Interventions on aortic arch aneurysms
Surgery should be considered in patients
who have isolated aortic arch aneurysm
with maximal diameter 55 mm.
Aortic arch repair may be considered in
patients with aortic arch aneurysm who
already have an indication for surgery of
an adjacent aneurysm located in the
ascending or descending aorta.
IIb
C
Interventions on descending aortic aneurysms
TEVAR should be considered, rather than
surgery, when anatomy is suitable.
IIa
C
TEVAR should be considered in patients
who have descending aortic aneurysm
with maximal diameter 55 mm.
IIa
C
When TEVAR is not technically possible,
surgery should be considered in patients
who have descending aortic aneurysm
with maximal diameter 60 mm.
IIa
C
When intervention is indicated, in cases
of Marfan syndrome or other
elastopathies, surgery should be indicated
rather than TEVAR.
IIa
C
IIa
C
IIb
C
IIa
C
a
Class of recommendation.
b
Level of evidence.
c
Decision should also take into account the shape of the different parts of the aorta.
Lower thresholds can be used for combining surgery on the ascending aorta for
patients who have an indication for surgery on the aortic valve.
d
Family history of AD and/or aortic size increase .3 mm/year (on repeated
measurements using the same imaging technique, at the same aorta level, with
side-by-side comparison and confirmed by another technique), severe aortic or
mitral regurgitation, or desire for pregnancy.
e
Coarctation of the aorta, systemic hypertension, family history of dissection, or
increase in aortic diameter .3 mm/year (on repeated measurements using the
same imaging technique, measured at the same aorta level, with side-by-side
comparison and confirmed by another technique).
f
Pending comorbidities in the elderly.
g
See text in section 8.
h
For patients with LDS or vascular type IV Ehlers-Danlos syndrome (EDS), lower
thresholds should be considered, possibly even lower than in Marfan syndrome.
There are no data to provide figures and a sensible case-by-case approach is the only
option.
ESC Guidelines
2904
7.2 Abdominal aortic aneurysm
7.2.1 Definition
While an aneurysm is generally defined as arterial enlargement with
loss of arterial wall parallelism, AAA—almost exclusively infra-
renal—is usually defined as a diameter
≥30 mm. Several authors
proposed an alternative definition of a .50% increased diameter,
but this cannot always be determined, especially when the limit
between the aneurysmal and disease-free zones is not well deli-
neated. The main aetiology of this disease is degenerative, although
it is frequently associated with atherosclerotic disease.
7.2.2 Risk factors
Age, male gender, personal history of atherosclerotic cardiovascular
disease, smoking and hypertension are all associated with the pres-
ence of AAA.
336
Dyslipidaemia is considered as a weaker risk
factor while, in contrast, diabetic patients are at decreased risk for
AAA.
336
A family history of AAA is a powerful predictor of prevalent
AAA and risk for the condition increases exponentially with the
number of siblings affected.
336
–
338
,
339
7.2.3 Natural history
Large and life-threatening AAA is preceded by a long period of
subclinical growth in the diameter of the aneurysm, estimated at
,1 – 6 mm/year.
95
,
340
These average rates cover a wide range of vari-
ability in diameter progression, which may depend on genetic and en-
vironmental factors—among which continued smoking is the most
potent factor for a rapid growth. Also, the larger the AAA, the
higher its growth rate.
340
The risk of rupture rises exponentially
with the aneurysm’s maximal diameter and is higher in women than
in men at similar diameters; women present ruptured AAA on
average 10 mm smaller than men.
7.2.4 Diagnosis
7.2.4.1 Presentation
Before its cataclysmic presentation when ruptured, AAA is mostly
silent. The most frequent mode of detection is incidental, during ab-
dominal imaging for any indication. Atypical abdominal or back pain
may be present but should not be awaited in order to reach a diagno-
sis. Systematic palpation of the abdomen during cardiovascular exam-
ination may detect a pulsatile abdominal mass, but its sensitivity is
poor. Acute abdominal pain and shock are usually present in the
case of ruptured AAA, sometimes preceded by a less intense abdom-
inal pain for contained rupture.
