What is the recommended treatment for a 6cm infrarenal aortic aneurysm?

Treatment for 6cm Infrarenal Aortic Aneurysm

Endovascular aortic repair (EVAR) should be considered as the preferred treatment for a 6cm infrarenal aortic aneurysm in patients with suitable anatomy and reasonable life expectancy (>2 years). 1

Indication for Intervention

A 6cm infrarenal aortic aneurysm requires intervention based on the following guidelines:

• The size threshold for repair is ≥5.5 cm for men and ≥5.0 cm for women 1, 2
• At 6cm, the aneurysm significantly exceeds this threshold, placing the patient at high risk for rupture
• Rupture risk increases dramatically with size, with 75-90% mortality rate when rupture occurs 2

Treatment Options

1. Endovascular Aortic Aneurysm Repair (EVAR)

EVAR is the preferred first-line treatment for several reasons:

• Reduces perioperative mortality to <1% compared to open repair 1
• Significantly lower perioperative morbidity 1, 2
• Shorter hospital stay and less invasive procedure 2
• Current devices offer features like active fixation, repositioning ability, and improved sealing 1

2. Open Surgical Repair

Open repair should be considered in specific circumstances:

• Patients who cannot comply with long-term surveillance required after EVAR 1
• Patients with anatomy unsuitable for endovascular repair 1
• Patients with reasonable life expectancy (>10 years) without significant comorbidities 1

Decision Algorithm for Treatment Selection

1. Assess patient's life expectancy:

   • If <2 years: Elective AAA repair is not recommended 1
   • If >2 years: Proceed with repair evaluation

2. Evaluate anatomical suitability for EVAR:

   • Assess neck length, angulation, and iliac access
   • Approximately 60-70% of infrarenal AAAs are anatomically suitable for EVAR 1

3. Consider patient-specific factors:

   • Age and comorbidities (renal insufficiency, COPD, previous stroke)
   • Ability to comply with lifelong surveillance after EVAR
   • Patient preference after shared decision-making

4. Choose treatment modality:

   • If anatomy suitable and patient can comply with surveillance: EVAR
   • If anatomy unsuitable or patient cannot comply with surveillance: Open repair

Post-EVAR Surveillance

Critical for long-term success:

• CCT or DUS/CEUS evaluation at 6-12 months post-procedure 1
• Annual surveillance for the first 5 years 1
• Monitor for endoleaks (present in up to one-third of cases) 1
• Immediate intervention for type I and type III endoleaks 1

Risk Modification

Regardless of treatment approach:

• Statin therapy for all AAA patients 2
• Aggressive blood pressure control (target SBP 120-129 mmHg if tolerated) 2
• Smoking cessation (smoking doubles aneurysm expansion rate) 2
• Beta-blockers to reduce shear stress on aortic wall 2

Common Pitfalls to Avoid

1. Delaying intervention: A 6cm aneurysm significantly exceeds the threshold for repair and has high rupture risk
2. Neglecting post-EVAR surveillance: Endoleaks occur in up to one-third of cases and require monitoring
3. Overlooking concomitant aneurysms: Prior to AAA repair, DUS assessment of the femoro-popliteal segment should be considered 1
4. Routine coronary angiography: Prior to AAA repair, routine evaluation with coronary angiography and systematic revascularization in patients with chronic coronary syndromes is not recommended 1

In summary, for a 6cm infrarenal aortic aneurysm, prompt intervention is necessary, with EVAR as the preferred approach in anatomically suitable patients who can comply with surveillance requirements.