How best to diagnose and manage abdominal aortic aneurysms

,; ,

doi:doi: 10.12788/jfp.0668

Applied Evidence

How best to diagnose and manage abdominal aortic aneurysms

J Fam Pract. 2023 October;72(8):325-331 | doi: 10.12788/jfp.0668

PDF Download

References

1. CDC. Wide-ranging Online Data for Epidemiologic Research (WONDER) database. Accessed August 30, 2023. https://wonder.cdc.gov/ucd-icd10.html

2. Reimerink JJ, van der Laan MJ, Koelemay MJ, et al. Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm. Br J Surg. 2013;100:1405-1413. doi: 10.1002/bjs.9235

3. Kent KC. Clinical practice. Abdominal aortic aneurysms. N Engl J Med. 2014;371:2101-2108. doi: 10.1056/NEJMcp1401430

4. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67:2-77.e2. doi: 10.1016/j.jvs.2017.10.044

5. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg. 2011;41 suppl 1:S1-S58. doi: 10.1016/j.ejvs.2010.09.011

6. Owens DK, Davidson KW, Krist AH, et al; US Preventive Services Task Force. Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement. JAMA. 2019;322:2211-2218. doi: 10.1001/jama.2019.18928

7. National Institute for Health and Care Excellence. Abdominal aortic aneurysm: diagnosis and management. NICE guideline [NG156]. March 19, 2020. Accessed June 30, 2023. www.nice.org.uk/guidance/ng156/chapter/recommendations

8. Canadian Task Force on Preventive Health Care. Recommendations on screening for abdominal aortic aneurysm in primary care. CMAJ. 2017;189:E1137-E1145. doi: 10.1503/cmaj.170118

9. Abdulameer H, Al Taii H, Al-Kindi SG, et al. Epidemiology of fatal ruptured aortic aneurysms in the United States (1999-2016). J Vasc Surg. 2019;69:378-384.e2. doi: 10.1016/j.jvs.2018.03.435

10. Kent KC, Zwolak RM, Egorova NN, et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg. 2010;52:539-548. doi: 10.1016/j.jvs.2010.05.090

11. [No authors listed] Smoking, lung function and the prognosis of abdominal aortic aneurysm. The UK Small Aneurysm Trial Participants. Eur J Vasc Endovasc Surg. 2000;19:636-642. doi: 10.1053/ejvs.2000.1066

12. Oliver-Williams C, Sweeting MJ, Turton G, et al. Lessons learned about prevalence and growth rates of abdominal aortic aneurysms from a 25-year ultrasound population screening programme. Br J Surg. 2018;105:68-74. doi: 10.1002/bjs.10715

13. Ulug P, Powell JT, Sweeting MJ, et al. Meta-analysis of the current prevalence of screen-detected abdominal aortic aneurysm in women. Br J Surg. 2016;103:1097-1104. doi: 10.1002/bjs.10225

14. Chabok M, Nicolaides A, Aslam M, et al. Risk factors associated with increased prevalence of abdominal aortic aneurysm in women. Br J Surg. 2016;103:1132-1138. doi: 10.1002/bjs.10179

15. Sweeting, MJ, Masconi KL, Jones E, et al. Analysis of clinical benefit, harms, and cost-effectiveness of screening women for abdominal aortic aneurysm. Lancet. 2018;392:487-495. doi: 10.1016/S0140-6736(18)31222-4

16. Sweeting MJ, Thompson SG, Brown LC, et al; RESCAN collaborators. Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms. Br J Surg. 2012;99:655-665. doi: 10.1002/bjs.8707

17. Skibba AA, Evans JR, Hopkins SP, et al. Reconsidering gender relative to risk of rupture in the contemporary management of abdominal aortic aneurysms. J Vasc Surg. 2015;62:1429-1436. doi: 10.1016/j.jvs.2015.07.079

18. Guirguis-Blake JM, Beil TL, Senger CA, et al. Primary care screening for abdominal aortic aneurysm: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;322:2219-2238. doi: 10.1001/jama.2019.17021

19. Thompson SG, Ashton HA, Gao L, et al; Multicentre Aneurysm Screening Study (MASS) Group. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg. 2012;99:1649-1656. doi: 10.1002/bjs.8897

