forasymptomaticpatients,electiverepairoftheaneurysmisthemosteffectivemanagementtoprevent
rupture.However,electiveaorticsurgeryisalsoassociatedwithrisks,andthus,electiveAAArepairisnot
recommendeduntiltheriskofruptureexceedstherisksassociatedwithrepair.Forasymptomaticpatients,
theriskofAAArupturegenerallyexceedstheriskassociatedwithelectiveAAArepairwhenaneurysm
diameterexceeds5.5cm[3,4].Otherfactorssuchasthepatient'sage,rateofaneurysmexpansion,andthe
presenceofcoexistentperipheralarterydiseaseorperipheralaneurysmarealsoimportanttoconsiderwhen
determiningwhentoproceedwithelectiveAAArepair.
ForpatientswithasymptomaticAAAwhodonothaveindicationsforelectiverepair,medicaltreatmentis
aimedatreducingcardiovascularriskintheeventthatAAArepairisneeded,andlimitingtherateofaortic
expansion.WhenelectiveAAArepairisindicated,thechoicebetweenopenandendovascularAAArepair
remainsdebated.AlthoughelectiveendovascularAAArepairisassociatedwithlowerratesofperioperative
(30day)morbidityandmortalitycomparedwithelectiveopenrepair(<2versusapproximately5percent),
longtermoutcomesaresimilar[5].
ThemanagementofthepatientwithasymptomaticAAAwillbereviewedhere.Theclinicalfeaturesand
issuesrelatedtodiagnosisandscreening,managementofsymptomatic(nonruptured)andrupturedAAA,
anddetailsofsurgicalandendovascularrepairarediscussedelsewhere.(See"Screeningforabdominal
aorticaneurysm"and"Epidemiology,riskfactors,pathogenesisandnaturalhistoryofabdominalaortic
aneurysm"and"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm"and"Managementof
symptomatic(nonruptured)andrupturedabdominalaorticaneurysm"and"Endovascularrepairofabdominal
aorticaneurysm"and"Opensurgicalrepairofabdominalaorticaneurysm"and"Surgicalandendovascular
repairofrupturedabdominalaorticaneurysm".)
ANEURYSMTERMINOLOGY
AneurysmdefinitionAnabdominalaortawithamaximaldiameter>3.0cmisconsideredaneurysmalin
mostadultpatients[3,4,6].Abdominalaorticaneurysm(AAA)mostoftenaffectsthesegmentofaorta
betweentherenalandinferiormesentericarteries(infrarenal)(figure1)approximately5percentinvolvethe
renal(pararenal)(image1)orvisceralarteries(suprarenal)[7].(See"Clinicalfeaturesanddiagnosisof
abdominalaorticaneurysm",sectionon'Aneurysmdefinitionandanatomy'.)
Forthepurposesofthisdiscussion:
Smallaneurysmshaveadiameter<4.0cm
Mediumaneurysmshaveadiameterbetween4.0and5.5cm
Largeaneurysmshaveadiameter5.5cm
Verylargeaneurysmshaveadiameter6.0cm
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Rapidexpansion,whichisthoughttoincreasetheriskforrupture,isdefinedasanincreaseinmaximalaortic
diameter5mmoverasixmonthperiodoftimeor>10mmoverayear,usingthesameradiographicmethod
ofmeasurement[4].(See"Epidemiology,riskfactors,pathogenesisandnaturalhistoryofabdominalaortic
aneurysm",sectionon'ExpansionandruptureofAAA'.)
ClinicalpresentationsMostAAAsdonotproduceanysymptoms.AnoccultAAAmaybediscoveredasa
resultofscreening,onroutinephysicalexamination,oronimagingstudiesobtainedtoevaluateanunrelated
condition.SymptomaticAAAreferstoanyofanumberofsymptoms(eg,abdominalpain,limbischemia)that
canbeattributedtotheaneurysm.SymptomsassociatedwithAAAmayormaynotbeduetoAAArupture.
TheclinicalfeaturesanddiagnosisofAAA,andthemanagementofsymptomatic(nonruptured)andruptured
AAAarediscussedindetailelsewhere.(See"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm"
and"Managementofsymptomatic(nonruptured)andrupturedabdominalaorticaneurysm",sectionon'Initial
management'.)
ANEURYSMREPAIRVERSUSCONSERVATIVEMANAGEMENTElectiveabdominalaorticaneurysm
(AAA)repairisthemosteffectivemanagementtopreventrupture.However,electiveaorticsurgeryis
associatedwithrisks,andthus,electiveAAArepairisnotrecommendeduntiltheriskofruptureexceedsthe
risksassociatedwithrepair(anestheticrisk,techniquerelatedrisks)[5].Forasymptomaticpatients,
randomizedtrialscomparingobservationwithopenorendovascularAAArepairhavefoundthattheriskof
AAArupturegenerallydoesnotexceedtheriskassociatedwithelectiveAAArepairuntilaneurysmdiameter
exceeds5.5cm[812].WeagreewithguidelinesfromtheSocietyforVascularSurgerythatrecommend
observationforasymptomaticAAA<5.5cmindiameterbaseduponthesetrials[5].(See'Aneurysmdiameter
andrupturerisk'below.)
ThetimingofAAArepairmaybeaffectedbyotherfactorssuchasthepresenceofcoexistentperipheral
arterydiseaseorperipheralaneurysm(eg,iliacaneurysm,femoralaneurysm)andotherfactorsthatincrease
theriskofrupture,includingadvancedageandrapidaneurysmexpansion.(See'Otherconsiderations'
below.)
AlthoughrepairmaynotbewarrantedinpatientswithAAAdiameter<5.5cm,thesepatientsremainatriskfor
aneurysmexpansion.Assuch,managementconsistsofongoingclinicalevaluationandAAAsurveillance,and
riskmodification.(See'Conservativemanagement'below.)
AneurysmdiameterandruptureriskAneurysmdiameteristhestrongestpredictorofaneurysmrupture,
withriskincreasingmarkedlyataneurysmdiametersgreaterthan5.5cm(figure2)[8,1320].Sinceitis
uncommonforAAAssmallerthan5cmtorupture,manyvascularsurgeonsadoptedthismeasurementasan
indicationforelectiverepair[21,22].Asanexample,inonesystematicreviewthatincluded21studiesof
patientswithAAAalsoreportingAAAoutcomes,37of2323(1.6percent)withsmallAAAwentontorupture
[23].
Largeraneurysmdiameterandfasterrateofaneurysmexpansioncorrelatetoanincreasedlikelihoodof
symptomsandcomplications.Ruptureisthemostfearedcomplication,andisassociatedwithhighmorbidity
andmortality.OtherrarecomplicationsofAAAincludeaneurysmthrombosisandthromboembolism,which
canleadtoacutelimbischemia.(See"Managementofsymptomatic(nonruptured)andrupturedabdominal
aorticaneurysm"and"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm",sectionon'Risk
factors'.)
RandomizedtrialsBaseduponobservationalstudiesofthenaturalhistoryofAAAshowingthatitwas
uncommonforasymptomaticAAAsmallerthan5cmtorupture,thiswasthetraditionalthresholdabovewhich
openaneurysmrepairwasperformed[22,24].Whetherthisrepresentedoptimalmanagementwasaddressed
inrandomizedtrialscomparinganeurysmrepairwithnonoperativemanagementplussurveillanceimagingfor
mediumsizedaneurysms(4.0to5.5cm),withtwotrialsusingopenAAArepair[8,9],andthreelatertrials
usingendovascularaneurysmrepair[1012,25,26].Independentmetaanalysesofthesetrialshavefoundno
advantagetoearlyrepair(openorendovascular)forAAAmeasuring4.0to5.5cm[27].
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ObservationversusopenrepairIntheUnitedKingdom(UK)SmallAneurysmand(US)Aneurysm
DetectionandManagement(ADAM)trials,whichwerepredominantlycomposedofmen,theriskofdeathdue
toruptureduringtheperiodofsurveillanceofmediumsized(4.0to4.4cm)AAAwaslowerthantheriskof
deathfromopenAAArepair[8,9].Alateranalysispooledresultsfrombothtrialsandfoundnodifferencesin
survivalbetweenimmediateopenrepairandsurveillance(2.6to8yearfollowup)foranydiameterinthe
rangeof4to5.5cm,formenorwomen,orforanyage[28].Asubsequentmetaanalysisin2007ofthese
trialsfoundnosignificantdifferencesinallcausemortalitybetweenthegroupsatfivetoeightyearsfollowup
[29].
Theimportantpointsofthesetrialsaresummarized:
UKSmallAneurysmtrialTheUKSmallAneurysmtrialrandomlyassigned1090patients(83percent
men)withasymptomaticAAAwithadiameterof4.0to5.5cmtoelectivesurgeryorobservationwith
ultrasoundsurveillanceeverysixmonths[8,30].Opensurgicalrepairwasperformediftheaneurysm
diameterexceeded5.5cm,expandedmorethan10mminayear,orbecametenderorsymptomatic.
Thetwogroupshadsimilarcardiovascularriskfactorsatbaseline.Afterameanfollowupofeightyears,
thefollowingfindingswerenoted:
Aninitialsurvivaladvantagewasapparentforpatientsintheobservationgroupbecauseofa30day
operativemortalityof5.4percent.However,ateightyearsfollowup,mortalitywassignificantlylower
forpatientswhounderwentelectivesurgery(43versus48percent).Equipoisebetweenthe
therapieswasachievedatapproximatelyfiveyears(figure3)(thepointatwhichtheareaunderthe
survivalcurveisequal).
