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Abdominal aortic aneurysm

Background

Overview

Definition
An AAA is a structural disease of the abdominal aorta characterized by a pathological, localized dilatation of > 30 mm or > 50% of the original aortic size.
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Pathophysiology
Multiple environmental factors (including smoking, hypertension, coronary artery disease, and collagen diseases) and genetic factors can induce and accelerate degeneration of the layers of the aortic wall. An inflammatory response in the aortic vessel wall leads to destruction of elastin and collagen in the media and adventitia, loss of smooth muscle cells, thinning of the media, and neovascularization.
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Epidemiology
In the US, the overall prevalence of AAA is estimated at 2,200 persons per 100,000 population.
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Disease course
The majority of AAAs are asymptomatic and are detected as an incidental finding on diagnostic imaging performed for other purposes. AAAs can also present with abdominal pain or complications such as thrombosis, embolization and rupture.
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Prognosis and risk of recurrence
The overall mortality associated with ruptured AAA is approximately 85-90%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of abdominal aortic aneurysm are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2024,2019), the American Heart Association (AHA/ACC 2022), the U.S. Preventive Services Task Force (USPSTF 2019), the Society for Vascular Surgery (SVS 2018), the European Society of Cardiology (ESC 2014), and ...
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Screening and diagnosis

Indications for screening: as per ESVS 2024 guidelines, obtain ultrasound screening for the early detection of AAA in high-risk populations to reduce death from aneurysm rupture.
A
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  • Indications for rescreening

Diagnostic investigations

Physical examination: as per SVS 2018 guidelines, perform a physical examination in patients with a suspected or known AAA, including an assessment of femoral and popliteal arteries. Evaluate for an AAA in patients with a popliteal or femoral artery aneurysm.
A

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  • Diagnostic imaging

  • Evaluation for carotid artery stenosis

  • Psychosocial assessment

Medical management

General principles: as per ESVS 2019 guidelines, consider initiating antihypertensive, antiplatelet, and statin therapy in all patients with AAA.
C

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  • Setting of care

  • Shared decision-making

  • Beta-blockers

  • Antithrombotic therapy

  • Statins

  • Antihypertensive therapy

  • Other medical therapies

Inpatient care

Setting of care: as per SVS 2018 guidelines, admit patients having undergone AAA repair to an ICU for postoperative monitoring and management in the following clinical scenarios:
patients with significant cardiac, pulmonary, or renal disease
patients requiring postoperative mechanical ventilation
patients who developed a significant arrhythmia or hemodynamic instability during operative treatment.
A

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  • Nutritional considerations

  • Pain management

  • Thromboprophylaxis

  • Monitoring for abdominal compartment syndrome

  • Monitoring for myocardial injury

Nonpharmacologic interventions

Smoking cessation: as per ACC/AHA 2022 guidelines, advise smoking cessation in smoker patients with AAA.
B

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  • Physical activity

Therapeutic procedures

Endovascular aneurysm repair: as per ACC/AHA 2022 guidelines, perform ultrasound-guided percutaneous closure over open cutdown for endovascular AAA repair to reduce operative time, blood loss, length of stay, time to wound healing, and pain in patients with suitable common femoral artery anatomy.
B

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  • Aortic balloon occlusion

  • Preoperative renal/mesenteric angioplasty

Perioperative care

Preoperative counseling: as per SVS 2018 guidelines, consider informing patients contemplating open repair or endovascular aneurysm repair of their perioperative mortality risk score (Vascular Quality Initiative score).
C

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  • Preoperative pulmonary function testing

  • Preoperative cardiac risk assessment

  • Preoperative renal function testing

  • Preoperative nutritional assessment

  • Preoperative hematologic assessment

  • Preoperative cardiac optimization

  • Preoperative renal optimization

  • Preoperative pulmonary optimization

  • Preoperative nutritional optimization

  • Preoperative dental optimization

  • Considerations for anesthesia

  • Preoperative antibiotic prophylaxis

  • Perioperative transfusions

  • Intraoperative temperature management

  • Intraoperative anticoagulation

  • Management of beta-blockers

  • Management of antiplatelet agents

  • Management of antihypertensives and antihyperglycemics

  • Preoperative imaging

Surgical interventions

General principles
As per ESVS 2019 guidelines:
Refer patients with incidentally detected AAAs to a vascular surgeon for evaluation, except for patients with very limited life expectancy.
B
Consider performing aortic aneurysm repair only in centers with a minimum yearly caseload of 30 repairs.
C

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  • Indications for surgery, symptomatic AAA

  • Timing of surgery

  • Choice of surgical approach

  • Indications for tube graft placement

  • Management of enlarging AAA post-repair

  • Management of endoleaks

Specific circumstances

Patients with ruptured AAA: as per ACC/AHA 2022 guidelines, obtain CT to evaluate whether the AAA is amenable to endovascular repair in hemodynamically stable patients presenting with Ruptured AAA.
B
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  • Patients with carotid artery stenosis

  • Patients with gastrointestinal bleeding

  • Patients with heparin-induced thrombocytopenia

  • Patients with an infected AAA graft

  • Patients with common iliac artery aneurysm

  • Patients with thoracoabdominal aortic aneurysm (indications for repair)

  • Patients with thoracoabdominal aortic aneurysm (open repair)

  • Patients with thoracoabdominal aortic aneurysm (endovascular repair)

  • Patients with Marfan syndrome

  • Patients with Loeys-Dietz syndrome

Preventative measures

Preprocedural antibiotic prophylaxis
As per ESVS 2019 guidelines:
Avoid routinely administering antibiotic prophylaxis for the prevention of graft infection in patients with previous AAA repair undergoing dental or other surgical procedures.
D
Consider administering antibiotic prophylaxis for the prevention of graft infection in patients with previous AAA repair undergoing high-risk procedures, including abscess drainage, dental procedures requiring manipulation of the gingival or peri-apical region of the teeth or breaching the oral mucosa, as well as in immunocompromised patients undergoing surgical or interventional procedures.
C

Follow-up and surveillance

Serial clinical assessment
As per SVS 2018 guidelines:
Perform thorough lower extremity pulse examination or ankle-brachial index in follow-up visits of patients after aneurysm repair.
B
Assess for possible graft limb occlusion in patients who develop new-onset lower extremity claudication, ischemia, or reduction in ankle-brachial index after aneurysm repair.
A

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  • Serial imaging assessment

  • Postoperative rehabilitation

  • Early postoperative imaging

  • Late postoperative imaging