Does a 77-year-old male with a history of infra-renal abdominal aortic aneurysm (AAA) repair with an endograft in 2017 and a newly discovered 4 cm aneurysm of the ascending aorta require ongoing surveillance scans?

Surveillance Recommendations for Aortic Aneurysms After Endograft Repair

Yes, this patient absolutely requires continued surveillance imaging for both the infrarenal AAA endograft and the newly discovered ascending aortic aneurysm. Based on current guidelines, lifelong surveillance is necessary for all patients who have undergone endovascular aneurysm repair (EVAR).

Surveillance for Infrarenal AAA Endograft

Recommended Protocol:

1. For the infrarenal AAA endograft (2017 repair):

   • Since the last CTA in 2018 showed no endoleak, the patient should immediately undergo:
     • Duplex ultrasound to assess for any current endoleaks or sac enlargement
     • CT or MRI of the abdomen and pelvis (as it has been 5+ years since last cross-sectional imaging)
   • If no abnormalities are found on current imaging:
     • Continue with annual duplex ultrasound surveillance 1
     • Schedule additional cross-sectional imaging (CT/MRI) every 5 years 1

2. If abnormal findings are detected (such as endoleak, sac enlargement, stent migration, or fracture):

   • Immediate cross-sectional imaging with CT or MRI 1
   • Potential intervention based on findings

Surveillance for Ascending Aortic Aneurysm

Recommended Protocol:

1. For the newly discovered 4 cm ascending aortic aneurysm:
   • Current size (4 cm) requires regular monitoring but not immediate intervention
   • Schedule CT or MRI imaging every 12 months 2
   • Consider more frequent imaging (every 6 months) if:
     • Patient has risk factors for rapid growth (smoking, uncontrolled hypertension)
     • Future imaging shows growth rate ≥5 mm in 6 months or ≥10 mm per year 2

Rationale and Important Considerations

1. Endograft surveillance is mandatory:

   • The incidence of late aortic rupture after EVAR is >5% through 8 years of follow-up 1
   • Endoleaks may develop years after initial repair and can lead to aneurysm sac enlargement and rupture
   • Stent graft fracture and migration occurs in 3-4% of patients by 4 years post-EVAR 1

2. Imaging modality selection:

   • Duplex ultrasound is 95% accurate for measuring aortic aneurysm sac diameter and 100% specific for detecting type I and III endoleaks 1
   • CT remains the gold standard but exposes the patient to radiation and contrast
   • For the ascending aortic aneurysm, CT or MRI is required for accurate measurement 2

3. Risk factors in this patient:

   • Advanced age (77 years)
   • Coronary artery disease (RCA occlusion, 40% left main)
   • Multiple aortic aneurysms (suggesting possible systemic aortopathy)

4. Common pitfalls to avoid:

   • Abandoning surveillance after several years of stability (late complications can still occur)
   • Relying solely on ultrasound without periodic cross-sectional imaging
   • Failing to monitor both aneurysm sites independently

Management Recommendations

1. Medical optimization:

   • Continue losartan for blood pressure control (target SBP 120-129 mmHg)
   • Continue statin therapy (Crestor)
   • Continue antiplatelet therapy (Plavix)
   • Ensure smoking cessation if applicable

2. Patient education:

   • Emphasize the importance of adhering to the surveillance schedule
   • Teach warning signs that require immediate medical attention (new back/abdominal pain, syncope)

This surveillance approach follows the Class I recommendation from the 2022 ACC/AHA guidelines that "periodic long-term surveillance imaging should be performed to monitor for endoleak, document shrinkage or stability of the excluded aneurysm sac, and determine the need for further intervention" 1.