What are the key points to cover when presenting on abdominal aortic aneurysm (AAA) repair to a surgery attending?

Key Points for Abdominal Aortic Aneurysm Repair Presentation

Endovascular repair should be the preferred approach for AAA when anatomically suitable, as it reduces perioperative morbidity and mortality compared to open repair. 1

Definition and Epidemiology

• AAA defined as permanent dilatation of abdominal aorta ≥3.0 cm
• Prevalence: 4-9% in men and 1% in women over 65 years 1, 2
• Mortality for ruptured AAA: 65-85%, with 54% mortality at 6 hours and 76% at 24 hours 3, 2
• Risk factors: smoking (strongest modifiable risk factor), male sex, hypertension, family history, age >65 years, peripheral artery disease 3, 4

Preoperative Assessment

Imaging

• CCT (contrast-enhanced CT) is the optimal pre-operative imaging modality 1
• Complete vascular evaluation including entire aorta (ascending, arch, descending) is mandatory 1
• DUS (duplex ultrasound) assessment of femoro-popliteal segment should be performed to detect concomitant aneurysms 1
• MRI can be considered when CCT is contraindicated, though calcification assessment is challenging 1

Anatomical Considerations

• Detailed assessment of:
  • Proximal and distal landing zones
  • Neck length and angulation
  • Iliac artery access (tortuosity, calcification)
  • Presence of thrombus
  • Relationship to renal and visceral arteries

Risk Stratification

• Routine coronary angiography and systematic revascularization in patients with chronic coronary syndromes is NOT recommended 1
• Assess comorbidities: COPD, renal function, cardiac status
• Life expectancy assessment (repair not recommended if <2 years) 1

Indications for Intervention

Size Thresholds

• Men: ≥5.5 cm diameter 1, 3
• Women: ≥5.0 cm diameter 1, 3
• Rapid growth: ≥5 mm in 6 months or ≥10 mm per year 1
• Saccular aneurysms: ≥4.5 cm may be considered 1

Surgical Approaches

Endovascular Repair (EVAR)

• Preferred approach when anatomically suitable and reasonable life expectancy (>2 years) 1
• Benefits:
  • Reduced perioperative mortality (<1%) 1
  • Shorter hospital stay
  • Less invasive
• Limitations:
  • Higher risk of re-intervention long-term 1, 3
  • Requires lifelong surveillance 1, 3
  • Anatomical constraints

Open Repair

• Traditional approach through midline laparotomy
• Indicated when EVAR not anatomically suitable
• Higher perioperative morbidity but fewer long-term reinterventions 1
• Incisional hernia risk, especially in obese patients (consider prophylactic mesh) 1

Complications to Highlight

Endoleaks

• Most common complication after EVAR (up to 1/3 of cases) 1
• Five types:
  • Type I: Seal failure at attachment sites (requires correction) 1
  • Type II: Retrograde flow from branch vessels (may self-resolve)
  • Type III: Graft defect/disconnection (requires correction) 1
  • Type IV: Graft porosity
  • Type V: Endotension (sac enlargement without visible leak)
• Chronic anticoagulation increases risk of reintervention 1

Other Complications

• Spinal cord ischemia
• Renal dysfunction
• Access site complications
• Graft infection
• Colonic ischemia

Postoperative Surveillance

• After EVAR:

  • First follow-up imaging at 1 month (CCT or CMR and DUS/CEUS) 1
  • 12-month follow-up with CCT or CMR and DUS/CEUS 1
  • Annual DUS/CEUS thereafter if no abnormalities 1
  • CCT or CMR every 5 years 1

• After open repair:

  • First follow-up imaging within 1 month 1
  • Annual follow-up for first 2 years 1
  • Every 5 years thereafter if findings stable 1

Risk Reduction Strategies

• Smoking cessation (doubles rate of aneurysm expansion) 3
• Blood pressure control (target SBP 120-129 mmHg if tolerated) 3
• Statin therapy (inhibits aneurysm expansion) 3
• Beta-blockers to reduce shear stress 3

Key Points for the Attending

• Emphasize your understanding of anatomical considerations that influence repair approach
• Demonstrate knowledge of size thresholds and their evidence base
• Show awareness of long-term surveillance requirements
• Highlight recognition of potential complications and management strategies
• Present familiarity with both open and endovascular techniques