From the Guidelines
Saccular aortic aneurysms should be excised to prevent potentially life-threatening complications, as recommended by the most recent guidelines 1. The primary recommendation is surgical excision of the aneurysm, typically through open repair or endovascular aneurysm repair (EVAR), depending on the patient's anatomy and overall health. Excision is necessary because saccular aneurysms have a higher risk of rupture compared to fusiform aneurysms, even at smaller sizes, as noted in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. The irregular, asymmetric shape of saccular aneurysms creates areas of weakness in the arterial wall that are more prone to rupture, as highlighted in the 2022 ACC/AHA guideline 1. Specific criteria for intervention include:
- Aneurysm size ≥ 45 mm in diameter, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1
- Rapid growth rate (> 0.5 cm in 6 months)
- Presence of symptoms (e.g., pain, embolization) Post-operative management typically involves:
- Close monitoring in ICU for 24-48 hours
- Gradual mobilization
- Blood pressure control (target systolic BP < 140 mmHg)
- Long-term follow-up imaging at 1,6, and 12 months, then annually Excision prevents catastrophic rupture, which has a mortality rate of up to 80%, and can relieve symptoms caused by compression of surrounding structures and reduce the risk of thromboembolic complications. Key considerations for excision include the patient's individual anatomy, as emphasized in the 2022 ACC/AHA guideline 1, and the potential benefits of EVAR over open repair in reducing peri-operative morbidity and mortality, as recommended by the 2024 ESC guidelines 1. Ultimately, the decision to excise a saccular aortic aneurysm should be based on the most recent and highest-quality evidence, prioritizing the patient's morbidity, mortality, and quality of life outcomes.
From the Research
Reasons for Excision of Saccular Aortic Aneurysm
- High risk of rupture: Saccular aortic aneurysms have a higher risk of rupture compared to other types of aneurysms, with mortality rates reported to be around 90% if left untreated 2.
- Risk factors for rupture: The size and type of the aneurysm, presence of intraluminal thrombus, multiplicity of the aneurysm, and adjacent positions can all contribute to arterial wall stress and increase the risk of rupture 2.
- Growth rate: While saccular aneurysms may not have a higher growth rate than fusiform aneurysms, they still require close monitoring and may ultimately require surgical intervention 3.
- Treatment options: Various treatment options are available, including open surgery, endovascular repair, and hybrid approaches, with the choice of technique depending on patient comorbidities and age 4, 5.
Considerations for Treatment
- Patient comorbidities: The presence of extensive pulmonal and cardiovascular comorbidities can increase the risk of surgery and may influence the treatment plan 6.
- Surgical risks: Surgery for saccular aortic aneurysms can be technically demanding and may be associated with high perioperative risks, particularly in patients with multiple comorbidities 6.
- Shared decision making: It is essential to consider the patient's vitality, comorbidities, and wishes when formulating a treatment plan, and shared decision making is crucial in determining the best course of action 6.