20. Ashton HA, Gao L, Kim LG, et al. Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg. 2007;94:696-701. doi: 10.1002/bjs.5780

21. Carnevale ML, Koleilat I, Lipsitz EC, et al. Extended screening guidelines for the diagnosis of abdominal aortic aneurysm. J Vasc Surg. 2020;72:1917-1926. doi: 10.1016/j.jvs.2020.03.047

22. Duncan A, Maslen C, Gibson C, et al. Ultrasound screening for abdominal aortic aneurysm in high-risk women. Br J Surg. 2021;108:1192-1198. doi: 10.1093/bjs/znab220

23. Shreibati JB, Baker LC, Hlatky MA, et al. Impact of the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act on abdominal ultrasonography use among Medicare beneficiaries. Arch Intern Med. 2012;172:1456-1462. doi: 10.1001/archinternmed.2012.4268

24. Hye RJ, Smith AE, Wong GH, et al. Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program. J Vasc Surg. 2014;59:1535-1542. doi: 10.1016/j.jvs.2013.12.016

25. Rubano E, Mehta N, Caputo W, et al., Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013. 20:128-138. doi: 10.1111/acem.12080

26. Blois B. Office-based ultrasound screening for abdominal aortic aneurysm. Can Fam Physician. 2012;58:e172-e178.

27. Arnold MJ, Jonas CE, Carter RE. Point-of-care ultrasonography. Am Fam Physician. 2020;101:275-285.

28. Nixon G, Blattner K, Muirhead J, et al. Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care. Rural Remote Health. 2019;19:5027. doi: 10.22605/RRH5027

29. Lederle FA, Wilson SE, Johnson GR, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1437-1444. doi: 10.1056/NEJMoa012573

30. Filardo G, Lederle FA, Ballard DJ, et al. Immediate open repair vs surveillance in patients with small abdominal aortic aneurysms: survival differences by aneurysm size. Mayo Clin Proc. 2013;88:910-919. doi: 10.1016/j.mayocp.2013.05.014

31. Lederle FA, Kyriakides TC, Stroupe KT, et al. Open versus endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2019;380:2126-2135. doi: 10.1056/NEJMoa1715955

32. Patel R, Sweeting MJ, Powell JT, et al., Endovascular versus open repair of abdominal aortic aneurysm in 15-years’ follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 2016;388:2366-2374. doi: 10.1016/S0140-6736(16)31135-7

33. van Schaik TG, Yeung KK, Verhagen HJ, et al. Long-term survival and secondary procedures after open or endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2017;66:1379-1389. doi: 10.1016/j.jvs.2017.05.122

34. Powell JT, Brady AR, Brown, LC, et al; United Kingdom Small Aneurysm Trial Participants. Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1445-1452. doi: 10.1056/NEJMoa013527

35. Paravastu SC, Jayarajasingam R, Cottam R, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev. 2014:CD004178. doi: 10.1002/14651858.CD004178.pub2

36. Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58:2020-2045. doi: 10.1016/j.jacc.2011.08.023

37. Bhak RH, Wininger M, Johnson GR, et al. Factors associated with small abdominal aortic aneurysm expansion rate. JAMA Surg. 2015;150:44-50. doi: 10.1001/jamasurg.2014.2025

38. Ouriel K, Clair DG, Kent KC, et al; Positive Impact of Endovascular Options for treating Aneurysms Early (PIVOTAL) Investigators. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms. J Vasc Surg. 2010;51:1081-1087. doi: 10.1016/j.jvs.2009.10.113

39. Cao P, De Rango P, Verzini F, et al. Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from a randomised trial. Eur J Vasc Endovasc Surg. 2011;41:13-25. doi: 10.1016/j.ejvs.2010.08.026

40. Karthaus EG, Tong TML, Vahl A, et al; Dutch Society of Vascular Surgery, the Steering Committee of the Dutch Surgical Aneurysm Audit and the Dutch Institute for Clinical Auditing. Saccular abdominal aortic aneurysms: patient characteristics, clinical presentation, treatment, and outcomes in the Netherlands. Ann Surg. 2019;270:852-858. doi: 10.1097/SLA.0000000000003529

41. Nathan DP, Xu C, Pouch AM, et al. Increased wall stress of saccular versus fusiform aneurysms of the descending thoracic aorta. Ann Vasc Surg. 2011;25:1129-2237. doi: 10.1016/j.avsg.2011.07.008

42. Durojaye MS, Adeniyi TO, Alagbe OA. Multiple saccular aneurysms of the abdominal aorta: a case report and short review of risk factors for rupture on CT Scan. Ann Ib Postgrad Med. 2020;18:178-180.

