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ABDOMINAL AORTIC ANEURYSM (AAA)

Population

  • Adults.

Recommendations

ACCF/AHA 2005/2011

Pharmacologic Therapy

  • Monitor and control BP and fasting serum lipids as recommended for patients with atherosclerotic disease (Class I, LOE C).

  • Smoking cessation: Provide counseling and medications to all patients with AAA or family history of AAA.

  • Monitor patients with infrarenal or juxtarenal AAA 4.0–5.4 cm in diameter with ultrasound or CT scan every 6–12 mo to detect expansion (Class I, LOE A).

  • Monitor patients with AAA <4.0 cm in diameter with ultrasound every 2–3 y (Class IIa, LOE B).

  • In patients undergoing surgical repair of AAA, administer beta-adrenergic blocking agents perioperatively, in the absence of contraindications, to reduce the risk of adverse cardiac events and mortality (Class I, LOE A).

Surgical Therapy

  • Repair infrarenal or juxtarenal AAA ≥5.5 cm in diameter to eliminate risk of rupture (Class I, LOE B).

  • Consider repair of suprarenal or type IV thoracoabdominal aortic aneurysm >5.5–6.0 cm diameter (Class IIa, LOE B).

  • Do not repair asymptomatic infrarenal or juxtarenal AAA if <5.0 cm in diameter in men or <4.5 cm in diameter in women (Class III, LOE A).

  • Obtain immediate surgical evaluation for patients with clinical triad of abdominal and/or back pain, a pulsatile abdominal mass, and hypotension (Class I, LOE B).

  • Repair symptomatic AAA regardless of diameter (Class I, LOE C).

  • In patients who are good surgical candidates, recommend open repair or EVARa of infrarenal and/or common iliac aneurysms.

  • After EVAR of infrarenal aortic and/or iliac aneurysms, perform periodic long-term surveillance imaging to monitor for vascular leak, document shrinkage/stability of the excluded aneurysm sac, confirm graft position, and determine the need for further intervention (Class I, LOE A).

  • Consider open aneurysm repair for patients who are good surgical candidates but who cannot comply with the periodic long-term surveillance required after endovascular repair (Class IIa, LOE C).

  • Endovascular repair of infrarenal aortic aneurysm in patients who are at high surgical or anesthetic risk (presence of coexisting severe cardiac, pulmonary, and/or renal disease) is of uncertain effectiveness (Class IIb, LOE B).

ESC 2014

Pharmacologic Therapy

  • Recommend smoking cessation slow the growth of the AAA.

  • In patients with HTN and AAA, give beta-blockers as first-line treatment.

  • Consider ACEI and statins in patients with AAA to reduce cardiovascular risk.

  • Consider aspirin therapy. Enlargement of AAA is usually associated with the development of an intraluminal mural thrombus. Overall data on the benefits of ASA in reducing AAA growth are contradictory; however, given the strong association between AAA and other atherosclerotic diseases, the use of ASA may be advisable.

  • Surveillance without intervention is indicated and safe in patients with AAA with a maximum diameter <5.5 cm and slow growth <1 cm/y.

  • In patients with small AAA, monitor with imaging at the following frequencies:

    • Every 4 y for AAA ...

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