Chapter 26: Cardiovascular Disorders

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 EVAR^a 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 ...