43. Bertges DJ, Neal D, Schanzer A, et al. The Vascular Quality Initiative Cardiac Risk Index for prediction of myocardial infarction after vascular surgery. J Vasc Surg. 2016;64:1411-1421.e4. doi: 10.1016/j.jvs.2016.04.045

44. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41:111-188. doi: 10.1093/eurheartj/ehz455

45. Twine CP, Williams IM. Systematic review and meta-analysis of the effects of statin therapy on abdominal aortic aneurysms. Br J Surg. 2011;98:346-353. doi: 10.1002/bjs.7343

46. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e596-e646. doi: 10.1161/CIR.0000000000000678

47. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35:2873-2926. doi: 10.1093/eurheartj/ehu281

48. Lederle FA, Noorbaloochi S, Nugent S, et al. Multicentre study of abdominal aortic aneurysm measurement and enlargement. Br J Surg. 2015;102:1480-1487. doi: 10.1002/bjs.9895

49. Itoga NK, Rothenberg KA, Suarez P, et al. Metformin prescription status and abdominal aortic aneurysm disease progression in the U.S. veteran population. J Vasc Surg. 2019;69:710-716.e3. doi: 10.1016/j.jvs.2018.06.19

Management options: Immediate repair or surveillance?

After diagnosing AAA, important decisions must be made regarding management, including indications for surgical repair, appropriate follow-up surveillance, and medications for secondary prevention and cardiovascular risk reduction.

EVAR vs open repair

The 2 main surgical strategies for aneurysm repair are open repair and endovascular repair (EVAR). In the United States, EVAR is becoming the more common approach and was used to repair asymptomatic aneurysms in > 80% of patients and ruptured aneurysms in 50% of patients.⁶ There have been multiple RCTs assessing EVAR and open repair for large and small aneurysms.^29-34 Findings across these studies consistently show EVAR is associated with lower immediate (ie, 30-day) morbidity and mortality but no longer-term survival benefit compared to open repair.

EVAR procedures require ongoing long-term surveillance for endovascular leakage and other complications, resulting in an increased need for re-intervention.^31,33,35 For these reasons, the National Institute for Health and Care Excellence (NICE) guidelines suggest open repair as the preferred modality.⁷ However, SVS and the American College of Cardiology Foundation/American Heart Association guidance support either EVAR or open repair, noting that open repair may be preferable in patients unable to engage in long-term follow-up surveillance.³⁶

Indications for repair. In general, repair is indicated when an aneurysm reaches or exceeds 5.5 cm.^4,7 Both SVS and NICE also recommend clinicians consider surgical repair of smaller, rapidly expanding aneurysms (> 1 cm over a 1-year period).^4,7 Based on evidence suggesting a higher risk for rupture in women with smaller aneurysms,^14,37 SVS recommends clinicians consider surgical repair in women with an AAA ≥ 5.0 cm. Several RCTs evaluating the benefits of immediate repair for smaller-sized aneurysms (4.0-5.5 cm) favored surveillance.^38,39 Accepted indications for surgical repair are summarized in TABLE 3.^4,7,34Surgical repair recommendations also are based on aneurysm morphology, which can be fusiform or saccular (FIGURE). More than 90% of AAAs are fusiform.⁴⁰ Although saccular AAAs are less common, some studies suggest they are more prone to rupture than fusiform AAAs, and SVS guidelines suggest surgical repair of saccular aneurysms regardless of size.^4,41,42

Perioperative and long-term risks. Both EVAR and open repair of AAA carry a high perioperative and long-term risk for death, as patients often have multiple comorbidities. A 2019 trial comparing EVAR to open repair with 14 years of follow-up reported death in 68% of patients in the EVAR group and 70% in the open repair group.³¹ Among these deaths, 2.7% in the EVAR group and 3.7% in the open repair group were aneurysm related.³¹ The study also found a second surgical intervention was required in 19.8% of patients in the open repair group and 26.7% in the EVAR group.³¹

Continue to: When assessing perioperative risk...