What is the next best step for a 68-year-old male with a 5.5 cm infrarenal aneurysm, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and a history of smoking, who has declined previous medication and has a family history of ruptured aortic aneurysm?

Urgent Vascular Surgery Referral for Aneurysm Repair

This patient requires immediate referral to vascular surgery for repair of his 5.5 cm infrarenal abdominal aortic aneurysm (AAA), as this size meets the threshold for intervention to prevent rupture. 1

Rationale for Immediate Surgical Referral

The patient's aneurysm has grown from 3.5 cm to 5.5 cm over two years, representing a growth rate of 1.0 cm/year—double the threshold (>0.5 cm/year) that independently warrants intervention regardless of absolute size. 1 Combined with the absolute diameter of 5.5 cm, this patient has two clear indications for repair. 1

Critical Risk Factors Present

• Family history of ruptured AAA: His sister's recent death from rupture significantly elevates his risk profile 1
• Rapid expansion rate: 1.0 cm/year growth substantially exceeds the 0.5 cm/year threshold 1
• Active smoking: 82.5 pack-years of smoking doubles the rate of aneurysm expansion 1
• Uncontrolled hypertension: BP 156/94 accelerates aneurysm growth 1

Choice Between Open vs. Endovascular Repair

Either open surgical repair or endovascular aneurysm repair (EVAR) is appropriate, with the choice depending on anatomic suitability and patient factors. 1

Key Decision Points:

• For good surgical candidates: Open repair of infrarenal AAAs is indicated (Class I recommendation) 1
• For high-risk patients with cardiopulmonary disease: EVAR is reasonable (Class IIa recommendation) 1
• Long-term outcomes are equivalent: The EVAR, DREAM, and OVER trials demonstrated no difference in all-cause mortality or aneurysm-related mortality between open and endovascular repair at 5-6 years follow-up 1

This Patient's Specific Considerations:

His COPD, obesity (BMI 35), uncontrolled hypertension, and baseline hypoxemia (92% on room air) place him at higher surgical risk, making him a reasonable candidate for EVAR if anatomically suitable. 1 However, EVAR requires lifelong surveillance imaging at 1 month, 6 months, then yearly to monitor for endoleaks and graft complications. 1 Given his history of declining all medications and poor compliance, this is a critical consideration—if he cannot commit to required follow-up imaging, open repair is the only appropriate option. 1

Essential Concurrent Medical Management

While awaiting surgery, aggressive risk factor modification is mandatory:

Blood Pressure Control

• Initiate antihypertensive therapy immediately despite his previous refusal—uncontrolled hypertension (156/94) accelerates aneurysm expansion and increases rupture risk 1
• Beta-blockers are traditionally used, though evidence for slowing AAA growth is limited 2

Smoking Cessation

• Smoking cessation is a Class I recommendation and must be aggressively pursued with pharmacotherapy (nicotine replacement, bupropion, or varenicline) and referral to cessation programs 1
• Smoking doubles the rate of aneurysm expansion 1
• His motivation following his sister's death should be leveraged immediately

Statin Therapy

• Initiate high-intensity statin therapy targeting LDL <70 mg/dL for patients at very high risk of ischemic events 1
• While statins don't prevent AAA expansion, this patient has multiple atherosclerotic risk factors requiring treatment 1

Critical Pitfalls to Avoid

Do not delay surgical referral for "optimization": At 5.5 cm with rapid growth, the rupture risk outweighs perioperative risks. The annual rupture rate for AAAs 5.5-5.9 cm is approximately 9%, with mortality from rupture exceeding 80%. 1

Do not offer EVAR without ensuring follow-up compliance: The EVAR 2 trial showed that patients too unfit for open repair may not benefit from EVAR, with 30-day mortality of 7.3% and no long-term survival advantage. 1 More importantly, reintervention rates are significantly higher with EVAR (5.1% vs 1.7% for open repair), requiring reliable follow-up. 1

Address medication refusal directly: His pattern of declining all medications is incompatible with optimal AAA management and post-EVAR surveillance. This must be confronted before proceeding with EVAR. 1

Timeline for Action

Referral should occur within days, not weeks. With a 5.5 cm aneurysm growing at 1.0 cm/year and strong family history of rupture, this patient is at imminent risk. Surgery should ideally occur within 2-4 weeks of referral. 1

The vascular surgery team will obtain CT angiography to assess anatomic suitability for EVAR and plan the specific repair approach. 1