7.2.4.2 Diagnostic imaging
Ultrasonography is an excellent tool for screening and surveillance,
without risk and at low cost. Diameter measurements should be per-
formed in the plane perpendicular to the arterial axis, to avoid any
overestimation of the actual diameter (see section 4).
Considered the ‘gold standard’ in the past, aortography enabled
optimal imaging of the length of the aorto-iliac lesion, the collateral
or variant anatomy, the location and severity of occlusive disease,
and the associated aneurysms in the visceral or iliac arteries. Its limita-
tions are high radiation dose, contrast load, and its invasive nature. Also,
this technique does not provide information about thrombus or the
aneurysmal sac, and may misjudge the aortic diameter.
Because of technical improvements, their relatively non-invasive
nature and lower cost, CT and MRI have emerged as the current
‘gold standards’ in the pre-operative and post-operative evaluation
of AAAs. Operator proficiency and availability of equipment may de-
termine the preferred modality. Computed tomography accurately
visualizes the aorto-iliac lesions, including calcifications, but requires
ionizing radiation and iodinated contrast. Breath-held dynamic
contrast-enhanced MRI allows rapid acquisition of images in any
plane, independent of flow. Its disadvantages include non-visualization
of calcifications and the usual contraindications (e.g. metal implants).
The pre-operative assessment of AAAs includes the measurement
of their maximal transverse perpendicular diameter and the relation-
ship of the aneurysm to the renal arteries (Web Figure 15). Their
lengths, as well as diameters, angulations, and tortuosity, are particular-
ly important for endovascular aneurysm repair at the level of the
segment of normal calibre of the aorta, below the renal arteries (‘prox-
imal neck’) and the iliac arteries (‘distal neck’). Pre-operative imaging
also reveals iliac or hypogastric aneurysms, occlusive disease in the
iliac or renal arteries, and the presence of vascular abnormalities.
7.2.4.3 Screening abdominal aortic aneurysm in high-risk populations
The grim prognosis of ruptured AAA (mortality .60 – 70%) con-
trasts with the excellent survival rate (.95%) after planned AAA op-
eration. This observation, along with the silent course of AAA and the
possibility of detecting it easily with ultrasound, led to the consider-
ation of mass screening in subgroups at risk (i.e. men
≥65 years,
smokers, and those with a family history of AAA). Using abdominal
echography, four randomized trials (.125 000 participants; three
exclusively in men) compared the outcomes of population-based
studies with or without AAA screening. The prevalence of AAA in
these studies was on average 5.5%. Overall, AAA screening in men
.65 years was associated with a significant 45% decreased risk of
AAA-related mortality at 10 years, with a borderline 2% total de-
crease in risk of mortality (P ¼ 0.05).
341
Few ( 9300) women
were included, confined to one trial, and showed no benefit from
ultrasound screening.
Based on these trials, population-wide AAA screening programmes
are currently proposed in several countries,
342
with mixed results
owing to difficulties over implementation.
343
Several countries have
not implemented such a programme, despite national guidelines in
favour of AAA screening.
342
Indeed, some doubts have been cast
over the good results of the trials performed during the 1990s, since
the epidemiology of AAA is evolving, with decreased rates of the inci-
dence of AAA attributed largely to the decreasing rates of smoking in
western countries. In a recent cohort of Swedish men .65 years of
age, the prevalence of AAA was estimated at 2.2%.
344
In the absence of a systematic population-screening programme,
opportunistic screening may be an alternative for the detection of
AAA. Indeed, in a series of patients with ruptured AAA who were
managed in Scotland, three-quarters were unaware of having an
AAA before rupture, even though three-quarters of the entire
study population had attended a medical facility in the preceding
5 years.