Themeandurationofsurvivalwasthesameinthetwogroups(6.7versus6.5years)sinceearly
mortalitywasoffsetbyimprovedlatesurvivalinthegroupthatunderwentsurgery.Theauthors
ascribetheimprovedlatesurvivalinthesurgerygrouptobeneficialchangesinlifestyle,particularly
smokingcessation,whichwasmorefrequentinthisgroup.
Duringfollowupofthesurveillancegroup,themediananeurysmgrowthratewas3.3mmperyear
andthemeanriskofaneurysmrupturewas1.6percentperyearduringtheinitialfollowupperiod,
butincreasedto3.2percentperyearduringthelastthreeyearsoffollowup,asexpected,sincethe
aneurysmsundersurveillancewerelargerduringthislatertimeperiod.
TheriskofAAArupturewasfourtimeshigherinwomencomparedwithmen(hazardratio[HR]4.0,
95%CI2.07.9).Theincidenceoffatalrupturewasalsosignificantlygreaterforwomencompared
withmen(19versus14percent).(See'Femalegender'below.)
ADAMtrialTheAneurysmDetectionandManagement(ADAM)Trialrandomlyassigned1136patients
(over99percentmale),aged50to79yearswithAAAdiameterbetween4.0to5.4cmtoopenaneurysm
repairorsurveillance[9].Electivesurgerywasperformedwhentheaneurysmexpandedto>5.5cmor
becamesymptomatic.Operativemortalityinthistrialwas2.7percent.After4.9yearsoffollowup,there
werenodifferencesinmortality(25versus21.5percent)oraneurysmrelateddeath(3versus2.6
percent)betweenthesurgeryandsurveillancegroups.Inthesurveillancearm,62percentofthepatients
eventuallyrequiredsurgery.AAAruptureoccurredin1.9percent(0.6percentperyear).
ObservationversusendovascularrepairTheUKSmallAneurysmTrialandtheADAMtrialwere
performedpriortothewidespreaduseofendovascularaneurysmrepair(EVAR).TwotrialscomparingEVAR
toobservationforAAA<5.5cmsimilarlyfoundnosignificantlongtermdifferencesbetweenAAArepairand
nonoperativemanagement,andthesestudieslendfurthersupporttothe5.5cmthresholdestablishedfrom
earlierrandomizedtrials[10,11,25,26].InspiteofthelowerperioperativemortalityrateassociatedwithEVAR,
thereappearstobenoadvantagetoelectiveEVARrepairforsmallandmediumsizedaneurysms.
OtherconsiderationsAdecisionforelectiverepairofasymptomaticAAAreliesprimarilyondetermining
ruptureriskbaseduponaneurysmdiameter>5.5cm.However,thediameterthresholdforrepairisnot
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absolute.DecidingwhentoperformelectiveAAArepairshouldalsotakeintoaccountthenaturalhistoryof
AAAandfactorsthatincreasetheriskforaneurysmexpansionorrupturesuchasadvancedage,female
gender,andongoingsmoking,aswellasexpansionrates.TimingofAAArepairmayalsobeaffectedby
coexistentvasculardiseaseorotherperipheralarteryaneurysms.TheriskfactorsassociatedwithAAA
expansionandrupturearediscussedindetailelsewhere.(See"Epidemiology,riskfactors,pathogenesisand
naturalhistoryofabdominalaorticaneurysm",sectionon'ExpansionandruptureofAAA'.)
Somestudieshavealsoidentifieddisparitiesinruptureratesbaseduponinsurancestatus[31,32].Differences
aremultifactorial,butcanbeexplainedinpartbylowersurveillanceratesforpatientswithknownAAAfor
patientseligibleforMedicaidinsurance.Thisfindinghighlightstheneedforandvalueofsurveillanceforall
patientswithAAAthatdoesnotmeetcriteriaforoperativerepair,preferablyusingastandardizedprotocol.
(See'Aneurysmsurveillance'below.)
FemalegenderTherandomizedtrialsdiscussedabovewerecomprisedpredominatelyofmen.For
women,alowerthresholdof5cmmaybejustifiedforelectiverepairofasymptomaticAAAduetothehigher
rateofruptureinwomencomparedwithmenforAAAofthesamediameter[8,33].Inanobservationalstudy,
theaorticsizeindex(ASI=aneurysmdiameter[cm]/bodysurfacearea[m2])wasmorepredictiveofrupture
forwomenratherthanaorticdiameteralone[34].However,becausetheriskofdeathfromelectiverepairis
alsoincreasedinwomen,inpartrelatedtoalaterageatpresentation,itcanbearguedthatthethresholdfor
repairforwomenshouldbethesameasformen,at5.5cm[3537].Womenathighriskformortalitywith
AAArepairaremorelikelytodiefromearlyinterventionthanfromrupture.Supportforthisviewcomesfroma
followupstudythatcomparedsurvivaldifferencesbetweenthosewithAAA4.0to5.4cmundergoing
immediateopenrepairversussurveillanceamongparticipantsoftheUKSmallAneurysmTrialandtheADAM
trials(n=2226)[38].Survivalwassimilarforbothwomenandmenindependentoftreatment(openrepairor
surveillance).Survivalforwomenwasalsosimilarforrelativelylarger(5.0to5.4cm)versussmaller(<4.0to5
cm)aneurysms.
Conversely,womenatlowriskformortalitywithrepairappeartohavealoweroverallriskofAAArelated
deathfollowingrepairwhentheaneurysmreachesorexceeds5cm.Areasonablecompromisemaybeto
offerAAArepairtowomenwhoareatlowoperativeriskatthelowerthresholdof5.0cm,whileusingthe
typicalthresholdforwomenwhohaveahigheroperativerisk.
PatientageYoungerpatientswithAAAwithalonglifeexpectancywilllikelyrequirerepairatsome
pointintheirlives[8].Thelikelihoodofreceivingsurgeryatsomepointinthefutureformediumsized
aneurysms(4.0to5.5cm),is50percentatthreeyears,60to65percentatfiveyears,and70to75percent
ateightyears(figure4)[8,9,29,30,39].
Amongolderpatients,endovascularrepairisassociatedwithanearlysurvivaladvantagethatgradually
decreasesovertime.OverallfiveyearsurvivalfollowingAAArepairwas69percentinonesystematicreview,
withagecorrelatingwithworsesurvival[40].Apropensityscorematchedcohortstudyinvolving39,966
matchedpairsofUnitedStatesMedicarebeneficiaries(>65yearsofage)foundnosignificantlongterm
survivaladvantageforendovascularrepaireventhoughperioperative(30day)mortalitywassignificantly
lowerforendovascularcomparedwithopenrepair(1.6versus5.2percent)[41].Thesurvivaladvantagefor
EVARlastedonlythroughthefirstthreeyearsoffollowup.
AlthoughsmallcaseserieshavedocumentedacceptableoutcomesforEVARincarefullyselected
octogenariansandnonagenarians[4246],continuedobservationmaybewarrantedforAAAthatexceeds5.5
cminolderpatients,particularlyamongthosewhoarefrailforwhomalongtermbenefitisunlikely[47].
Thosewithmedicalcomorbiditiesoftendiefromassociatedillnesses.(See'Counselingthehighriskpatient'
below.)
RapidexpansionEarlierrepairmaybenefitpatientswithwelldocumentedrapidaneurysmexpansion
(>5mminsixmonthsor10mmperyear)onserialimagingstudiesperformedbythesamemodality[8].
SomedatasuggestthatrapidlyexpandingAAAsaremorelikelytohavesymptomsandhaveahigherriskof
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rupture.Rapidexpansionmayrepresentinstabilityoftheaorticwallandmaybeasignofimpendingaortic
rupture.(See"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm",sectionon'Riskfactors'.)
CoexistentaneurysmorPADRepairofAAAwithadiameterthathasnotexceededthethresholdof
5.5cmmaybereasonableinpatientswithotherassociatedarterialdiseasessuchasaneurysmaldiseaseof
theiliac,femoral,orpoplitealarteries,orsymptomaticcoexistentaortoiliacocclusivearterialdisease.Itis
importanttonotethataneurysmexpansiontendstobelessrapidinpatientswithperipheralarterydiseaseor
diabetesmellitus[9,48].(See"Poplitealarteryaneurysm"and"Iliacarteryaneurysm".)
Repairofsuprarenaland/orthoracoabdominalaneurysmsinvolvesmoreextensivesurgeryandgreater
operativerisk.Forthisreason,andconsideringthatthenormaldiameteroftheproximalaortaislarger,repair
ofsuchaneurysmsistypicallynotundertakenuntiltheaorticdiameterhasexceeded5.5to6.0cm.(See
"Managementofthoracicaorticaneurysminadults".)
VerylargeaneurysmMostpatientswithasymptomaticAAAcanbemanagedonanoutpatientbasis.
However,onoccasion,apatientwillpresentclinicallywithaverylarge(6.0cmindiameter)asymptomatic
AAAthatmaywarrantadmissionandinpatientevaluation.
Althoughtherearenodatatoassistwithclinicalmanagementofverylarge,asymptomaticAAAorany
uniformlyacceptedstandardsofcare,wesuggestimmediatereferraltoavascularsurgeonbecauseofthe
highriskforrupture.Wesuggestearlierratherthanlateraneurysmrepaironceappropriatepreoperative
studies,medicalriskassessment,andassessmentofaortoiliacanatomyarecompleted.Thereisno
advantagetoanexcessivedelay.Forpatientsfoundtohaveaverylarge,asymptomaticAAAinapractice
settingthatdoesnothavevascularexpertise,wesuggestreferraltoavascularcenterinatimelymanner.
