SVS Guidelines on Care of Patients With Abdominal Aortic Aneurysms

In January 2018, the Society for Vascular Surgery (SVS) issued updated guidelines on the care of patients with abdominal aortic aneurysms (AAAs).^{[18, 19]} These guidelines included the following recommendations:

Surveillance imaging at 12-month intervals is recommended for patients with an AAA of 4.0 to 4.9 cm in diameter.
Recommend performing physical examination that includes an assessment of femoral and popliteal arteries.
Endovascular aneurysm repair (EVAR) is recommended as the preferred method of treatment for ruptured aneurysms.
To incorporate knowledge gained through the Vascular Quality Initiative (VQI) and other regional quality collaboratives, it is suggested that the VQI mortality risk score be used for mutual decision-making with patients considering aneurysm repair.
It is suggested that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year.
It is suggested that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year.
To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergency repair, a door-to-intervention time of < 90 minutes, based on a framework of 30-30-30 minutes, is suggested for the management of the patient with a ruptured aneurysm.
Recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion.
Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised.
Increased utilization of color duplex ultrasonography is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion.
Recommend a preoperative resting 12-lead electrocardiogram (ECG) in all patients undergoing EVAR or open surgical repair within 30 days of planned treatment.
Suggest deferring open aneurysm repair for at least 6 months after drug-eluting coronary stent placement or, alternatively, performing EVAR with continuation of dual antiplatelet therapy.
Perioperative transfusion of packed red blood cells recommended if the hemoglobin level is < 7 g/dL.
Recommend elective repair for the patient at low or acceptable surgical risk with a fusiform AAA that is ≥5.5 cm.
General endotracheal anesthesia is recommended for patients undergoing open aneurysm repair.

Medication

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Media Gallery

Radiograph shows calcification of abdominal aorta. Left wall is clearly depicted and appears aneurysmal; however, right wall overlies spine.
On radiography, lateral view clearly shows calcification of both walls of abdominal aortic aneurysm, allowing diagnosis to be made with certainty.
CT demonstrates abdominal aortic aneurysm (AAA). Aneurysm was noted during workup for back pain, and CT was ordered after AAA was identified on radiography. No evidence of rupture is seen.
Arteriography demonstrates infrarenal abdominal aortic aneurysm. This arteriogram was obtained in preparation for endovascular repair of aneurysm.
Lateral arteriogram demonstrates infrarenal abdominal aortic aneurysm. Demonstration of superior mesenteric artery, inferior mesenteric artery, and celiac artery on lateral arteriogram is important for complete evaluation of extent of aneurysm.
Arteriogram after successful endovascular repair of abdominal aortic aneurysm.
Ultrasonogram from patient with abdominal aortic aneurysm (AAA). This aneurysm was best visualized on transverse or axial image. Patient underwent conventional AAA repair.
MRI of 77-year-old man with leg pain believed to be secondary to degenerative disk disease. During evaluation, abdominal aortic aneurysm was discovered.
Age is risk factor for development of aneurysm.
Inflammation, thinning of media, and marked loss of elastin.
Pulsatile abdominal mass.
Aneurysm with retroperitoneal fibrosis and adhesion of duodenum.
Aortic endoprosthesis (Cook aortic and aortobi-iliac endograft).
Endoaneurysmorrhaphy
Endovascular grafts.
Atheroemboli from small abdominal aortic aneurysms produce livedo reticularis of feet (ie, blue toe syndrome).
Enhanced spiral CT scans with multiplanar reconstruction and CT angiogram.
Angiography is used to diagnose renal area. In this instance, endoleak represented continued pressurization of sac.

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Table 1. Operative Mortality Risk With Open Repair of Abdominal Aortic Aneurysm

Lowest Risk	Moderate Risk	High Risk
Age < 70 y	Age 70-80 y	Age 80 y
Physically active	Active	Inactive, poor stamina
No clinically overt cardiac disease	Stable coronary disease; remote MI; LVEF >35%	Significant coronary disease; recent MI; frequent angina; CHF; LVEF < 25%
No significant comorbidities	Mild COPD	Limiting COPD; dyspnea at rest; O₂ dependency; FEV₁< 1 L/sec
...	Creatinine 2.0-3.0 mg/dL	...
Normal anatomy	Adverse anatomy or AAA characteristics	Creatinine >3 mg/dL
No adverse AAA characteristics	...	Liver disease (↑PT; albumin < 2 g/dL)
Anticipated operative mortality, 1-3%	Anticipated operative mortality, 3-7%	Anticipated operative mortality, at least 5-10%; each comorbid condition adds ~3-5% mortality risk
AAA = abdominal aortic aneurysm; CHF = chronic heart failure; COPD = chronic obstructive pulmonary disease; FEV₁ = forced expiratory volume in 1 second; LVEF = left ventricular ejection fraction; MI = myocardial infarction; PT = prothrombin time.

Table 2. Abdominal Aortic Aneurysm Size and Estimated Annual Risk of Rupture

AAA Diameter (cm)	Rupture Risk (%/y)
< 4	0
4-5	0.5-5
5-6	3-15
6-7	10-20
7-8	20-40
>8	30-50
AAA = abdominal aortic aneurysm.

Table 3. Factors Affecting Risk of Abdominal Aortic Aneurysm Rupture

Factor	Low Risk	Average Risk	High Risk
Diameter	< 5 cm	5-6 cm	>6 cm
Expansion	< 0.3 cm/y	0.3-0.6 cm/y	>0.6 cm/y
Smoking/COPD	None, mild	Moderate	Severe/steroids
Family history	No relatives	One relative	Numerous relatives
Hypertension	Normal blood pressure	Controlled	Poorly controlled
Shape	Fusiform	Saccular	Very eccentric
Wall stress	Low (35 N/cm²	Medium (40 N/cm²	High (45 N/cm²)
Sex	...	Male	Female
COPD = chronic obstructive pulmonary disease.

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Author

Saum A Rahimi, MD, FACS Interim Chief, Assistant Professor of Surgery, Division of Vascular Surgery, Rutgers Robert Wood Johnson Medical School

Saum A Rahimi, MD, FACS is a member of the following medical societies: American College of Surgeons, Society for Vascular Surgery, Eastern Vascular Society, Vascular Society of New Jersey

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Integrated Vascular Surgery Residency and Fellowship, Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

Suman Annambhotla, MD Fellow in Vascular Surgery, Northwestern University, The Feinberg School of Medicine

Suman Annambhotla, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, and Society for Vascular Surgery