What is the best management approach for a 79-year-old male with Type 2 Diabetes Mellitus (DM II), atrial fibrillation (a fib), and Heart Failure with Reduced Ejection Fraction (HFrEF) who has a 6cm diameter and 11cm length abdominal aortic aneurysm (AAA)?

Management of 6cm Abdominal Aortic Aneurysm in High-Risk Patient

This 79-year-old patient with a 6cm AAA meets absolute criteria for repair, but given his multiple high-risk comorbidities (DM II, atrial fibrillation, HFrEF), endovascular aneurysm repair (EVAR) is the preferred approach over open surgery, with careful perioperative optimization of his cardiac conditions. 1

Aneurysm Repair Indication

• Repair is definitively indicated for this patient because his AAA diameter of 6cm exceeds the threshold of 5.5cm, at which the annual rupture risk (approximately 10%) substantially outweighs operative mortality risk 1
• The 2022 ACC/AHA guidelines explicitly state that repair is recommended when AAA diameter is ≥5.5cm in good surgical candidates, and this patient's aneurysm clearly meets this criterion 1
• The 2024 ESC guidelines similarly recommend elective repair for infrarenal AAA ≥55mm 1

Choice of Repair Method: EVAR vs Open Surgery

Endovascular repair (EVAR) is strongly preferred over open surgery for this patient given his multiple high-risk comorbidities 1

Rationale for EVAR:

• HFrEF is NOT a contraindication to EVAR: The 2022 ACC/AHA guidelines specifically note that on multivariable analysis, patients with LVEF <40% undergoing TAAA repair were not more prone to operative death (OR 0.28) or long-term death (OR 0.55) compared to those with higher ejection fractions 1
• Advanced age (79 years) favors EVAR: Carefully selected octogenarians can undergo repair with acceptable mortality rates (5.2% vs 5.7% in younger patients), but EVAR offers lower perioperative risk than open surgery 1
• Multiple comorbidities justify endovascular approach: The presence of DM II, atrial fibrillation, and HFrEF collectively increase surgical risk, making EVAR more appropriate 1

Important Caveat:

• EVAR requires lifelong surveillance imaging to monitor for endoleaks, aneurysm sac stability, and need for reintervention 1
• If the patient cannot comply with this mandatory long-term surveillance, open repair becomes more reasonable despite higher perioperative risk 1

Perioperative Cardiac Optimization

Heart Failure Management:

• Continue all guideline-directed medical therapy (GDMT) for HFrEF through the perioperative period unless acute decompensation occurs 1, 2
• Beta-blockers are mandatory perioperatively to reduce adverse cardiac events and mortality in patients with coronary disease undergoing aortic surgery (Class I recommendation) 1
• The patient should be on foundational HFrEF therapy including beta-blocker, ACE inhibitor/ARB or ARNI, mineralocorticoid receptor antagonist, and SGLT2 inhibitor 1, 3
• Do NOT discontinue beta-blockers perioperatively unless the patient develops cardiogenic shock or severe hypotension with hypoperfusion 2, 4

Atrial Fibrillation Management:

• Anticoagulation must be addressed: With HFrEF and atrial fibrillation, this patient has a CHA₂DS₂-VASc score ≥2 and requires chronic anticoagulation 1
• Direct oral anticoagulants (DOACs) are preferred over warfarin 1
• Anticoagulation will need to be temporarily interrupted perioperatively with appropriate bridging strategy
• Rate control is essential: Beta-blockers serve dual purpose for both HFrEF and AF rate control 1

Diabetes Management:

• Optimize glycemic control preoperatively but avoid hypoglycemia, which can trigger arrhythmias 1
• Continue SGLT2 inhibitors if the patient is on them, as they improve outcomes in HFrEF regardless of diabetes status 1, 3
• Avoid thiazolidinediones as they worsen heart failure 1, 2

Multidisciplinary Team Approach

• Referral to a center with a Multidisciplinary Aortic Team is strongly recommended for this high-risk patient 1
• Such centers achieve excellent outcomes even in patients with multiple comorbidities through meticulous perioperative preparation and technically sound surgery 1
• The team should include vascular surgery, cardiology (heart failure specialist), anesthesiology, and endocrinology 1

Critical Monitoring Parameters

Pre-procedure Assessment:

• Echocardiography to confirm LVEF and assess for valvular disease, particularly given HFrEF 1
• Renal function (creatinine, eGFR) as baseline, since contrast will be used for EVAR 1
• Volume status assessment to ensure euvolemia before procedure 1, 2
• Cardiac rhythm monitoring to assess AF burden and ventricular rate control 1

Post-procedure Monitoring:

• Daily weights to detect fluid shifts (target <2-3 pounds gain in 24 hours) 2
• Blood pressure monitoring in both supine and standing positions to detect hypotension 4
• Serum electrolytes, creatinine, and BUN especially during first few months 2
• Surveillance imaging (CT angiography) at regular intervals to detect endoleaks and monitor aneurysm sac 1

Common Pitfalls to Avoid

• Do NOT delay repair thinking the patient is "too high risk" - rupture risk at 6cm diameter is substantial and likely exceeds operative risk even with comorbidities 1
• Do NOT stop beta-blockers perioperatively unless absolutely necessary due to hemodynamic instability 1, 2
• Do NOT use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) for rate control in this patient with HFrEF - they are contraindicated 1, 2
• Do NOT forget lifelong surveillance after EVAR - this is mandatory and failure to comply leads to worse outcomes 1
• Do NOT use NSAIDs perioperatively or long-term as they worsen heart failure 2, 5

Alternative Consideration: Observation

• Observation is NOT appropriate for this patient given the 6cm diameter 1
• Observation with surveillance imaging every 6-12 months is only reasonable for AAAs measuring 4.0-5.4cm 1
• At 6cm, the intervention threshold has been definitively exceeded 1