345
Opportunistic screening is defined here as the use of ultra-
sound to detect AAA (while abdominal imaging is not specifically
planned) in situations where both the ultrasound machines and ex-
pertise are easily accessible. The most appealing situation for cardiol-
ogists is during echocardiography, since abdominal aorta imaging can
be performed using the same probe. Several single-centre studies
reported detection of AAAs during TTE in 0.8 – 6.0% of cases, with
ESC Guidelines
2905
discrepancies related to inclusion and definition criteria, as well as
specific factors inherent to each centre.
346
In a recent nationwide
survey in France, the prevalence of AAA screened immediately
after TTE was 3.7%, at a low extra cost related to the time necessary
for screening.
347
7.2.5 Management of small abdominal aortic aneurysms
The definition of ‘small’ AAA varies in the literature, being usually
either 30 – 49 mm or 30 – 54 mm, the upper limit depending on the
threshold set for intervention; however, the AAA diameter cannot
be considered as the sole criterion for the decision to intervene.
In this document, ‘small’ AAA encompasses situations where
endovascular or surgical intervention is not yet considered. Indeed,
two trials, the Aneurysm Detection And Management (ADAM)
and the UK Small Aneurysm Trial (UKSAT) compared the benefits
of early surgery for AAAs of 40 – 55 mm diameter against a surveil-
lance strategy.
348
,
349
A recent meta-analysis of these two trials
demonstrated an early survival benefit in the surveillance group
(due to the mortality in the surgery arm) without significant differ-
ences in long-term survival (6-year mortality: odds ratio (OR) 1.11;
95% confidence interval [CI] 0.91 – 1.34).
350
In line with these trials,
the Comparison of surveillance vs. Aortic Endografting for Small An-
eurysm Repair showed no benefits from early EVAR in AAAs of 41 –
54 mm diameter, compared with the surveillance strategy combining
regular imaging and prompt intervention in cases of predefined cri-
teria (symptoms, or AAA .55 mm or enlargement .10 mm/
year).
351
However, the management of these patients should not
be limited to a strategy of ‘watchful waiting’: they are at higher risk
by far of dying from major cardiovascular events (e.g. myocardial in-
farction) than from AAA rupture. The participants in the Cardiovas-
cular Health Study with an AAA .30 mm had a 10-year risk of fatal
myocardial infarction of 38%, compared with an AAA-related mor-
tality of 2%.
54
Accordingly, in the UK Small Aneurysm Trial, aneurys-
mal diameter was an independent predictor of cardiovascular
mortality (hazard ratio 1.34 and 1.31 for every 8 mm enlargement
during surveillance and after surgery, respectively). Hence, medical
therapy in small AAAs presents three objectives: to prevent cardio-
vascular events, to limit AAA growth, and to prepare the patient op-
timally in order to reduce perioperative risk once intervention is
indicated. These patients should be categorized as at high risk, so
all of the usual actions for secondary prevention can be applied, al-
though no specific trial on patients with small AAAs has ever been
undertaken. The measures addressed below will focus only on
actions to specifically reduce the AAA rate of growth, but they are
all useful for achieving the other two aforementioned objectives.
7.2.5.1 Management of risk factors
In a recent meta-analysis using data from 15 475 patients with AAA
.30 mm, current smoking was associated with an increased rate of
expansion of 0.35 mm/year, which is twice as fast as AAA growth
in previous- or non-smokers.
352
Similarly, data from population-
based studies indicated that tobacco smoking was the most import-
ant predictor of future aortic aneurysm outcomes.
353
There is no evidence of any beneficial effect on AAA growth from
diet intervention or exercise prescription, but both are reasonable in
patients at high risk of AAA. In a recent trial involving 140 patients
with small (,55 mm) AAAs, in-house and home training over
3 years led to improved cardiopulmonary fitness, without any
greater rate of enlargement than in the usual care arm.
354
Intense iso-
metric exercise is usually discouraged.