Verylarge,asymptomaticAAAhasanestimatedruptureriskovera12monthperiodof10to20percentfor
thosebetween6and7cm,20to40percentforthose7to8cmand30to50percentforthoselargerthan8
cm.Theruptureriskoveraperiodofweeksormonthsduringtheinterveningperiodfromthetimeofinitial
diagnosisanddefinitivetreatmentisnotknown.Rupturecanoccurduringthisinterval.Becauseofthe
potentialforrupture,somevascularsurgeonsroutinelyadmitpatientswithverylarge,asymptomaticAAAfor
preoperativeevaluation,butthevalidityofthispracticehasnotbeensubstantiated.
Thepatientandhisorherfamilyshouldunderstandtheriskofrupturepriortodefinitiverepairandshouldbe
counseledregardingpotentialsymptomsthatcanbeassociatedwithAAAandencouragedtocommunicate
thedevelopmentofsymptomstothesurgeonandprimarycarephysician.
MEDICALRISKASSESSMENTTheprimarygoalofelectiveAAArepairistopreventruptureand
minimizeaneurysmrelatedmorbidityandmortality.Theassessmentofriskforelectiveaneurysmrepair
versustherisksofobservationshouldincludethepatient'sexpectedsurvivalfromothermedicalconditions.
Repairmaynotbewarrantediftheexpectedmortalityratefromanotherconditionishigherthantheexpected
aneurysmrelatedmortality.
Patientswithcoexistentcoronaryarterydiseaseandcigarettesmokerswithsignificantchronicobstructive
pulmonarydiseasearemorelikelytoexperienceseriousperioperativecomplications(eg,coronaryischemia,
arrhythmias,pneumonia)[49,50].TheriskforperioperativemorbidityandmortalityrelatedtoelectiveAAA
repairisalsoincreasedinolderpatients,femalepatients,andthosewithrenaldysfunction.
PatientsdiagnosedwithAAAhaveanincreasedriskforcardiovasculardisease,andallpatientswithAAA
shouldundergocardiovascularriskassessment[23,51].Thisincreaseinriskwasillustratedinaprospective
studythatidentifiedAAAin8.8percentofpatientsscreenedAAAwas<3.5cmindiameterin88percentof
thepatients[51].Duringa4.5yearfollowupperiod,patientswithAAAhadahigheroverallmortalitythan
thosewithoutAAA(adjustedrisk[RR]1.3,95%CI1.041.67)andanincreasedriskofincidental
cardiovasculardisease(adjustedrisk1.57,95%CI1.182.07).Inasystematicreviewthatincluded21studies
ofpatientswithsmallAAA(<5.5cm)alsoreportingcardiovascularoutcomes(althoughtherewaswide
variabilityindefinitionsused),theprevalenceofischemicheartdiseaseamongthosewithsmallAAAwas45
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percent,27percentformyocardialinfarction,and14percentforstroke[23].(See"Evaluationofcardiacrisk
priortononcardiacsurgery"and"Managementofcardiacriskfornoncardiacsurgery".)
TheprevalenceofsmokinginrandomizedtrialsamongpatientsundergoingAAArepairis24to40percent
[8,5254].Currentsmokersandpatientswithasignificantsmokinghistoryorpulmonarydiseaseshouldbe
evaluatedbaseduponstandardguidelinesforassessingperioperativerisk.Patientswithseverepulmonary
diseasewhoarenotcandidatesforgeneralanesthesiamaybeconsideredforendovascularaneurysmrepair
iftherearenoothercontraindicationsforendovascularrepair.Smokingcessationpriortoelectivesurgeryis
discussedindetailelsewhere.(See"Evaluationofpreoperativepulmonaryrisk"and"Strategiestoreduce
postoperativepulmonarycomplicationsinadults",sectionon'Smokingcessation'.)
RenalfailureisuncommonafterAAArepair.Onestudyidentifiedsixriskfactorsassociatedwithrenalfailure
(definedasarequirementofpostoperativerenalreplacementtherapy)followingopenAAArepair[55].These
includedpreoperativecreatinine>1.7mg/dL,age>75years,symptomaticAAA,AAArupture,treated
hypertension,andpulmonarydisease.Preoperativerenaldysfunctionwasthestrongestpredictorof
postoperativerenalfailure.InastudythatevaluateddatafromtheUKEVARtrials,theredidnotappeartobe
anysignificantlongtermdifferenceinrenalfunctioncomparingendovascularwithopenAAArepair[56].
CONSERVATIVEMANAGEMENTOnlyasmallproportionofpatientsdiagnosedwithabdominalaortic
aneurysm(AAA)meetthecriteriaforinterventionatthetimeoftheinitialdiagnosis.Basedupontheresultof
randomizedtrials,patientswithAAA<5.5cmindiametershouldbemanagedconservatively.However,the
naturalhistoryofAAAisoneofprogressiveexpansionnecessitatingperiodicclinicalevaluationand
surveillanceofaneurysmdiametertoidentifyAAAthatexceedsthethresholdforrepairorisrapidly
expanding[57].
MedicaltherapiesforAAAfocusonthemanagementofmodifiableriskfactorsforAAAandcardiovascular
diseasewiththegoalsofreducingtheneedforinterventionduetoaneurysmexpansionorrupture,reducing
morbidityandmortalityassociatedwithrepair,andreducingcardiovascularmorbidityandmortality[58,59].
AlthoughmanypharmacologictherapiesaimedatlimitingAAAexpansionandpreventingrupturehavebeen
investigated,nopharmacologictherapyhasbeenprovensuccessfulatachievingthesegoals,andassuch,
wesuggestnotimplementinganyofthepharmacologictherapiesdiscussedbelowforthesolepurposeof
treatingAAA.However,amongthefactorsassociatedwithAAAexpansionandrupture,smokingisthemost
importantmodifiableriskfactorandwerecommendsmokingcessationforallpatientswithAAA.Although
reducedaneurysmexpansionandruptureriskhavenotbeenclearlydemonstratedamongthosewhohave
stoppedsmoking,smokingcessationhasotherbenefits.Inaddition,becauseAAAisregardedasacoronary
riskequivalent,weagreewithmajorsocietyguidelinesthatrecommendaspirin(ASA)andstatintherapyfor
patientswithAAAtoreducetheriskofafuturecardiovascularevent,unlesscontraindicated[4,5].Other
medicalconditionsshouldbetreatedasappropriate(eg,hypertension).
CardiovascularriskreductionCurrentmultidisciplinaryguidelinesregardAAAasacoronaryheart
diseaseequivalentandrecommendmedicaltherapy(antiplatelettherapy,statintherapy,antihypertensive
therapy)toreducecardiovascularrisk,unlesscontraindicated[4].Thereisnoevidencetosuggestthataspirin
therapycontributesinanywaytoinitiatingAAAexpansionorrupture.Thesetherapiesalsodonotappearto
significantlyreduceratesofAAAexpansion[60].(See'Therapiestolimitaorticexpansion'belowand
"Preventionofcardiovasculardiseaseeventsinthosewithestablisheddiseaseorathighrisk".)
Inastudythatincludedover12,000patientswithadiagnosisofAAA,thepercentageuseofmedicationsto
managecardiovascularriskincreasedfrom2000to2012(from26to77percentforstatins,56to74percent
forantiplateletagents,and75to84percentforantihypertensivedrugs)[61].OnKaplanMeieranalysis,five
yearsurvivalimprovedforpatientsreceivingversusnotreceivingeachtherapy(68versus42percentfor
statins,64versus40percentforantiplateletagents,and62versus39percentforantihypertensiveagents).
ManagingcardiovascularriskisalsoimportantforimprovingoveralloutcomesassociatedwithAAArepair
(opensurgicalorendovascularrepair)giventhatapproximatelyonehalfofpatientswithsmallAAAwhoare
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beingconservativelymanagedwilleventuallyundergoAAArepair[4,62].Asystematicreviewofstatinusein
patientswithAAAfoundasignificantlydecreasedriskofallcausemortalityatfiveyearsfollowingAAArepair
forthoseonstatinscomparedwithnostatintherapy(oddsratio[OR]0.57,95%CI0.420.79)[60].
Perioperative(30day)mortalitywasnotsignificantlydifferent.Otherstudieshavesimilarlyfoundabenefitfor
statintherapyforpatientswithAAA[6375].
Patientswithhypertensionshouldbeevaluatedandtreatedtorecommendedbloodpressuregoals.No
specificantihypertensivetherapyhas,thusfar,beenshowntoalterthenaturalhistoryofAAA.Whenever
possible,patientsshouldavoidbloodpressurespikes.(See"Overviewofhypertensioninadults"and"Whatis
goalbloodpressureinthetreatmentofhypertension?"and'UncertainbenefitforlimitingAAAexpansion'
belowand'Exercise'below.)
TherapiestolimitaorticexpansionThelikelihoodthatananeurysmwillexpandorruptureisinfluenced
byanumberoffactors,includinganeurysmdiameter,rateofexpansion,gender,ongoingsmoking,recent
surgery,andothermedicalfactors[76,77].Theseriskfactorsarediscussedelsewhere.(See"Epidemiology,
riskfactors,pathogenesisandnaturalhistoryofabdominalaorticaneurysm",sectionon'Expansionand
ruptureofAAA'.)
