From the Guidelines
Elective repair is recommended for abdominal aortic aneurysm (AAA) if the diameter is ≥55 mm in men or ≥50 mm in women, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Diagnosis and Management of AAA
The diagnosis of AAA is typically made using imaging studies such as ultrasound, CT, or MRI. The management of AAA depends on the size of the aneurysm, as well as the patient's overall health and risk factors.
- For small aneurysms (<55 mm in men or <50 mm in women), regular surveillance with imaging studies is recommended to monitor the size of the aneurysm.
- For larger aneurysms (≥55 mm in men or ≥50 mm in women), elective repair is recommended to prevent rupture.
- In cases of ruptured AAA, emergency repair is necessary to prevent death.
Risk Factors for AAA
Several risk factors have been identified for the development of AAA, including:
- Advanced age
- Male sex
- Smoking
- Family history of AAA
- Hypertension
- Hypercholesterolemia
- Peripheral artery disease
Treatment Options for AAA
Treatment options for AAA include:
- Elective repair: This is the recommended treatment for large aneurysms (≥55 mm in men or ≥50 mm in women).
- Endovascular repair: This is a minimally invasive procedure that involves placing a stent-graft in the aorta to exclude the aneurysm from blood flow.
- Open repair: This is a surgical procedure that involves replacing the affected portion of the aorta with a graft.
- Surveillance: This is recommended for small aneurysms (<55 mm in men or <50 mm in women) to monitor the size of the aneurysm and prevent rupture.
Importance of Screening
Screening for AAA is important, especially in high-risk populations such as men over 65 years of age with a history of smoking or family history of AAA. The 2024 ESC guidelines recommend screening for AAA in these populations 1. According to the acr appropriateness criteria® screening for abdominal aortic aneurysm, the prevalence of AAA in persons >65 years of age ranges from 1.7% to 4.5% for men and 0.5% to 1.3% for women 1. The natural history of AAA is progressive expansion and potential rupture, which is a medical emergency with high mortality, as stated in the acr appropriateness criteria® pulsatile abdominal mass, suspected abdominal aortic aneurysm: 2023 update 1. Therefore, early detection and treatment of AAA are crucial to prevent rupture and improve outcomes.
From the Research
AAA Overview
- Abdominal aortic aneurysms (AAA) are the most common arterial aneurysms, with a prevalence of 4-8% in Western society 2.
- AAA can be asymptomatic, with about 75% of cases being asymptomatic, and are often discovered during routine physical check-ups or diagnostic investigations 3.
- The presence of AAA is associated with a high cardiovascular risk, including myocardial infarction, stroke, or cardiovascular death, which exceeds the risk of aneurysm rupture 4.
Diagnosis and Monitoring
- Ultrasonography and CT are the two most commonly used imaging modalities for diagnosing AAA 3.
- Contrast-enhanced CT angiography is considered the gold standard for preoperative imaging and image-based treatment planning in AAA repair 2.
- Non-contrast MR angiography allows for accurate monitoring of aortic diameters in AAA patients 2.
- Measurement of aortic diameters is more accurate with 3D-CT/MRI compared to ultrasound 2, 3.
Treatment and Management
- Endovascular or open surgical aneurysm repair is indicated in patients with large AAA ≥ 5.5 cm in diameter to prevent aneurysm rupture 4.
- Treatment with statins has been shown to reduce cardiovascular mortality in AAA patients and slow the rate of AAA growth 4.
- The use of beta-blockers, ACE inhibitors, and AT1-receptor antagonists does not affect AAA growth but may be indicated for comorbidities 4.
- Antibiotic therapy with roxithromycin has a small effect on AAA growth, but its use must be weighed against the potential risk of widespread antibiotic use 4.
Guidelines and Recommendations
- The Society for Vascular Surgery practice guidelines recommend endovascular repair as the preferred method of treatment for ruptured aneurysms 5.
- Elective EVAR should 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 5.
- Elective open aneurysm repair should 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 5.