7.2.5.2 Medical therapy
Several small studies of unequal quality have assessed different drug
classes with a view to reducing AAA growth, hypothetically by reducing
either the wall shear stress or the inflammation, both of which play key
roles in growth of AAAs. A meta-analysis
355
of these studies led to the
following results: while cohort studies suggested potential benefits of
beta-blockers (pooled growth rate difference –0.62 mm/year; 95%
CI –1.00 to –0.24) this finding was not confirmed in three RCTs
(pooled growth rate difference –0.05 mm/year; 95% CI –0.16 to
0.05). The results of another meta-analysis were consistent with these
findings.
356
Two cohort studies suggested that statins were beneficial
(pooled growth rate difference of –2.97; 95% CI –5.83 to –0.11), con-
sistent with another meta-analysis of five longitudinal series.
357
Doxy-
cycline and roxithromycin have been evaluated in two RCTs without
significant benefits (pooled growth rate difference –1.32 mm/year;
95% CI –2.89 to 0.25). Regarding ACE-inhibitors, a large population-
based case-control study suggested a beneficial effect for this therapeut-
ic class to prevent rupture (odds ratio 0.82; 95% CI 0.74–0.90), while
this association was not found with other hypertensive drugs, including
beta-blockers.
358
Recently two studies provided mutually contradictory
results: while the use of ACE-inhibitors was associated with increased
AAA growth in UKSAT (the trial was not designed to assess this
therapy),
352
the Chichester study suggested beneficial effects of
renin-angiotensin inhibitors, with significant results for those on angio-
tensin receptors blockers.
359
Overall, these data require further inves-
tigation in well-designed, large RCTs; however, both statins and
ACE-inhibitors should also be considered in these patients, to reduce
risk of cardiovascular disease. According to the latest ESC Guidelines
on hypertension in 2013, beta-blockers should be included as a first-line
treatment for patients with hypertension and AAA.
82
Enlargement of an AAA is usually associated with the development
of an intraluminal mural thrombus. The presence, development, and
rupture of aneurysms have been related to thrombus size, so that
the use of antiplatelet therapy has been suggested to reduce complica-
tion rates in AAA.
360
In the absence of any RCT, several cohort studies
have analysed the potential benefits of aspirin in patients with AAA, es-
pecially in those in whom the lesion is large enough for the develop-
ment of mural thrombus. In the Viborg study,
361
the perioperative
risk was more than twice as high in non-users of aspirin vs. users,
even after adjustment for smoking and comorbidities. In a Swedish
study,
362
the concomitant use of aspirin and statins was significantly
associated with the lowest rates of AAA growth. In contrast, a second-
ary analysis of UKSAT,
363
as well as another study,
364
did not find any
significant difference in terms of AAA growth between aspirin users
and non-users. Overall, data on the benefits of aspirin in reducing
AAA growth are contradictory; however, most patients with AAAs
are at increased risk of non-AAA-related cardiovascular events.
Given the strong association between AAA and other atherosclerotic
diseases, the use of aspirin may be considered according to the pres-
ence of other cardiovascular comorbidities.
The analysis of the RESCAN collaborative study is awaited, to
provide insights regarding the benefits of these different drug
classes in slowing AAA growth.
365
ESC Guidelines
2906
7.2.5.3 Follow-up of small abdominal aortic aneurysm
Several studies have attempted to address the optimal pace for ultra-
sound surveillance of small AAAs. After a first imaging of the abdominal
aorta, those with an aorta diameter ,25 mm can be considered to be
at very low risk of large AAA within the following 10 years,
54
while an
initial aorta of 26– 29 mm merits a new assessment after 4 years.
54
,
366
During the 13-year follow-up of participants in the Multicentre Aneur-
ysm Screening Study (MASS), half of the ruptured AAAs had a baseline
aortic diameter within the 25–29 mm range.