AnumberofdrugtargetsthatmayinhibitAAAformationorprogressionhavebeenidentifiedinanimalmodels
andinvitrostudies.Thesestudieshavegeneratedmuchinterestforthetreatmentofpatientswithsmall
aneurysmshowever,todate,thereisnoprovenevidencethatanyofthesetargetsunequivocallyprevents
aorticexpansionandrupture[7882].Amulticenterstudythatidentified5362patientswithAAAfoundno
significantassociationbetweenAAAprogressionandusageofstatins,betablockers,angiotensinconverting
enzymeinhibitors,orangiotensinIIreceptorblockers[83].
Potentiallybeneficialtherapies
SmokingcessationCigarettesmokingistheriskfactormoststronglyassociatedwithaneurysm
formation,aneurysmexpansion,andaneurysmrupture,andisthemostimportantmodifiableriskfactorin
patientswithAAA[48,59,77,8486].Weagreewiththemultidisciplinaryguidelinessuggestingthatindividuals
diagnosedwithAAAandthosewhohaveafamilyhistoryofAAAbeadvisedtostopsmokingandoffered
cessationinterventions[4,5,87].Smokingcessationhasmanyotherbenefits.Themanagementofsmoking
cessationisdiscussedindetailelsewhere.(See"Benefitsandrisksofsmokingcessation"and"Overviewof
smokingcessationmanagementinadults".)
Smokingcessationispresumedtoprovideabenefitbyreducingtheharmfuleffectsofsmokinginmediating
connectivetissuedegradation,althoughthishasnotbeenproven[88].Withsmokingcessation,theriskof
developingAAAslowlydeclinesovertime[77,85],buttheeffectofsmokingcessationonAAAthatisalready
formedisunknown.TherearenocontrolledtrialsofsmokingcessationinpatientswithAAA,anditisunlikely
thatanysuchstudieswilleverbeperformed.However,formersmokersundergoingAAArepairhavelower
ratesofaneurysmrelatedmortalityandallcausemortalitycomparedwithcurrentsmokers,suggestingthe
importanceofsmokingcessation[89,90].SmokingcessationforatleasttwomonthspriortoAAArepairwas
foundinoneprospectivestudytosignificantlyreducetheincidenceofpostoperativerespiratorycomplications
(57versus15percent)[91].
ExerciseItiswidelyacceptedthathigherlevelsofphysicalactivityareassociatedwithalowerriskof
cardiovascularmorbidityanddeath.WeagreethatpatientswithAAAshouldparticipateinanexercise
programforsecondarypreventionofcardiovasculardisease.Patientsshouldbecounseledthatmoderate
physicalactivitysuchasrunning,biking,swimming,hiking,orsexualactivityandactivitiessuchasgardening,
golfing,andhorsebackridingdonotprecipitateAAArupture[92].However,heavylifting,especiallywhile
holdingthebreath,andotheractivitiesthatleadtoValsalva,transientlyinducesignificantincreasesinblood
pressureandshouldbeavoided.
Moderatephysicaltherapymayalsolimitaneurysmexpansion[93].Inexperimentalaneurysms,increased
aorticbloodflowappearstoinhibitAAAexpansion[94].MagneticresonanceimaginginpatientswithAAA
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whohaveexercisedhasdemonstratedincreasedabdominalaorticbloodflow[95],andthus,exercisemay
havethepotentialtolimitAAAexpansioninhumansaswell.Althoughtheexactmechanismsremaintobe
determined,exercisereducesthelevelsofsystemicmarkersofinflammationrelevanttoAAAs.Onetrialthat
randomlyassigned140patientswithAAA<5.5cmfoundnosignificanteffectofanexerciseprogramonAAA
expansionratesoveranaverageof23months[96,97].Thereweremarkedimprovementsinexercise
capacityinthetraininggroup,andtherewasamodestinverseassociationbetweenthechangeinexercise
capacityandchangeinAAAdiameter.(See"Exerciseandfitnessinthepreventionofcardiovasculardisease"
and"Thebenefitsandrisksofexercise".)
UncertainbenefitforlimitingAAAexpansion
BetablockertherapyBetablockershavearoleinmanagingpatientswithcardiovasculardisease,
buttheyhavenotbeenclearlyshowntoreduceaneurysmexpansionrates[98].(See"Managementof
cardiacriskfornoncardiacsurgery",sectionon'Betablockers'.)
AnumberofearlyanimalstudiesandretrospectivereviewssuggestedthatbetablockersmayinhibitAAA
expansion[98101].Onestudyevaluated121patientswithaninfrarenalaorticaneurysmwhoweremonitored
byserialultrasoundexamination38ofthepatientsweretreatedwithabetablocker[99].Themean
expansionratewassignificantlylowerinthepatientsreceivingabetablocker(0.36versus0.68cmperyear).
However,twolargetrialsfoundnosignificantdifferencesinAAAexpansionratesinpatientsreceivingbeta
blockerscomparedwiththosewhodidnot[98,102].Thelackofbenefitmayhavebeenrelatedtopoor
complianceduetothesideeffectsofbetablockadethatmeasurablydiminishedqualityoflife.Althoughthese
studiesdidnotshowabenefitforpropranololinlimitingAAAexpansion,theydonotexcludethepossibility
thatabettertoleratedselectivebetaadrenergicblockercouldbebeneficial.
ARBsandACEinhibitorsAlthoughanimalstudieshavesuggestedtheutilityofangiotensin
receptorblockersorangiotensinconvertingenzyme(ACE)inhibitorsindecreasingtherateofaneurysm
expansion[103,104],theclinicaluseoftheseagentshasnotclearlydemonstratedthesamebenefits.Infusion
ofangiotensinIIintorodentspromotesAAAformation,whichisthoughttobeduetoaorticinflammationand
proteolysisandnotduetothesecondaryincreaseinbloodpressure[105107].Angiotensintype1receptor
blockade(ARB)usually[108113],butnotalways[109],inhibitsaneurysmdevelopmentinvariousanimal
modelssuchasAAAsinducedbyangiotensinII,AAAsinducedbychemicalagents,andAAAsinmice
geneticallypredisposedtoaneurysm.ACEinhibitorsarenotreliableforinhibitingexperimentalAAA
development[108,109,114].
AnumberofclinicalstudieshaveassociatedreducedratesofAAAexpansionorrupturewiththeuseofACE
inhibitorsandARBs[115117].Twotrialsareongoing[118120].Astudyof15,326patientswhopresented
withAAA(intactorruptured)evaluatedtheprehospitaluseofACEinhibitors[115].PatientstakingACE
inhibitorsweresignificantlylesslikelytopresentwithrupturedaneurysmcomparedwiththosewhowerenot
onACEinhibitors(OR0.82,95%CI0.740.90).Bycontrast,areportfromtheUnitedKingdomSmallAAA
studyfoundanincreasedriskofAAAexpansionforpatientsonACEinhibitors[117].
OtherantihypertensivesagentsDiureticsandcalciumchannelblockershavealsobeenstudiedfor
theireffectsonAAAexpansion.Althoughatrendtowardlowerexpansionrateshasbeenobservedfor
calciumchannelblockers,significantdifferenceshavenotbeenseen[48].Diureticsappeartohavenoimpact
onexpansionrates.
StatintherapyThepathogenesisofAAAinvolvesdiminishedintegrityofthearterialwalldrivenby
localinflammation,analteredbalanceinarterialwallrepair,anddegradationbyenzymessuchasmatrix
metalloproteinases(MMPs)[121].StatinsreducetheexpressionofMMPsinaconcentrationdependent
manner,independentoftheircholesterolloweringeffects[122,123].
AnimalstudiessuggestthatstatinsmaylimitAAAexpansion[124129].However,theinfluenceofstatinsfor
inhibitingatherosclerosismayberelativelygreater[128].Norandomizedtrialshavespecificallyassessedthe
effectofstatinsonAAAexpansionorrupture.Anumberofobservationalstudieshaveexaminedtheeffectof
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statintherapyontheexpansionofsmallAAAs[64,75,116,117,119,130134].Earlystudiesreportedreduced
ratesofAAAexpansioninpatientstreatedwithstatins[64,75,119,132134]however,mostlargerstudies
havenotconfirmedarelationship[116,117,131,135,136].IntheTrmsostudy,statintherapywasassociated
withanincreasedriskofdevelopingAAA(OR3.8,95%CI1.459.81)[84].However,inapopulationbased
casecontrolstudythatincluded7168patients,adecreasedriskforAAArupturewasfoundforcurrentstatin
userscomparedwithneverusers(OR0.70,95%CI0.610.95),ariskdifferencethatpersistedafter
adjustmentforconfoundingfactors[130].However,multiplemetaanalysesfoundnoevidencethatstatins
impactAAAexpansionratebutdidobserveasurvivalbenefitforthoseonstatins[60,137].Thus,although
thereisinsufficientevidencetorecommendtheinitiationofstatintherapysolelyforthetreatmentofAAAs
[58],statintherapyshouldbeconsideredforpatientswithAAAtoreduceoverallcardiovascularrisk.
