Abdominal Aortic Aneurysm

Publication Date: January 3, 2018

Key Points

Key Points

Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes.

The SVS recommends endovascular repair as the preferred method of treatment for ruptured aneurysms.

The SVS suggests that the Vascular Quality Initiative mortality risk score (https://qxmd.com/calculate/calculator_322/vascular-quality-initiative-vqi-cardiac-risk-index-cri-evar) be used for mutual decision-making with patients considering aneurysm repair.

The SVS also suggest that elective endovascular aneurysm repair (EVAR) be limited to hospitals with a documented mortality and conversion rate to open surgical repair of ≤2% and that perform ≥10 EVAR cases each year. The SVS also suggests that elective open aneurysm repair be limited to hospitals with a documented mortality of ≤5% and that perform ≥10 open aortic operations of any type each year.

The SVS suggests a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm.

The SVS recommends treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion.

Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised.

Increased utilization of color duplex ultarasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion.

Diagnosis

Diagnos...

...sical Examinati...

...ts with a suspected or known abdominal aortic ane...

...h a popliteal or femoral artery aneurysm,...


...ssment of Medical Comorbiditi...

...ts with active cardiac conditions, inclu...

...significant clinical risk factors, such as...

The SVS recommends a preoperative resting 12-lead...

The SVS recommends echocardiography befor...

...SVS suggests coronary revascularization be...

...sts coronary revascularization before aneurys...

...patients who may need aneurysm re...

The SVS suggests deferring elective aneurysm repa...

...VS suggests deferring open aneurysm repair for...

...atients with a drug-eluting coronary stent requi...

...suggests continuation of beta blocker...

...ecision was made to start beta blocker the...

...suggests preoperative pulmonary functio...

...mmends smoking cessation for ≥2 weeks befor...

...sts administration of pulmonary bronchodilators fo...

...s holding angiotensin-converting enzyme...

...SVS recommends preoperative hydration in non-d...

...commends preprocedure and postprocedur...

...SVS recommends holding metformin at the...

...he SVS recommends restarting metformin no sooner...

The SVS recommends perioperative t...

The SVS suggests hematologic assessment i...


...reoperative Cardiac Evaluation for the Patient Und...


...ble 2. Functional Capacity Estimation From...


...urysm Imaging

...recommends using ultrasound, when feasible, as...

...sts that the maximum aneurysm diameter derived f...

...SVS recommends a one-time ultrasound screeni...

...SVS suggests ultrasound screening for AAA in...

...s a one-time ultrasound screening for AAAs i...

...initial ultrasound screening ident...

...surveillance imaging at 3-year inte...

...surveillance imaging at 12-month intervals for...

...gests surveillance imaging at 6-month in...

...ds a CT scan to evaluate patients tho...


Treatment

...atment...

...ision to Treat...

...VS suggests referral to a vascular surgeon at...

...ommends repair for the patient who presents w...

...mmends elective repair for the patient at lo...

...ts elective repair for the patient who prese...

...sts repair in women with AAA 5.0–5.4 cm in max...

...patients with a small aneurysm (4.0–5.4...


...al Management During the Period of AA...

...recommends smoking cessation to reduce...

...S suggests NOT administering statins, doxyc...

...gests NOT administering beta blocker the...


Timing for Interv...

...ends immediate repair for patients who pr...

...pair of a symptomatic AAA be delaye...


...Operative Risk and Life Expectancy...

...gests informing patients contemplating o...


Table 3a. Mortality Risk Scoring Scheme for P...


...le 3b. Risk Categorization Based on Mortali...


...VAR...

The SVS recommends preservation of flow to...

...commends using Food and Drug Administrati...

The SVS recommends staging bilateral internal i...

...sts renal artery or superior mesenteric artery...

...prophylactic treatment of an asymptomatic, high-g...

The SVS suggests preservation of accesso...

...ioperative Outcomes of Ele...

...e SVS suggests that elective EVAR be perfor...

...Elective EVAR in the High-Risk and Un...

...SVS suggests informing high-risk patients of t...


...SR

...mends a retroperitoneal approach for pat...

The SVS suggests a retroperitoneal...

...SVS recommends a thrombin inhibito...

...mends straight tube grafts for OSR of AAA in...

...ds performing the proximal aortic anastomosis as c...

...ends that all portions of an aortic graft...

...nds reimplantation of a patent IMA under circum...

...recommends preserving blood flow to...

...he SVS suggests concomitant surgical t...

...ests concomitant surgical repair of an AAA and coe...


...able 4. Surgical Approaches for Open Aneury...


Perioperative Outcomes of Op...

...SVS suggests that elective OSR for AAA be per...

...5. Estimated Perioperative Complications...


...tient with a Ruptured Aneurysm...

...sts a door-to-intervention time of...

...ished protocol for the management of ruptured A...

...he SVS recommends implementing hypotensive...

...VS suggests that patients with rupture...

If it is anatomically feasible, the SVS...

...Suspected Ruptured Abdominal Aortic Ane...

...ring Hospital Checklist for the Patient With a S...

...ceiving Hospital Personnel Alert Checklist for...


...Anesthetic Technique And Agent...

...he SVS recommends general endotracheal...


Antibiotic Prophylaxi...

...recommends intravenous administrat...

...ecommends that any potential sources of dental se...


...ve Fluid Resuscitation And Blood Con...

...ecommends using cell salvage or an ultrafiltra...

...perative hemoglobin level is...


...rdiovascular Monitorin...

...ggests using pulmonary artery cathe...

...mends central venous access and arterial...

...mends postoperative ST-segment monitori...

...nds postoperative troponin measuremen...


...aintenance of Body Temperat...

...commends maintaining core body temperature ≥...


...ole of the ICU

...e SVS recommends postoperative man...


...Decompression And Perioperative Nutrition...

...nds optimization of preoperative nutritional...

...he SVS recommends using nasogastric decompression...

...e SVS recommends parenteral nutrition if a p...


Prophylaxis For Deep Venous Thromb...

...recommends thromboprophylaxis that incl...

...ggests thromboprophylaxis with unfractionated...


...toperative Blood Transfusio...

...e absence of ongoing blood loss, th...


...rioperative Pain Management...

...ecommends multimodality treatment, includin...


...e Outcome...

The SVS recommends treatment of type...

The SVS suggests treatment of type II endol...

...he SVS recommends surveillance of type I...

...ommends treatment of type III endoleaks. ( 1 â...

...suggests no treatment of type IV endoleaks....

...SVS recommends open repair if endovascular inte...

...sts open repair if endovascular inter...

...VS suggests treatment for ongoing aneur...

...ends that follow-up of patients after aneurysm re...

...S recommends a prompt evaluation for possib...

The SVS recommends antibiotic prophylaxis to pr...

...suggests antibiotic prophylaxis before respira...

...sm repair, the SVS recommends prompt evaluation...

...SVS recommends prompt evaluation for possible ao...

...atients presenting with an infected gr...

...esenting with an infected graft with minimal...

...a stable patient presenting with an infected...

...able patients with infected graft,...


...ation For Postoperative Surveillance...

...S recommends baseline imaging in t...

If a type II endoleak is observed 1 month aft...

...ndoleak nor AAA enlargement is observe...

...a type II endoleak is associated with an ane...

If a new endoleak is detected, the SVS s...

The SVS suggests non-contrast-enhanced C...


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