367
Based on a recent
individual-based meta-analysis of trials and observational studies with
repeated AAA measurements over time, intervals of 3, 2, and 1
year(s) can be safely proposed for AAAs of 30– 39, 40– 44 and 45–
54 mm diameter, respectively, with a risk ,1% of rupture in men.
365
In the same report, women experienced similar growth rates but a
fourfold increased risk of rupture. Web Table
2
presents the average
growth, risk of surgery, and risk of rupture in men and women accord-
ing to AAA diameter. Women with 45 mm AAA had a risk of rupture
equivalent to men with a 55 mm AAA, so a lower intervention thresh-
old, rather than shorter intervals of follow-up, may be considered.
Recommendations for abdominal aortic aneurysm
screening
Recommendations
Class
a
Level
b
Ref.
c
Population screening for AAA with ultrasound:
357,367
•
is recommended
in all men >65
years of age.
I
A
•
may be
considered in
women >65 years
of age with
history of
current/past
smoking.
IIb
C
•
is not
recommended in
female non-
smokers without
familial history.
III
C
Targeted screening for AAA
with ultrasound should be
considered in first-degree
siblings of a patient with AAA.
IIa
B
338,339
Opportunistic screening for AAA during TTE:
346,347
•
should be
considered in all
men >65 years of
age.
IIa
B
•
may be
considered in
women >65 years
with a history of
current/past
smoking.
IIb
C
a
Class of recommendation.
b
Level of evidence.
c
Reference(s) supporting recommendations.
AAA ¼ abdominal aortic aneurysm; TTE ¼ transthoracic echocardiography.
7.2.6 Abdominal aortic aneurysm repair
7.2.6.1 Pre-operative cardiovascular evaluation
Coronary artery disease is the leading cause of early mortality after
surgery for AAA. Angiographic evidence of coronary artery disease
can be found in approximately two-thirds of patients with AAA, of
which one-third are asymptomatic.
336
,
367
,
368
The long duration of
AAA repair procedures, the need for aortic clamping, and physio-
logical stress from blood loss and fluid shifts may be strong triggers
for acute ischaemic events. Thus, open repair of AAA is associated
with a high risk (.5%) for perioperative cardiovascular complica-
tions (death, myocardial infarction, stroke).
369
Endovascular AAA
repair procedures, however, carry a lower risk (1 – 5%) than open
surgery.
370
The need for—and clinical value of—pre-operative risk
stratification before repair of AAA depends on the risk of the proced-
ure (i.e. open vs. endovascular repair) and clinical, patient-specific risk
factors.
371
For a more detailed description of risk stratification
algorithms, the reader is referred to the recently updated ESC
Guidelines.
372
7.2.6.2 Aortic repair in asymptomatic abdominal aortic aneurysm
The management of AAA depends on aneurysm diameter. The indi-
cation for AAA repair needs to balance the risk of aneurysm surveil-
lance and the associated risk of rupture against the surgical risk at a
certain threshold diameter. Today, periodic ultrasound surveillance
of the aneurysm—until it reaches 55 mm or becomes symptomatic
or fast growing (.10 mm/year)—is regarded as a safe strategy for
patients with small AAAs. This is based on the findings of two large
multicentre RCTs (UKSAT and ADAM), both launched in the early
1990s.
348
,
373
Few women were included in these trials and neither
had the power to detect differences in all-cause mortality in this spe-
cific subgroup; however, there is evidence that women are more
likely to rupture under surveillance and tend to suffer AAA rupture
at a smaller aortic diameter than men.
348
,
365
,
374
Even though evi-
dence for threshold diameter in women is scarce, intervention at a
smaller diameter (.50 mm) may be justified.
7.2.6.3 Open aortic aneurysm repair
Since its first use by Dubost et al. in the early 1950s, open AAA repair
has been regarded as the default surgical intervention for AAA,
375
but
it carries a certain risk of mortality and morbidity, particularly in terms
of cardiovascular events. Operative mortality from elective open sur-
gical AAA repair was estimated in a variety of studies, but the figures
vary considerably between centres and countries—relating to the
type and design of the study—and range from 1% (selected centres
of excellence) to 8% (population-based cohorts).