AntibiotictherapyAntibiotictherapyhasalsobeenevaluatedforitspotentialeffectonAAA
expansion.Itwasinitiallypostulatedthataneurysmprogressionmaybeenhancedbysecondarymicrobial
infectionwithintheaorticwall.SerologicevidenceofChlamydiapneumoniaeinfectionwasassociatedwithan
increasedrateofAAAexpansion[138],andtwosmalltrialssuggestedthatroxithromycinmaydecreaseAAA
expansionrates[139,140].Althoughinfectionisknowntopotentiallyleadtotheformationofaneurysms,clear
evidencesupportingaroleforinfectionintheformationandprogressionofthemajorityofAAAs(noninfected)
remainstobeestablished[92].[139]
Inthelate1980s,itwasrecognizedthatthecommonlyusedtetracyclineantibioticsinhibitedmatrix
metalloproteinases(MMPs)invitro[141],andinaneurysmtissue[142,143].MMPsarepostulatedtoplaya
roleinaneurysmformation.Inatleast14separatestudiesinanimalmodels,doxycyclinehasbeenfoundto
inhibitaneurysmdevelopmentandprogression[79,144].Intwoanimalstudies,rapamycinsimilarlyinhibited
experimentallyinducedAAA[145,146].
Inhumans,doxycyclinedecreasesinflammatorymarkersinAAA[147,148],buthasnotbeenfoundto
definitivelyreducetherateofAAAexpansion[149151].ThePHarmaceuticalAneurysmStabilizationTrial
(PHAST)didnotfindareductioningrowthofsmallAAA(3.5to5.0cm)following18monthsofdoxycycline
(100mgdaily)comparedwithplacebo,ratheraneurysmexpansionwasgreaterinthedoxycyclinegroup(4.1
mmversus3.3mm),butthiswasnotconsideredtobeclinicallyrelevant[149].Doxycyclinetreatmentdidnot
influencetheneedfor,ortimingofelectiveAAArepair.Thestudywaslimitedbythehighnumberofpatients
lostfromthestudyduetononadherence,adversetreatmenteffects,orelectiveAAArepair.Nevertheless,
theseresultsmayindicatethatmethodsforgeneratinganeurysmsinanimalsmaybeaninadequatemodelfor
humandisease.AnothertrialisunderwayusingahigherdoseofDoxycycline[150].
AntiplatelettherapyAntiplatelettherapymayinfluencetheformationofthrombuswithinAAAand
reduceprogressioninpatientswithsmallAAA,butadefinitiveassociationbetweenplateletinhibitionand
aneurysmprogressionhasnotbeenidentified[116].
Antiplatelettherapy(aspirin)ispostulatedtodecreasethrombusformation,reduceaorticwallinflammation
andstabilizetheaorticwall[152].ThevolumeofthrombuswithinAAAscorrelatestomaximumAAAdiameter
[153],andcirculatingconcentrationsofthrombindegradationproducts(Ddimer)arestronglyassociatedwith
thepresenceofAAAandprogressioninpatientswithsmallAAAs[154,155].Thrombusfromhuman
infrarenalAAAsalsocontainsinflammatorycells[156,157].Inanimalmodels,plateletinhibitionhasbeen
foundtolimitAAAformation[157,158].Althoughanumberofclinicalstudieshavebeenperformed,
antiplatelettherapyhasnotbeenevaluatedinrandomizedtrials[64,75,116,117,119,131134,152].Inone
study,ASAwasassociatedwithdecreasedratesofprogressionofsmallAAA[152].However,largerstudies
havefoundnosignificantassociationbetweenantiplatelettherapyandAAAexpansion[116,117,131].
AntiinflammatoryagentsAcharacteristichistologicalfeatureofhumanAAAisadense
inflammatoryinfiltratewithavarietyofcellsincludingmacrophages,neutrophilsandlymphocytestypically
present[159,160].
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Elastases(proteases)secretedfromthesecellsdegradethenormalarterialwallarchitecture,and,
particularly,theelasticlamellae.Aorticthrombusalsocontainsneutrophils,andhighconcentrationsof
proinflammatorycytokinesandproteolyticenzymes[156,157].Inhibitionoftheseinflammatorycells
suppressesthedevelopmentofAAAinrodentmodels[161].Anumberofproteaseinhibitorshavebeen
developedasantineoplasticagents,butmosthavesideeffectsthatwouldlimittheiruseinpatientswithAAA
[162].
Mastcells,whichcontainchymaseandotherproinflammatorycytokines,maycontributetoAAAformation
[163].MicethataredeficientinthiscelltypeareprotectedfromexperimentalAAA[164,165].Thesefindings
haveraisedinterestintheuseofmastcellstabilizingagentsinpatientswithsmallAAAs.However,atrialthat
randomized326patientstopemirolastorplacebofoundnosignificantdifferencesinsmallAAA(3.0to4.9
cm)expansionrates(mean2.42mm)overa12monthperiod[166].
SafetyofantiplatelettherapyandAAAItiscurrentlyunknownwhetherASAalonehasasubstantial
effectwithrespecttohemorrhageinassociationwithAAArupture.Theoretically,thrombusformationwouldbe
impededhowever,theretroperitonealstructuresprobablyplayagreaterroleinlimitingtheinitialexpansionof
hematomafollowingAAArupture.Ingeneral,wefeelthatthebeneficialeffectsofASAinreducing
cardiovascularmorbidityandmortalityoutweighthetheoreticrisksofincreasedbleedingwithAAArupture.
CounselingthehighriskpatientAsymptomaticpatientswithAAArepair>5.5cmwhohavemedical
comorbiditiesthatincreasetheirriskforrepair(opensurgicalorendovascular)abovetheexpectedlevelmay
bebestmanagedconservatively,reservingrepaironlyifsymptomsdevelop(includingrupture).(See
"Managementofsymptomatic(nonruptured)andrupturedabdominalaorticaneurysm".)
InadatabasereviewbytheVascularStudyGroupofNewEngland,among1653patientsundergoing
endovascularaneurysmrepair,19percentweredeemedunfittoundergoopenaneurysmrepair[167].
Patientswhowereunfitforopenrepairwereolder,andmorelikelytohavecardiacdiseaseorchronic
obstructivepulmonarydisease.Bycontrast,comparedwiththosedeemedfitforopenAAArepair,patients
deemedunfithadsignificantlyhigherratesofcardiac(7.8versus3.1percent)andpulmonary(3.6versus1.6
percent)complications.Survivalforthosedeemedunfitwassignificantlyworsethanthosedeemedfit(one
yearsurvival93versus96percentthreeyearsurvival73versus89percent,andfiveyearsurvival61versus
80percent).Evenadjustingforage,designationasunfitwasasignificantpredictorofworsefiveyearsurvival
(hazardratio1.6,95%CI1.22.2).InareviewofoutcomesinmenwithscreendetectedlargeAAAdeemed
notfitforrepair,deathoccurredin14/34atamedianof34.9monthsafterdiagnosis,9fromrupturedAAA
[168].Longtermoutcomesforpatientsdeemedunfitforopensurgeryshouldalsobeconsideredwhen
consideringendovascularrepair.(See'Openversusendovascularaneurysmrepair'below.)
Expectedruptureratesforuntreatedpatientsvarydependingonthepopulationstudied,aneurysmdiameter,
andotherriskfactorsforrupture(eg,smoking,chronicobstructivepulmonarydisease,unmanagedmedical
conditions).ThebiologyofAAAmayalsobechanging.Theriskofruptureanddeathhasbeendeclining,in
parallelwithreductionsinpercapitasmoking[169].(See"Epidemiology,riskfactors,pathogenesisand
naturalhistoryofabdominalaorticaneurysm",sectionon'ExpansionandruptureofAAA'.)
Onestudyevaluated198menwithcontraindicationstorepairorrefusal[170].Theoneyearincidenceof
rupture(anddeath)was9.4percentforAAA5.5to5.9cmindiameter,10.2percentforAAA6.0to6.9
cm,and37.5percentforAAA>7.0cm.
Inanotherstudyof72patientswhoweredeemedunfitforAAArepair,mediansurvivalforAAA5.1to
6.0cmwas44monthsand11percentdiedofruptureforAAA6.1and7.0cm,mediansurvivalwas26
monthsand20percentdiedofruptureandforAAA>7cm,survivalwassixmonthsand43percent
ruptured[171].
Inalaterstudythatincluded1514patientswithuntreatedAAA,cumulativeannualrupturerateswere3.5
percentforAAAs5.5to6.0cm,4.1percentforAAAs6.1to7.0cm,and6.3percentforAAAs>7.0cm
[172].
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select
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Longtermsurvivalinhighriskpatientsmaybeunaffectedbyrepair.TheEVAR2(Endovascularrepairof
aorticaneurysminpatientsphysicallyineligibleforopenrepair)trialrandomlyassigned404patientswithAAA
>5.5cmandwhowereaged60yearsoroldertoendovascularaneurysmrepairornointervention[12].The
endovasculargrouphadalowerriskofaneurysmrelatedmortality(adjustedhazardratio0.53,95%CI0.32
0.89)buttherewerenosignificantdifferencesinallcausemortalityHR0.99(95%CI0.781.27)ateightyears
followup.
Decisionmakinginhighriskpatientsisdifficult,butshouldincludeacandiddiscussionwiththepatientandhis
orherfamilymembers.Thisdiscussionshouldincludecounselingthepatienttocreateanadvanceddirective
detailingthepatient'swishesintheeventofrupture.Familymembersshouldbemadeawareofthesewishes,
giventhatthepatientmaynotbeabletoreporthisorherwishesatthetimeofaneurysmrupture.
