Clinical Decision Making for Endovascular Repair of Abdominal Aortic Aneurysm

Abstract

Case presentation: Mr JG is a 78-year-old retired banker who was referred for evaluation and treatment of a 6-cm abdominal aortic aneurysm (AAA), seen on a recent surveillance abdominal ultrasound, that had expanded 9 mm since an earlier study (8 months previous). His comorbidities for vascular disease include hypertension, non–insulin-dependent (type 2) diabetes mellitus, moderate obstructive pulmonary disease, and coronary artery disease. He underwent coronary bypass surgery 5 years ago. Moderate residual congestive heart failure was managed medically. A CT scan obtained to better assess the arterial anatomy demonstrated an infrarenal AAA measuring 6.2 cm in maximal diameter (Figure 1A). Should AAA repair be recommended to this patient, and if so, AAA repair by what method? Figure 1. Radiological imaging of AAA. A, Preoperative spiral CT angiogram showing an infrarenal AAA. B, Intraoperative angiogram showing the delivery system containing the main body of the stent graft, which is advanced over a stiff guide wire through the aneurysmal lumen, with the proximal part of the stent graft being partially deployed below the level of the renal arteries. C, Completion angiogram after the deployment of the stent graft, which verified an appropriate position of the device and confirmed the exclusion of the aneurysm from direct pulsatile flow. D, 1-y postoperative CT angiogram showing a decrease of the diameter of the aneurysm. Abdominal aortic aneurysm (AAA) is defined as a permanent localized dilation of the aorta that has at least a 50% increase in diameter as compared with the expected normal diameter of the aorta, which may vary according to age, sex, and body size.1 Numerous possible etiologies for AAA have been investigated, including degenerative processes affecting connective tissue integrity, inflammatory disorders, genetic susceptibility, and infectious causes. Risk factors include advanced age, smoking, male gender, and family history. Other factors that …