376
There is even
a discrepancy in quoted surgical mortality between different RCTs.
For instance, the UKSAT and the ADAM trial quoted 30-day mortal-
ity rates of 5.6% and 2.7%, respectively, but it must be remembered
that both trials included all AAAs, irrespective of anatomy, unless
renal artery re-implantation was expected.
348
,
373
A review combin-
ing results from 64 studies found an average mortality rate of 5.5%.
377
Patient fitness is an important predictor and many authors tried to
estimate the individual patient operative risk in order to identify
subsets at different risk levels. The presence of cardiac and respira-
tory diseases as well as impaired renal function increases periopera-
tive mortality of elective open AAA repair, whilst the impact of age as
an independent factor is controversial.
378
,
379
Other predictors of
outcome are operator experience and hospital volume as discussed
elsewhere in this document.
Outcomes of open ruptured AAA repair are much worse than
those for elective AAA repair, and again results vary substantially
across centres and countries. Bown et al. combined the results
ESC Guidelines
2907
from 171 studies in a meta-analysis to determine the outcomes of
ruptured AAA.
380
The pooled estimate of operative mortality rate
was 48%, although single centres report prospectively collected mor-
tality results as low as 15%.
381
A meta-regression analysis accounting
for date of each study showed a 3.5% reduction in operative mortality
per decade, whereas the intraoperative mortality rate remained
stable at 15%, suggesting that overall improvements in outcome
were not due to surgery-related factors.
380
7.2.6.4 Endovascular aortic aneurysm repair
Endovascular aortic aneurysm repair was introduced in the early
1990s. The greatest advantage of EVAR is in its less invasive nature,
which allows a shorter post-operative convalescence time. A
meta-analysis of 161 studies reported a pooled operative mortality
rate of 3.3% (95% CI 2.9 – 3.6); however, results have improved
rapidly over time with lower mortality rates, at 1.4%, in recent
studies.
382
On the other hand, the long-term efficacy of EVAR remains a
matter of concern. Subsequent lifelong imaging surveillance is cur-
rently required to monitor for late complications, including endo-
leaks, migration, and rupture. Late complications, including
secondary sac ruptures, are closely linked to aortic sac enlargement
over time. A recent study evaluated current compliance with ana-
tomical guidelines for EVAR and the relationship between baseline
aorto-iliac arterial anatomy and post-EVAR sac enlargement. This
study from the USA showed that the incidence of AAA sac enlarge-
ment .5 mm after EVAR was 41% at 5 years and this rate increased
over the study period, probably due to a more liberal use of EVAR
outside the indication for use.
383
The key feature of EVAR is the fluoroscopically guided insertion of
an endograft through the femoral arteries, in order to re-line the
aorta. Its feasibility depends on multiple factors, including aortic
anatomy, individual clinical judgment, and manufacturers’ guidelines.
The proportion of AAAs suitable for EVAR varies between different
studies, ranging from 15 – 68%.
384
A recent study involving 241
patients and three different devices showed an overall 49.4% suitabil-
ity rate for EVAR. Its authors assumed that the use of newer, low-
profile devices would allow for EVAR in up to 60% of the AAA
cases.
385
7.2.6.5 Comparative considerations of abdominal aortic aneurysm
management
Endovascular aortic repair is a valid alternative to surgical repair of
AAA; however, in patients with more complex aortic anatomy—i
ncluding those with aneurysms in close proximity to- or involving
the renal arteries, who are unsuitable for EVAR—open repair
remains the standard. Endovascular treatment strategies exist to
address such aneurysms, for instance branched or fenestrated endo-
grafts, but comparisons with open repair in RCTs are still awaited.
