From the Guidelines
The treatment for an infrarenal abdominal aortic aneurysm (AAA) with an irregular mural thrombus typically involves surgical intervention, either through open surgical repair or endovascular aneurysm repair (EVAR), depending on patient factors and aneurysm characteristics, with EVAR being preferred in higher-risk patients due to its less invasive nature, as supported by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Patient Evaluation and Management
When evaluating a patient with an infrarenal AAA and an irregular mural thrombus, several factors must be considered, including the size of the aneurysm, the patient's overall health, and the presence of any comorbid conditions.
- For aneurysms larger than 5.5 cm in men or 5.0 cm in women, or those showing rapid growth (>0.5 cm in 6 months), surgical intervention is generally recommended, as indicated by various studies, including those referenced in the ACR Appropriateness Criteria for screening for abdominal aortic aneurysm 1.
- While awaiting surgery, patients should receive medical management including blood pressure control with antihypertensives, statin therapy, and antiplatelet therapy, as these measures can help reduce the risk of complications and improve outcomes, as suggested by guidelines and studies such as those published in the Journal of the American College of Radiology 1.
- The presence of an irregular mural thrombus raises concern for embolization and may influence the urgency and approach to repair, highlighting the need for careful evaluation and planning, as discussed in the context of EVAR and open repair 1.
Surgical Intervention
The choice between open surgical repair and EVAR depends on various factors, including the patient’s anatomy, overall health, and the extent of the aneurysm, as outlined in the 2024 ESC guidelines 1.
- EVAR is often preferred in higher-risk patients as it's less invasive, with current devices offering features like active fixation, repositioning ability, low-profile design, and polymer-filled rings for improved sealing, as noted in the guidelines 1.
- Open repair may be more appropriate for younger, healthier patients or those with complex anatomy, where the benefits of a more traditional approach may outweigh the risks, as considered in the evaluation of treatment options 1.
Post-Procedure Care
Post-procedure, patients require lifelong surveillance with imaging (typically ultrasound or CT) at regular intervals to monitor for complications or recurrence, as emphasized in the guidelines for follow-up after EVAR and open repair 1.
- Smoking cessation is essential as continued smoking significantly increases rupture risk and complications, underscoring the importance of lifestyle modifications in the management of AAA, as highlighted in various studies and guidelines 1.
From the Research
Treatment Options for Infrarenal Abdominal Aortic Aneurysm with Irregular Mural Thrombus
- The primary treatment methods for infrarenal abdominal aortic aneurysms are open surgical repair (OSR) and endovascular aneurysm repair (EVAR) 2, 3.
- EVAR is currently the primary treatment method due to improved short-term morbidity and mortality outcomes 2.
- The indication for repair includes either symptomatic aneurysms or aneurysms with a diameter greater than 5.4 cm 2.
Considerations for Open Surgical Repair (OSR)
- OSR is still necessary for patients with anatomic constraints that preclude the use of endovascular devices, such as a short aneurysm neck, extensive aortic neck thrombus, or iliac artery tortuosity 4.
- A study found that 92.6% of patients underwent OSR due to at least one anatomic constraint that precluded the use of the FEVAR device 4.
Endovascular Aneurysm Repair (EVAR) Considerations
- EVAR has replaced open surgery as the primary modality for aneurysm repair, with approximately 60% of abdominal aortic aneurysms being confined to the infrarenal portion of the aorta and amenable to repair with off-the-shelf endovascular devices 3.
- Advances in endovascular aneurysm repair have been made with new commercially available devices for treatment of more complex aortic pathology 4, 5.