Surgical Treatment of Abdominal Aortic Aneurysm
Elective surgical repair is recommended for abdominal aortic aneurysms (AAA) when the diameter reaches ≥55 mm in men or ≥50 mm in women. 1, 2
Size Thresholds for Intervention
- Men: Repair when AAA diameter ≥55 mm 1
- Women: Repair when AAA diameter ≥50 mm 1, 2
- Saccular aneurysms: Consider repair at ≥45 mm 1
- Rapidly growing aneurysms: Consider repair when growth is ≥5 mm in 6 months or ≥10 mm per year 1
Pre-operative Evaluation
- Complete vascular evaluation of the entire aorta is mandatory using CCT (computed tomography) as the optimal pre-operative imaging modality 1
- When CCT is contraindicated, consider CMR (cardiac magnetic resonance), though calcification assessment is challenging 1
- DUS (duplex ultrasound) assessment of the femoro-popliteal segment is recommended to detect concomitant aneurysms 1
- Important caveat: Routine coronary angiography and systematic revascularization in patients with chronic coronary syndromes is NOT recommended prior to AAA repair 1
Surgical Approach Selection
Endovascular Aneurysm Repair (EVAR)
EVAR should be considered as the preferred therapy for patients with:
- Suitable anatomy
- Reasonable life expectancy (>2 years)
- Ruptured AAA (to reduce peri-operative morbidity and mortality) 1
Benefits of EVAR:
- Lower perioperative mortality (<1%) 1
- Reduced cardiovascular complications 1
- Reduced invasiveness 1
- Shorter operation time 1
Considerations for EVAR:
- Percutaneous femoral approach with ultrasound guidance reduces access-related complications 1
- Requires lifelong surveillance due to risk of late complications (endoleaks, migration, rupture) 1
- Higher risk of re-intervention in the long term 1
Open Surgical Repair
Open repair considerations:
- Traditional approach through mid-line laparotomy with Dacron graft 1
- Higher perioperative mortality (5-10%) and cardiovascular complications 1
- Consider prophylactic mesh use in obese patients to reduce incisional hernia risk 1
Special Considerations
Complex Aneurysms
- For juxta- or para-renal AAA, both open and endovascular treatment can be proposed in high-volume centers 1
- For complex endovascular treatment, consider fenestrated or branch stent endografts 1
Contraindications for Elective Repair
Post-operative Surveillance
- After EVAR: 30-day imaging is mandatory to assess success of intervention 1
- Lifelong surveillance is required after EVAR due to risk of endoleaks (present in up to one-third of cases) 1, 2
- Surveillance methods: CCT + DUS/CEUS (contrast-enhanced ultrasound) 1
- Surveillance schedule after EVAR: imaging at 6-12 months post-procedure with annual surveillance for at least 5 years 2
Risk Management
- Aggressive cardiovascular risk management is recommended for all AAA patients to reduce expansion rate and improve outcomes 2
- Key interventions:
- Blood pressure control
- Statin therapy (inhibits aneurysm expansion)
- Smoking cessation (critical as smoking doubles aneurysm expansion rate)
- Beta-blockers
- Lipid management 2
Surveillance for Small Aneurysms
For AAAs not yet meeting surgical criteria, recommended surveillance intervals:
- AAA 4.0-4.4 cm: Ultrasound every 12 months
- AAA 4.5-5.4 cm (men)/4.5-4.9 cm (women): Ultrasound every 6 months 2