What is the recommended follow-up for a patient with a history of repaired visceral pseudo-aneurysm, hypertension, poor wound healing, claw toes, and myopia?

Follow-Up After Visceral Pseudo-Aneurysm Repair

After successful repair of a visceral pseudo-aneurysm, obtain baseline CT angiography within 30 days post-procedure, followed by imaging at 12 months, then annually for the first 2 years, and every 5 years thereafter if findings remain stable. 1

Initial Post-Repair Surveillance

• Perform baseline CT angiography (CTA) within 1 month of the repair to establish a reference point and assess treatment success 1, 2
• This early imaging is critical to detect immediate complications such as endoleaks (if endovascular repair was performed), residual filling of the pseudo-aneurysm, or early graft-related issues 2, 3
• The 30-day scan serves as the foundation for all subsequent surveillance comparisons 2

Standard Long-Term Surveillance Protocol

For open surgical repair:

• Obtain CTA at 12 months post-operatively 1
• Continue yearly CTA for the first 2 post-operative years 1
• After 2 years of stability, extend surveillance to every 5 years 1
• Complications after open repair are rare (2-4%), primarily consisting of anastomotic or para-anastomotic issues 1

For endovascular repair:

• Obtain imaging at 1 month and 12 months post-procedure 1
• Continue yearly imaging until the fifth post-operative year 1
• After 5 years without complications, extend surveillance to every 5 years 1
• Endovascular repairs have higher complication rates (16-30%) requiring more intensive lifelong surveillance 1, 2

Alternative Imaging Modalities

• Consider duplex ultrasound (DUS) or contrast-enhanced ultrasound (CEUS) for long-term surveillance in low-risk patients after the first year, particularly if frequent monitoring is needed to reduce radiation exposure 1
• If DUS/CEUS shows any abnormality, confirm with CTA or cardiovascular MRI 1
• Cardiovascular MRI should be considered instead of CTA when frequent controls are required after the first year of follow-up to minimize radiation exposure 1

Surveillance for Specific Complications

If endoleak is detected (endovascular repair):

• Type I or III endoleaks require immediate re-intervention to achieve seal 1, 2
• Type II or V endoleaks with significant sac expansion (≥10 mm) warrant consideration for re-intervention 1, 2

If aneurysm sac growth is observed without endoleak:

• Repeat CTA every 6-12 months depending on the growth rate observed 1
• Growth rate determines surveillance intensity: faster growth requires 6-month intervals, slower growth allows 12-month intervals 1

Essential Medical Management

Aggressive cardiovascular risk factor modification is mandatory:

• Target LDL-C reduction by ≥50% from baseline with goal <1.4 mmol/L (<55 mg/dL) 1, 4
• Statin therapy is associated with decreased short- and long-term mortality after visceral aneurysm repair 1, 4
• Implement guideline-directed blood pressure control, particularly given the patient's hypertension 1
• Smoking cessation is critical if applicable, as smoking accelerates aneurysm disease progression 4

Special Considerations for Visceral Pseudo-Aneurysms

• Visceral pseudo-aneurysms have high rupture risk and require urgent treatment when identified 3
• Technical success rates for endovascular treatment are approximately 85.7%, with clinical success around 71.4% 3
• Most patients (77%) with traumatic visceral pseudo-aneurysms are treated within 24 hours of identification 3
• No rebleeding or reintervention typically occurs after discharge if initial repair is successful 3

When to Intensify Surveillance

Shorten surveillance intervals if:

• Any new symptoms develop (abdominal pain, back pain, signs of bleeding) 4
• Imaging demonstrates interval growth or new abnormalities 1
• Patient has poor wound healing (as noted in this case), which may indicate underlying connective tissue disorder requiring closer monitoring 1
• Multiple cardiovascular risk factors remain uncontrolled 1, 4

Common Pitfalls to Avoid

• Do not eliminate the 1-month baseline scan - this is essential for establishing the reference point for all future comparisons 2
• Do not rely solely on physical examination for follow-up; imaging is mandatory as most complications are asymptomatic until catastrophic failure 5, 3
• Avoid fluoroquinolone antibiotics unless absolutely necessary with no alternative, as they may accelerate aneurysm growth 6, 4
• Do not discontinue surveillance after 5 years - lifelong follow-up is recommended, though intervals can be extended to every 5 years if stable 1