FollowupPatientswithsmallandmediumsizedAAAandhighriskpatientswhoarebeingmanaged
conservativelyshouldundergoperiodicclinicalevaluationtoevaluateforanysymptomsthatmightberelated
totheaneurysm,andtomonitorbloodpressureandthesuccessofriskreductionstrategies.Amongpatients
identifiedwithsmallAAA(3.6cm),inonestudy,followupwasoverallpoorat65percent[173].Therateof
followupisevenpoorerforthoseidentifiedincidentallyonimagingstudiesperformedforanotherreason
[174].
Forpatientswhoelectnorepairorwhoarenotcandidatesforanytypeofrepair,ongoingevaluationand
surveillanceisnotneeded.(See'Counselingthehighriskpatient'above.)
AneurysmsurveillancePatientswithsmallaneurysmsunderobservationshouldundergoperiodic
imagingtoassessforaorticexpansion,buttheoptimalsurveillanceschedulehasnotbeenclearlydefined
[8,9,30,175,176].Weobtainanannualultrasoundstudyforaneurysms<4.5cmandannualormorefrequent
intervals(eg,everysixmonths)forlargeraneurysmsdependinguponthecharacteristicsoftheaneurysm(eg,
expansionrate).PatientswithknownAAAwhopresentwithrupturehavebeennotedtobemorelikelyto
havegapsintheirsurveillance[173,177].
IntheUnitedKingdomsmallaneurysmstudy,ascheduleforsurveillanceintervalswasdeterminedthat
minimizedthelikelihoodofaneurysmgrowthtogreaterthan5.5cmbetweenscreeningvisits[48].Asmightbe
expected,therecommendedintervalsforsurveillancewereshorterforlargeraneurysmsandlongerfor
smalleraneurysms.Surveillancewasevery3monthsforAAA5.0to5.4cm,every12monthsforAAA4.5to
4.9cm,every24monthsforAAA4.0to4.4cmandevery36monthsforAAA3.5to3.8cm.Inthisstudy,less
frequentsurveillancewasfelttobesafe,andthesuggestedsurveillancescheduleresultedina<1percent
chanceofananeurysmsurpassing5.5cmindiameterbetweenscreeningvisits[178].Theseintervalsare
consistentwiththoseusedintheMulticentreAneurysmScreeningStudy(MASS)[179].Basedlargelyupon
thesestudies,multidisciplinaryguidelinesforthediagnosisandmanagementofperipheralarterydisease
recommendsurveillanceevery6to12monthsusingultrasoundorCTforaneurysms4.0to5.4cmin
diameter,butalessfrequentinterval(everytwotothreeyears)foraneurysms3.0to4.0cmindiameter,and
everyfiveyearsforaorticdiameterbetween2.6to2.9cm[4,5,175].RecommendationsforAAAsurveillance
schedulevarywidelyaroundtheglobe[175].
Morefrequentfollowupandsurveillance(annualultrasoundforAAA<4.5cmormorefrequentforlarger
aneurysm)maybeprudentgiventhelowcostofultrasoundandforthefollowingreasons.
Whentheaneurysmsurveillanceintervalisextendedbeyondayear,theinherentinaccuraciesassociated
withaorticmeasurementsusingultrasoundandCTbecomemorerelevant.Multiplestudiesobtainedover
morefrequentintervalshelpresolveconflictsandaremorelikelytocapturerapidaorticexpansion.
Thereisapotentialforpatientstobelosttofollowupwhenextendedsurveillanceintervalsareused.
GapsinsurveillanceofAAAareassociatedwithAAArupture.Thus,ifalongersurveillanceintervalis
chosen,itisimportanttohavearemindersysteminplace.Inadatabasereviewofnearly10,000patients
withknownAAAwhounderwentrepairofanintactorrupturedaneurysm,gapsinsurveillancewere
definedasnoimagingwithinoneyearpriortosurgeryornoimagingformorethantwoyearsafterthe
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initialimage[177].PatientswithrupturedAAAweresignificantlymorelikelytohavegapsinsurveillance
comparedwiththosereceivingrepairforintactAAA(47.4versus11.8percent).Inamultivariateanalysis,
gapsinsurveillanceremainedthelargestpredictorofruptureafteradjustingformedicalcomorbidities
(OR5.82,95%CI,4.647.31).
SignificantanxietyisoftenassociatedwithadiagnosisofAAAandmanypatientsfindreassurancewitha
fixedsurveillanceinterval[180].Althoughformanypatients,theseanxietiesmaybereducedwithproper
education.
Annualclinicalexaminationandriskreductionassessmentcanbeperformedconcurrently[181,182].
ThereisinterestinusingAAAsacvolumeforsurveillance[183185].AAAsacvolumehasbeennotedin
researchstudiestochangewhenAAAdiameterhasnothowever,thesignificanceofthisobservationis
unknown.MorefrequentCTscanning,whichisrequiredforthismeasurement,isexpensiveandwouldsubject
thepatienttoadditionalradiationexposure.Thus,wedonotusesuchmeasurementsforroutineAAA
surveillance.
AAAREPAIRElectiveabdominalaorticaneurysm(AAA)repairisthemosteffectivemanagementto
preventrupture.Twomethodsofaneurysmrepairarecurrentlyavailable:opensurgeryandendovascular
aneurysmrepair(EVAR).ThemortalityofelectiveAAArepairis3to5percentforopenAAArepair,butlower
at0.5to2percentforEVAR[186188].Whenchoosingthetypeofrepair,itisimportanttotakeintoaccount
thepatient'sexpectedsurvival(shorttermandlongterm),whichdependsuponthepatient'sageandmedical
comorbidities.(See'Medicalriskassessment'above.)
OpenAAArepairOpenaneurysmrepairinvolvesreplacementofthediseasedaorticsegmentwitha
tubeorbifurcatedprostheticgraft(figure5)throughamidlineabdominalorretroperitonealincision[189].
WithtechnicalrefinementsforopenAAArepair,complicationssuchasacuterenalfailure,distal
embolization,woundinfection,colonicischemia,falseaneurysmformation,aortoduodenalfistula,graft
infection,andperioperativebleedinghavebecomelesscommonfollowingroutineelectivesurgerybut
remainsignificantissuesfollowingemergentopenAAArepair.
EVAREVARinvolvestheplacementofmodulargraftcomponentsdeliveredviatheiliacorfemoral
arteriestolinetheaorta(figure5)andexcludetheaneurysmsacfromthecirculation.EVARrequires
fulfillmentofspecificanatomiccriteria.Upto70percentofpatientsareEVARcandidates.This
percentageisexpectedtoincreasewiththeapprovalofspecializedendograftdesignsthatwillallowthe
treatmentofmorechallengingaorticaneurysmanatomy.AlthoughEVARisassociatedwithlower
perioperativemortality,lateAAArupturehasbeenreported.
SummaryofindicationsforelectiveAAArepairRepairofasymptomaticAAAisgenerallyindicated
underthecircumstanceslistedbelow.Theseindicationsarediscussedinmoredetailabove.Repairof
symptomatic(nonruptured)andrupturedAAAarediscussedseparately.(See'Aneurysmrepairversus
conservativemanagement'aboveand"Managementofsymptomatic(nonruptured)andrupturedabdominal
aorticaneurysm".)
AsymptomaticAAA5.5cm
RapidlyexpandingAAA
AAAassociatedwithperipheralarterialaneurysm(eg,iliac,popliteal)orperipheralarterydisease(eg,
iliacocclusivedisease)
OpenversusendovascularaneurysmrepairRandomizedtrialscomparingopenAAArepairwithEVAR
havefoundsignificantlyimprovedshortterm(30day)morbidityandmortalityforEVAR,butnosignificant
differencesinlongtermoutcomes[53,190197].Apooledanalysisofthesetrialsidentifieda69percent
reductionintheriskforperioperativemortalityforendovascularcomparedwithopenrepair(oddsratio[OR]
33,95%CI0.170.64)[198].EVARappearstobeassociatedwiththeneedformoresecondaryprocedures,
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andanongoingfutureriskofaorticrupture.However,thereappearstobenosignificantdifferencesinoverall
complicationrateswhenallcomplicationsforeachprocedureareincluded[199].Theimportantpointsof
theserandomizedtrialsaresummarizedbelow.
DREAMtrialTheDutchRandomizedEndovascularAneurysmManagement(DREAM)trialrandomly
assigned351patientstoopenrepairorEVAR[52].AllpatientshadAAA>5cminmaximaldiameterand
weresuitablecandidatesforeithertechnique.
Theperioperative(30day)mortalityratewaslowerforEVARcomparedwithopenAAArepair(1.2versus4.6
percent),thoughthisresultwasnotsignificant.Attwoyearspostrandomization,thecumulativeratesof
aneurysmrelateddeathremainedlessforEVAR(2.1versus5.7percent)comparedwithopenrepair,a
differencethatwasentirelyduetotheinitialperioperativeoutcomes[191].However,therewerenosignificant
differencesinoverallsurvival(89.7percentforEVARand89.6percentforopenrepair).Theperioperative
survivaladvantageseenwithEVARwasnotsustainedafterthefirstpostoperativeyear,duetoanincreasein
nonaneurysmrelatedmortalityintheEVARgroup.Theseresultsweremaintainedatsixyearswithsurvival
ratesforEVARat68.9percentandopenrepairat69.9percent[192].