For a subset of AAA patients, all being anatomically and physio-
logically eligible for both conventional EVAR and open repair, a
head-to-head comparison of the two techniques was prompted
in the late 1990s. The first and largest RCT comparing open with
endovascular repair for large AAA started in the United Kingdom
in 1999, the UK EndoVascular Aneurysm Repair (EVAR)-1
trial.
386
–
388
Similar trials followed in the Netherlands: the Dutch
Randomized Aneurysm Management (DREAM) trial.
389
–
391
In the
Unites States, there was the Open Vs. Endovascular Repair
(OVER) trial;
392
,
393
and in France, the Ane´vrisme de l’aorte abdomi-
nale: Chirurgie vs. Endoprothe`se trial.
394
The results of all these, in-
cluding two smaller trials from Canada and the Netherlands,
395
,
396
were combined in a recent meta-analysis resulting in 1470 patients
allocated to EVAR and 1429 allocated to open repair.
397
The trials
reported different follow-up periods, with only the EVAR-1 and
DREAM trials reporting longer-term follow-up (.6 years). Short-
term (30 day), intermediate-term (up to 2 years), and long-term
(
≥3 years) results were analysed in the meta-analysis. Thirty-day
all-cause mortality was lower with EVAR [relative risk (RR) 0.35;
95% CI 0.19 – 0.64].
397
This 66% reduction was consistent in all
except for the Ane´vrisme de l’aorte abdominale: Chirurgie vs.
Endoprothe`se trial, which quoted similar operative mortality
rates for EVAR and open repair (1.3 vs. 0.6%, respectively).
394
However, the early benefit in favour of EVAR was gradually lost
during follow-up (due to secondary sac ruptures after EVAR), yield-
ing an RR of 0.78 (95% CI 0.57 – 1.08) at intermediate-term follow-
up (
≤2 years following procedure) and 0.99 (95% CI 0.85–1.15) at
long-term follow-up (.2 years).
397
Similarly, the long-term results
from the OVER trial suggested a mortality ‘catch-up’ in the EVAR
group after 3 years.
393
The rate of secondary interventions was
considerably higher in the EVAR group at both intermediate (RR
1.48; 95% CI 1.06 – 2.08) and long-term (RR 2.53; 95% CI 1.58 –
4.05) follow-up. Similar findings were reported from another
meta-analysis that included data from the aforementioned rando-
mized controlled trials and two large registries (Medicare data
and Swedish Vascular database).
398
Optimal treatment for patients who are unfit for open surgery was
addressed only in EVAR-2, a sister trial of EVAR-1. Patients were allo-
cated to either EVAR with best medical care or best medical care
alone. The operative mortality of EVAR was 7.3%. Aneurysm-related
mortality was significantly lower in the long-term follow-up, but this
benefit did not translate into improved all-cause mortality.
388
These
findings are corroborated by a recently published observational
study that included a total of 1652 patients treated by EVAR, of
whom 309 (18.7%) were deemed unfit for open repair.
399
In conclusion, in patients with suitable anatomy, EVAR is asso-
ciated with a 66% reduction in operative mortality, a benefit
that is lost during follow-up, and which comes at the cost of an
increased re-intervention rate. For all other AAA aneurysms
that are not suitable for EVAR, open repair remains the reference
standard.
7.2.7 (Contained) rupture of abdominal aortic aneurysm
7.2.7.1 Clinical presentation
The classic presentation of ruptured AAA, which includes abdominal
pain, hypotension, and abdominal pulsatile mass, may be present in up
to 50% of cases. Patients with contained rupture of AAA may present
with abdominal or back pain. Since the clinical presentation of rup-
tured AAA may mimic other abdominal emergencies and early rec-
ognition of this condition is imperative, diagnosis cannot be based
solely on clinical signs and symptoms and the threshold for immediate
imaging should be low.
ESC Guidelines
2908
Recommendations on the management of
asymptomatic patients with enlarged aorta or
abdominal aortic aneurysm
Dostları ilə paylaş: |