From the Guidelines
The treatment for an aortic aneurysm should be guided by the most recent and highest quality evidence, which recommends elective repair if the AAA diameter is ≥55 mm in men or ≥50 mm in women, as stated in the 2024 ESC guidelines 1.
Key Considerations
- The size of the aneurysm is a critical factor in determining the treatment approach, with larger aneurysms requiring surgical intervention to prevent rupture.
- The location of the aneurysm, whether it's in the thoracic or abdominal aorta, also plays a role in determining the best course of treatment.
- The growth rate of the aneurysm is another important consideration, with rapidly growing aneurysms (more than 0.5 cm in 6 months) requiring closer monitoring and potentially surgical intervention.
Treatment Options
- For small aneurysms (less than 5.5 cm in diameter), watchful waiting with regular imaging every 6-12 months is typically recommended, along with blood pressure control using medications such as beta-blockers or ACE inhibitors.
- For larger aneurysms (greater than 5.5 cm), rapidly growing aneurysms, or those causing symptoms, surgical intervention is necessary, which typically involves open surgical repair or endovascular aneurysm repair (EVAR).
- Lifestyle modifications, including smoking cessation, cholesterol management, and moderate exercise, are crucial in managing aortic aneurysms.
Surgical Intervention
- The 2024 ESC guidelines recommend endovascular repair over open repair for ruptured AAA with suitable anatomy to reduce peri-operative morbidity and mortality 1.
- The choice of surgical approach depends on the location and size of the aneurysm, as well as the patient's overall health and suitability for surgery.
Post-Surgical Follow-Up
- Regular imaging is necessary to ensure the repair remains intact and to monitor for complications.
- The frequency of follow-up imaging depends on the type of repair and the patient's individual risk factors.
Medical Therapy
- The main aim of medical therapy is to reduce shear stress on the diseased segment of the aorta by reducing blood pressure and cardiac contractility, as stated in the 2014 ESC guidelines 1.
- Beta-blockers, ACE inhibitors, and statins may be used to control blood pressure and reduce the risk of aneurysm expansion.
From the Research
Treatment Options for Aortic Aneurysm
The treatment of aortic aneurysm depends on various factors, including the size and location of the aneurysm, as well as the patient's overall health. The main treatment options are:
- Endovascular aneurysm repair (EVAR): a minimally invasive procedure where a stent graft is placed inside the aorta to exclude the aneurysmal segment 2, 3, 4, 5
- Open surgical repair (OSR): a traditional surgical procedure where the aneurysmal segment is replaced with a graft 2, 3, 4, 5
Indications for Treatment
Surgery is indicated in men with an asymptomatic abdominal aortic aneurysm (AAA) ≥ 5.5 cm and in women, ≥ 5.0 cm 2. The indication in men is based on four randomized trials, while in women the data are not conclusive.
Comparison of EVAR and OSR
EVAR is preferred over OSR for most patients due to its minimally invasive nature and lower perioperative mortality rate 2, 3, 4. However, OSR may be preferred for younger patients with long life expectancy and low perioperative risk 3, 5. EVAR has a higher rate of secondary interventions due to graft-related issues, such as endoleaks, while OSR has a higher rate of complications, such as mechanical ventilation and blood transfusions 3, 4.
Outcomes and Complications
The pooled 30-day mortality rate is 1.16% (95% confidence interval [0.92; 1.39]) following EVAR, and 3.27% [2.7; 3.83] after OSR 2. Women have higher operative/interventional mortality than men (odds ratio 1.67%) 2. The mortality rate for ruptured AAA is extremely high, with around 80% of women and 70% of men dying after AAA rupture 2, 4.
Long-term Monitoring
Long-term periodic monitoring by means of imaging (duplex sonography, plus computed tomography if needed) is essential, particularly following EVAR, to detect and treat endoleaks, document stable diameter of the eliminated aneurysmal sac, and determine whether reintervention is necessary (long-term reintervention rate circa 18%) 2.