TherateofmoderateandseveresystemiccomplicationswassignificantlylowerforEVAR(11.7versus26.4
percent)comparedwithopenrepair.Ratesofmoderateandseverevascularorgraftrelatedcomplications
weresignificantlygreaterforEVAR(16.4versus8.6percent)comparedwithopenrepair.Theneedfor
secondaryvascularinterventionwassignificantlyhigherforEVAR(29.6versus18.1percent)comparedwith
openrepair.
EVAR1trialTheendovascularaneurysmrepairversusopenrepairinpatientswithAAA(EVAR1)trial
randomlyassigned1252patientstoAAArepairwithEVAR(n=626)oropenAAArepair(n=626)[193].
Perioperative(30day)mortalitywassignificantlylessforEVAR(1.8versus4.3percent).Nosignificant
differenceswereseeninoverallmortality,andgraftrelatedcomplicationsoccurredmorefrequentlywith
EVAR.NewcomplicationsrelatedtoEVARcontinuedtooccurouttoeightyearsoffollowup[53].Theearly
benefitofEVARwaslostbeginningapproximatelyeightyearsafterrandomizationduetolatefatalsecondary
aneurysmruptures.Overameanof12.7yearsoffollowup,theoverallmortalityratewassimilar(9.3versus
8.9deathsper100personyearsfortheEVARandopengroups,respectively)[200].However,aneurysm
relatedmortalitywassignificantlyincreasedforEVARaftereightyears(7versus1percent)andwasmainly
attributabletosecondaryaneurysmsacrupture.Whethernewergenerationstentgraftswouldhavethese
samelongtermaneurysmrelatedrisksisunknownoveronethirdofthestentgraftdevicesreceivedbythe
enrolleesinthisstudyarenolongerused[193].Anotherfindingoflongertermfollowupwasthatthenumber
ofcancerdeathswas50of179intheEVARgroupand31of154intheopengroup(aftereightyears,
adjustedhazardratio1.87,95%CI1.19to2.96).Nootherstudyhasobservedanincreasedcancerriskwith
theuseofaorticstentgrafts.IntheEVARgroup,37of50ofthesecancerdeathsweredescribedas"other"
(ie,notlungcancer).Ifthesewereabdominalcancers,theirincreaseddetectioncouldberelatedtomore
frequentsurveillance.Baseduponestimatedcancerrisks[201,202],itisunlikelythesecanbeattributedto
imagingrelatedradiationexposure.
ReinterventionratesweresignificantlyhigherforEVARcomparedwithopenrepair.Acriticismofthistrialwas
thatallcomplicationsrelatedtoopenrepair,suchasincisionalhernia,werenotincludedinthestudy.The
shorttermbenefitofEVARwaslostduetolatefatalaneurysmruptures.Theauthorsconcludedthat
treatmentbyEVARsignificantlyreducedtheoperativemortalitycomparedwithopenrepair,buttherewereno
longtermadvantagesofonetypeofrepairforaneurysmrelatedoroverallmortality.
OVERtrialTheOpenVersusEndovascularRepair(OVER)trialisanongoingmulticentertrialatthe
VeteransAffairsMedicalCentersthatrandomlyassigned881veterans49withAAA>5.0cm,anassociated
iliacaneurysmwithmaximaldiameter3.0cm,oradiameterof4.5cmwithrapidenlargement(definedas
0.5cmgrowthinsixmonthsor1.0cminoneyear)toopenAAArepairorEVAR[54].Patientswere
candidatesforeithertypeofrepair.
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Overallmortalitywasnotsignificantlydifferentbetweenthegroupsat(7.0percentEVAR,9.8percentopen
repair)overnineyearsoffollowup[195].Sixaneurysmruptureswereconfirmedintheendovascularrepair
groupcomparedwithnoneintheopenrepairgroup(meanfollowup5.2years)however,thedifferencewas
notstatisticallysignificant.
EVARwasassociatedwithsignificantlyshorterproceduretimes(2.9versus3.7hours),ashorterdurationof
mechanicalventilation(3.6versus5.0hours),shorterintensivecareunitstay(1versus4days),shorterlength
ofhospitallength(3versus7days),andlowertransfusionrequirements(0versus1unit).
Inthistrial,incisionalherniawasincludedasanopenrepairrelatedcomplication.Asaresult,theratesof
secondaryinterventionwerefoundtobesimilarbetweenthegroups(13.7percentEVAR,12.5percentopen
AAArepair)withthemajorityofsecondaryproceduresintheEVARgroupduetoendovascularrevisions
comparedwithrepairofincisionalherniaintheopenAAAgroup.Aseparatedatabasereviewalsofound
similarcomplicationratesbetweenopenandendovascularrepairwhenallcomplicationswereincluded[199].
ACEtrialTheAneurysmedel'aorteabdominale:ChirurgieversusEndoprothese(ACE)trialrandomly
assigned316patientswithAAA>5cmtoEVARoropensurgery[194].Aswiththestudiesabove,therewere
nosignificantdifferencesinthecumulativesurvivalormajoradverseeventsrates(95.9versus93.2percentat
oneyearfollowup,and85.1versus82.4percent,respectively,atthreeyearsfollowup).Inhospitalmortality
wasalsonotsignificantlydifferent(0.6versus1.3percent).Theneedforreinterventionwashigherinthe
EVARgroup(16versus2.4percent),comparedwithopenAAArepair,althoughincisionalherniarepairwas
notconsidered.
ChoiceofAAArepairapproachWhenithasbeendeterminedthatapatientshouldundergoelective
AAArepair,weagreewithguidelinesfrommajormedicalandsurgicalsocietiesthatemphasizean
individualizedapproachwhenchoosingthetypeofAAArepair,takingintoaccounttheanatomicfactors,
patientage,gender,riskforAAArupture,andriskforperioperativemorbidityandmortality[4,92,203205]:
Endovascularrepairmaybepreferredinpatientswithfavorableanatomy(asdefinedbythe"Instructions
forUse[IFU]"ofagivendevice)whoareatahighlevelofperioperativerisk.
Endovascularrepairmaybeappropriateinpatientswithfavorableanatomybutwhodonothaveahigh
surgicalrisk.
Opensurgicalrepairmaybepreferredforyoungerpatientswhohavealoworaverageperioperativerisk.
Basedupontherandomizedtrialspresentedabove,themainbenefitsofEVARappeartobethegreatestin
theshortterm,andthus,EVARisthemostappropriatechoiceforpatientswithalimitedlifeexpectancyand
thosewithahighlevelofperioperativerisk.However,whetheryoungerpatientswhoarenotathighriskfor
opensurgeryshouldundergoopensurgicalrepairversusEVARremainscontroversial[206209].Surveillance
ofendovascularstentgraftsoveranextendedperiodoftimeexposesthepatienttogreaterlevelsof
cumulativeradiationhowever,ultrasoundsurveillanceisbecomingmorecommon.AlthoughEVARdoesnot
eliminatetheriskoffutureaorticrupture,thisisalsotrueforopenAAArepair,whichcanhavelate
complicationssuchasanastomoticpseudoaneurysm(proximal,distal)anddevelopment/progressionofiliacor
suprarenalaneurysms.(See"Endovascularrepairofabdominalaorticaneurysm",sectionon'Endograft
surveillance'and"Complicationsofendovascularabdominalaorticrepair".)
IntheUnitedStates,morethan80percentofAAAsoverallarerepairedusinganendovascularapproach.For
patientswithanatomythatissuitableforendovascularrepair(ie,asdefinedbytheIFUofagivendevice),the
authorsspeculatethatthisrateisnearly100percent,giventhatmostofthelimitationstoEVARhavefallen
awaywithnewergenerationdevices,aswellasabetterunderstandingofthemodesoffailurefollowing
endovascularrepair.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
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gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easyto
readmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore
detailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowant
indepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremail
thesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsby
searchingon"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patienteducation:Abdominalaorticaneurysm(TheBasics)")
BeyondtheBasicstopics(see"Patienteducation:Abdominalaorticaneurysm(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Abdominalaorticaneurysm(AAA)isacommonandpotentiallylifethreateningcondition.Approximately
7000deathsperyearareattributedtorupturedAAAintheUnitedStates.Withoutrepair,rupturedAAA
isnearlyuniformlyfatal.Forasymptomaticpatients,electiverepairoftheaneurysmisthemosteffective
managementtopreventrupture.(See'Introduction'above.)
FormostpatientswithasymptomaticinfrarenalAAA<5.5cm,werecommendconservativemanagement
(watchfulwaiting)ratherthanelectiveAAArepair(Grade1A).Theriskofaneurysmrupturedoesnot
exceedtheriskofrepairuntiltheaneurysmdiameterreaches5.5cm.Forgoodrisksurgicalcandidates
(openorendovascularrepair)withAAA>5.5cm,werecommendelectiveAAArepair(Grade1A).
SituationsforwhichelectiverepairofasymptomaticAAA<5.5cmmayalsobeappropriateinclude(see
'Aneurysmrepairversusconservativemanagement'above):
Rapidlyexpanding(>0.5cminsixmonthsor>1cmperyear)infrarenalAAAinwelldocumented
serialstudies.Rapidexpansionmayrepresentinstabilityoftheaorticwall,andsomestudiessuggest
thatrapidlyexpandingAAAshaveahigherriskofrupture.
Patientswithassociatedarterialdiseasesuchascoexistingiliac,femoral,orpoplitealartery
aneurysms,orsymptomaticperipheralarterydisease.
