- 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 ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion.
- In patients with a suspected or known abdominal aortic aneurysm (AAA), the SVS recommends performing physical examination that includes an assessment of femoral and popliteal arteries. (1-A)
- In patients with a popliteal or femoral artery aneurysm, the SVS recommends evaluation for an AAA. (1-A)
Assessment of Medical Comorbidities
- In patients with active cardiac conditions, including unstable angina, decompensated heart failure, severe valvular disease, and significant arrhythmia, the SVS recommends cardiology consultation before EVAR or open surgical repair (OSR). (1-B)
- In patients with significant clinical risk factors, such as coronary artery disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic renal insufficiency, and unknown or poor functional capacity (metabolic equivalent [MET] <4), who are to undergo OSR or EVAR, the SVS suggests noninvasive stress testing. (2-B)
- The SVS recommends a preoperative resting 12-lead electrocardiogram (ECG) in all patients undergoing EVAR or OSR within 30 days of planned treatment. (1-B)
- The SVS recommends echocardiography before planned operative repair in patients with dyspnea of unknown origin or worsening dyspnea. (1-A)
- The SVS suggests coronary revascularization before aneurysm repair in patients with acute ST-segment or non-ST–segment elevation myocardial infarction (MI), unstable angina, or stable angina with left main coronary artery or three-vessel disease. (2-B)
- The SVS suggests coronary revascularization before aneurysm repair in patients with stable angina and two-vessel disease that includes the proximal left descending artery and either ischemia on noninvasive stress testing or reduced left ventricular function (ejection fraction <50%). (2-B)
- In patients who may need aneurysm repair in the subsequent 12 months and in whom percutaneous coronary intervention is indicated, the SVS suggests a strategy of balloon angioplasty or bare-metal stent placement, followed by 4–6 weeks of dual antiplatelet therapy. (2-B)
- The SVS suggests deferring elective aneurysm repair for 30 days after bare-metal stent placement or coronary artery bypass surgery if clinical circumstances permit. As an alternative, EVAR may be performed with uninterrupted continuation of dual antiplatelet therapy. (2-B)
- The SVS suggests deferring open aneurysm repair for ≥6 months after drug-eluting coronary stent placement or, alternatively, performing EVAR with continuation of dual antiplatelet therapy. (2-B)
- In patients with a drug-eluting coronary stent requiring open aneurysm repair, the SVS recommends discontinuation of P2Y12 platelet receptor inhibitor therapy 10 days preoperatively with continuation of aspirin. The P2Y12 inhibitor should be restarted as soon as possible after surgery. The relative risks and benefits of perioperative bleeding and stent thrombosis should be discussed with the patient. (1-B)
- The SVS suggests continuation of beta blocker therapy during the perioperative period if it is part of an established medical regimen. (2-B)
- If a decision was made to start beta blocker therapy (because of the presence of multiple risk factors, such as coronary artery disease, renal insufficiency, and diabetes), the SVS suggests initiation well in advance of surgery to allow sufficient time to assess safety and tolerability. (2-B)
- The SVS suggests preoperative pulmonary function studies, including room air arterial blood gas determinations, in patients with a history of symptomatic chronic obstructive pulmonary disease (COPD), long-standing tobacco use, or inability to climb one flight of stairs. (2-C)
- The SVS recommends smoking cessation for ≥2 weeks before aneurysm repair. (1-C)
- The SVS suggests administration of pulmonary bronchodilators for at least 2 weeks before aneurysm repair in patients with a history of COPD or abnormal results of pulmonary function testing. (2-C)
- The SVS suggests holding angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor antagonists on the morning of surgery and restarting these agents after the procedure once euvolemia has been achieved. (2-C)
- The SVS recommends preoperative hydration in non-dialysis–dependent patients with renal insufficiency before aneurysm repair. (1-A)
- The SVS recommends preprocedure and postprocedure hydration with normal saline or 5% dextrose/sodium bicarbonate for patients at increased risk of contrast-induced nephropathy (CIN) undergoing EVAR. (1-A)
- The SVS recommends holding metformin at the time of administration of contrast material among patients with an estimated glomerular filtration rate (eGFR) of <60 mL/min or ≤48 hours before administration of contrast material if the eGFR is <45 mL/min. (1-C)
- The SVS recommends restarting metformin no sooner than 48 hours after administration of contrast material as long as renal function has remained stable (<25% increase in creatinine concentration above baseline). (1-C)
- The SVS recommends perioperative transfusion of packed red blood cells if the hemoglobin level is <7 g/dL. (1-B)
- The SVS suggests hematologic assessment if the preoperative platelet count is <150,000/mL. (2-C)
Table 1. Preoperative Cardiac Evaluation for the Patient Undergoing Aneurysm Repair
1. Is there an active cardiac condition?
Presence cancels or delays aneurysm repair until conditions are treated. Implement medical management and consider coronary angiography.
2. Does the patient have good functional capacity without symptoms?
May proceed with aneurysm repair. In patients with known cardiovascular disease or at least one clinical risk factor, beta blockade is appropriate.
3. Is functional capacity poor or unknown?
In patients with three or more clinical risk factors, preoperative noninvasive testing is appropriate if it will change management.
From: Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(Suppl):S2-49; originally adapted from Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary. Circulation 2007;116:1971-96.
Table 2. Functional Capacity Estimation From an Assessment of Physical Activity
Examples of activity level
Poor (1–3 METs)
Eating, walking at 2–3 mph, getting dressed, light housework (washing dishes)
Moderate (4–7 METs)
Climbing a ﬂight of stairs or walking up a hill, running a short distance, heavy housework (scrubbing ﬂoors or moving furniture)
Good (7–10 METs)
Doubles tennis, calisthenics without weights, golﬁng without cart
Excellent (>10 METs)
Strenuous sports such as football, basketball, singles tennis, karate, jogging 10-minute mile or more, chopping wood
From Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009;50(Suppl):S2-49; originally adapted from Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651-4.
- The SVS recommends using ultrasound, when feasible, as the preferred imaging modality for aneurysm screening and surveillance. (1-A)
- The SVS suggests that the maximum aneurysm diameter derived from computed tomography (CT) imaging should be based on an outer wall to outer wall measurement perpendicular to the path of the aorta. (G-U)
- The SVS recommends a one-time ultrasound screening for AAAs in men or women 65–75 years of age with a history of tobacco use. (1-A)
- The SVS suggests ultrasound screening for AAA in first degree relatives of patients who present with an AAA. Screening should be performed in first-degree relatives who are 65–75 years of age or in those >75 years and in good health. (2-C)
- The SVS suggests a one-time ultrasound screening for AAAs in men or women ≥75 years with a history of tobacco use and in otherwise good health who have not previously received a screening ultrasound examination. (2-C)
- If initial ultrasound screening identified an aortic diameter >2.5 cm but <3 cm, the SVS suggests rescreening after 10 years. (2-C)
- The SVS suggests surveillance imaging at 3-year intervals for patients with an AAA 3.0–3.9 cm. (2-C)
- The SVS suggests surveillance imaging at 12-month intervals for patients with an AAA of 4.0–4.9 cm in diameter. (2-C)
- The SVS suggests surveillance imaging at 6-month intervals for patients with an AAA 5.0–5.4 cm in diameter. (2-C)
- The SVS recommends a CT scan to evaluate patients thought to have AAA presenting with recent-onset abdominal or back pain, particularly in the presence of a pulsatile epigastric mass or significant risk factors for AAA. (1-B)