Abdominal Aortic Aneurysm Management in the Inpatient Setting
The management of abdominal aortic aneurysms (AAA) in the inpatient setting should follow a structured approach based on aneurysm size, symptoms, and patient factors, with elective repair recommended for men with AAA ≥55 mm or women with AAA ≥50 mm to prevent rupture. 1
Initial Assessment and Risk Stratification
- Patients presenting with the clinical triad of abdominal/back pain, pulsatile abdominal mass, and hypotension require immediate surgical evaluation due to high likelihood of rupture 1
- All symptomatic AAAs warrant repair regardless of diameter, as symptoms indicate increased risk of rupture 1
- For asymptomatic patients, management depends primarily on aneurysm size, with different thresholds for men and women 1
- Duplex ultrasound (DUS) is recommended as the initial imaging modality for AAA assessment, with CT or MRI indicated when DUS is inadequate 1
Management Based on Aneurysm Size
Small AAAs (<5.0 cm in men, <4.5 cm in women):
- Surveillance rather than intervention is recommended 1
- Monitoring schedule:
Large AAAs (≥5.5 cm in men, ≥5.0 cm in women):
- Elective repair is recommended to eliminate rupture risk 1
- The choice between open or endovascular repair should be based on anatomical suitability, patient risk factors, and life expectancy 1
Special Considerations for Intervention
- Rapid growth (≥5 mm in 6 months or ≥10 mm per year) may warrant repair even at smaller diameters 1
- Saccular aneurysms ≥45 mm may be considered for elective repair due to higher rupture risk compared to fusiform aneurysms 1
- In patients with limited life expectancy (<2 years), elective AAA repair is not recommended 1
- For ruptured AAA with suitable anatomy, endovascular repair is recommended over open repair to reduce perioperative morbidity and mortality 1
Medical Management
- Optimize cardiovascular risk factors:
- Routine coronary angiography and systematic revascularization prior to AAA repair is not recommended in patients with chronic coronary syndromes 1
Surgical Approaches
Open Repair:
- Traditional approach through midline laparotomy with Dacron graft replacement 1
- Higher perioperative morbidity but fewer long-term complications 1
- Reasonable option for patients who cannot comply with long-term surveillance required after endovascular repair 1
Endovascular Aortic Repair (EVAR):
- Reduces perioperative mortality to <1% compared to open repair 1
- Associated with higher risk of long-term complications requiring reintervention 1
- Should be considered as preferred therapy in patients with suitable anatomy and reasonable life expectancy (>2 years) 1
- Requires mandatory lifelong surveillance 1
Post-Procedure Surveillance
After Open Repair:
- First follow-up imaging within 1 month post-operatively 1
- If findings are stable, imaging every 5 years thereafter 1
After EVAR:
- Follow-up imaging with CT/MRI and DUS at 1 month and 12 months post-operatively 1
- If no abnormalities are documented, annual DUS/CEUS with CT or MRI every 5 years 1
- Monitoring for endoleaks, which may require reintervention 1
Management of Complications
- Type I and Type III endoleaks require prompt reintervention to achieve seal 1
- Type II endoleaks may seal spontaneously but require surveillance; intervention is indicated if associated with aneurysm sac growth 1
- For patients with growing aneurysm sac (≥10 mm) after EVAR, consider embolization if feasible 1
Common Pitfalls to Avoid
- Delaying intervention for symptomatic AAAs, which have higher mortality than elective repairs 1, 2
- Using the same size threshold for intervention in women as in men (women have higher rupture risk at smaller diameters) 1
- Failing to assess for concomitant aneurysms, particularly in the femoro-popliteal segment 1
- Overlooking the need for lifelong surveillance after EVAR 1