ForthesamediameterAAA,theriskforAAAruptureishigherforwomenthanformen.Elective
repairofasymptomaticAAA>5cmmaybeappropriatehowever,theriskofdeathfromelective
repairisalsoincreasedinwomen.Alowerthresholdforrepairisbestreservedforwomenwhohave
alowriskforperioperativemorbidityandmortality.
ForpatientswithAAA>5.5cmwhohaveashortlifeexpectancy(<2years)duetoadvanced
comorbidities,particularlycardiopulmonarydiseaseormalignancy,wesuggestnorepairover
endovascularaneurysmrepair(Grade2B).Forthesepatientsandotherswhoelectnottoundergo
repair,ongoingAAAsurveillanceisnotneeded.Thepatientshouldbeencouragedtocreatean
advanceddirectivedetailingtheirwishesfornorepairofanykindintheeventofrupture.Familymembers
shouldbemadeawareofthesewishes,giventhatthepatientmaynotbeabletoreporthisorherwishes
atthetimeofaneurysmrupture.(See'Counselingthehighriskpatient'aboveand'Followup'above.)
Conservativemanagementconsistsofperiodicclinicalevaluationandsurveillanceofaneurysmdiameter
toidentifyAAAthatexceedsthethresholdforrepairorisrapidlyexpanding.Medicaltherapiesfor
patientswithAAAfocusonthemanagementofmodifiableriskfactorsforAAAandcardiovascular
diseasewiththegoalsofreducingtheneedforinterventionduetoaneurysmexpansionorrupture,
reducingmorbidityandmortalityassociatedwithAAArepair,andreducingcardiovascularmorbidityand
mortality.(See'Conservativemanagement'above.)
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ForpatientswithAAAwhosmoke,werecommendsmokingcessation(Grade1A).Smokingis
stronglyassociatedwithAAAexpansionandrupture,andisthemostimportantmodifiableriskfactor.
Eventhoughreducedaneurysmexpansionandruptureriskhavenotbeenclearlydemonstrated
amongthosewhohavestoppedsmoking,smokingcessationhasotherclearbenefits.(See"Benefits
andrisksofsmokingcessation".)
PatientswithAAAareconsideredtohaveacoronaryequivalent.Statinsandaspirinareconsidered
appropriatetherapiestodecreasetheriskoffuturecardiovascularevents,asdiscussedelsewhere.
(See"Preventionofcardiovasculardiseaseeventsinthosewithestablisheddiseaseorathighrisk".)
AlthoughmanypharmacologictherapiesaimedatlimitingAAAexpansionandpreventingrupture
havebeentried,notherapyhasbeenprovensuccessfulatachievingthesegoals,andassuch,we
suggestnotimplementinganyofthepharmacologictherapiesdiscussedaboveforthesolepurpose
oftreatingAAA(Grade2C).
TheoptimalsurveillancescheduleforpatientswhoarenotundergoingAAArepairhasnotbeenclearly
defined.BasedlargelyuponthesurveillanceintervalsidentifiedintheUnitedKingdomSmallAneurysm
Trial,theSocietyofVascularSurgery(SVS)guidelinesforthediagnosisandmanagementofperipheral
arterydiseaserecommendsurveillanceevery6to12monthsusingultrasoundorcomputedtomography
(CT)formediumsizedaneurysms(4.0to5.4cmindiameter)butlessfrequentintervals(everytwoto
threeyears)forsmalleraneurysms.Wefrequentlyperformsurveillanceonsmallaneurysmsannuallyto
minimizeimagingvariabilityandalleviatepatientanxieties.Annualclinicalexaminationandriskreduction
assessmentcanalsobeperformedconcurrentlywithAAAsurveillance.(See'Aneurysmsurveillance'
above.)
Theprimarygoalsofaneurysmrepairaretopreventrupturewhileminimizingmorbidityandmortality
associatedwithrepair.Twomethodsofaneurysmrepairarecurrentlyavailable:traditionalopensurgery
andendovascularaneurysmrepair(EVAR).Inrandomizedtrials,EVARisassociatedwithlower
perioperativemorbidityandmortalitycomparedwithopenAAArepair,butdoesnotcompletelyeliminate
thefutureriskofAAArupture,whereasopenrepairisassociatedwithhigherperioperativemorbidityand
mortalitythanEVAR,butprovidesamoredefinitiverepair.PerioperativemortalityforelectiveopenAAA
repairis3to5percent,andforEVARis0.5to2percent.Longtermmortalityratesarenotsignificantly
different.(See'Openversusendovascularaneurysmrepair'above.)
Weagreewithguidelinesfrommajormedicalandsurgicalsocietiesthatemphasizeanindividualized
approachwhenchoosingtheapproachtoAAArepair,takingintoaccountaorticanatomy,patientage,
lifeexpectancy,andriskfactorsforperioperativemorbidityandmortality.Forpatientswithfavorable
anatomyforendovascularrepair(asdefinedbythe"InstructionsforUse"ofagivendevice)andahigh
levelofperioperativerisk,werecommendendovascularrepair,ratherthanopensurgicalrepair(Grade
1B).Endovascularrepairmayalsobeappropriateforpatientswithfavorableanatomy,butwhodonot
haveahighsurgicalrisk.Youngpatients(<60years)whohavealoworaverageperioperativeriskand
anexpectedlifespan>10yearsmayelectopensurgicalrepairratherthanendovascularrepairtolimit
lifelongexposuretoradiationthatmightresultfromstentgraftsurveillanceafterendovascularrepair.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic15188Version19.0
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GRAPHICS
Anatomyabdominalaorticaneurysm
Graphic60682Version13.0
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Pararenalabdominalaorticaneurysm
Alarge6by5.4cmpararenalAAAcanbeseeninthecoronalCTreconstruction(A)encroachingon
therightrenalartery(arrow).Inthecrosssectionalimages,therightrenalartery(arrowinB)andthe
leftrenalartery(arrowinC)canbeseen.
AAA:abdominalaorticaneurysmCT:computedtomography.
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AAAruptureprimarilyoccursinlargeraneurysms
Riskofruptureofanabdominalaorticaneurysm(AAA)overtimeaccordingto
thefirstmeasurementofaneurysmdiameterin1792menand465women.The
riskofruptureincreasedmarkedlyinaneurysmslargerthan5.5cmindiameter.
Datafrom:Powell,JT,Greenhalgh,RM,NEnglJMed2003348:1895.
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Patientsundergoingelectiverepairofanabdominal
aorticaneurysmdobetterateightyears
IntheUKSmallAneurysmtrialof1090patientswithamediumsizedabdominal
aorticaneurysm,thereisnodifferenceinsurvivalwithearlyelectivesurgery
comparedwithinitialsurveillance.However,byeightyearspatientsundergoing
earlysurgeryhaveasignificantlybetteroutcomethanthoseinthesurveillance
group(P=0.05).Ibarsrepresentthe95percentconfidenceintervalsforthe
pointestimates.
Datafrom:TheUnitedKingdomSmallAneurysmTrialParticipants.NEnglJMed
2002346:1445.
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Theneedforsurgicalrepairofanabdominalaortic
aneurysmincreasesovertime
IntheUSADAMtrialof1136patientswithamoderatesizedabdominalaortic
aneurysm,theneedforsurgicalrepairinthoserandomizedtoinitialsurveillance
increasedovertime.
DatafromLederle,FA,Wilson,SE,Johnson,GRetal,NEnglJMed2002:346:1437.
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Abdominalaorticaneurysmrepair
(Top)Foropensurgicalrepairofabdominalaorticaneurysm,theaortaisclamped
andtheaneurysmsacopened.Agraftissuturedintotheaortaproximallyand
distally.Atubegraft(illustrated)orabifurcatedgraftisuseddependinguponthe
extentofiliacarterydisease(aneurysmorstenosis).Oncethegraftisinplace,the
aneurysmsacandretroperitoneumareclosedoverthegraft.
(Bottom)Forendovascularrepair,thefoldedendograftisintroducedthroughthe
femoral(oriliac)arteryand,onceitisproperlyposititioned,theselfexpanding
endograftisdeployed.Iliacarteryextensionsarepositionedanddeployedto
completetherepair.
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8/1/2017
ContributorDisclosures
RonaldLDalman,MD Nothingtodisclose MatthewMell,MD,FACS Nothingtodisclose JosephLMills,
Sr,MD Grant/Research/ClinicalTrialSupport:CescaTherapeutics[Criticallimbischemia(Hepatocytegrowth
factor)]VoyagerTrial[Peripheralarterydisease(Rivoxaraban)]NTA3CTAAATrial[Abdominalaortic
aneurysm].Consultant/AdvisoryBoards:GoreBypassSummit[Veinbypass(PTFEgraftsandendografts)].
OtherFinancialInterest:ElsevierRutherford[Vascularsurgery(RutherfordandComprehensiveVascularand
EndovascularSurgerytextbooks)]. JohnFEidt,MD Nothingtodisclose EmileRMohlerIII,
MD Grant/Research/ClinicalTrialSupport:NIH,PluristemandCelgene[PAD(Mesenchymalstemcells)].
PatentHolder:UniversityofPennsylvania[Cardiovascular(Vascularhealthprofilebloodtest)].Equity
Ownership/StockOptions:Cytovas[Cardiovascularbiomarker(Vascularhealthprofilebloodtest)]. DenisL
Clement,MD,PhD Nothingtodisclose KathrynACollins,MD,PhD,FACS Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.
Conflictofinterestpolicy
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Management of Asymptomatic Abdominal Aortic Aneurysm - UpToDate

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