Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm

Abstract

•The optimal timing of abdominal aortic aneurysm (AAA) repair is based on clinical presentation and aneurysm status:○A ruptured AAA requires emergent repair.○A symptomatic, nonruptured aneurysm is best treated urgently.○An asymptomatic AAA can be treated electively after completion of preoperative assessment.•The choice of endovascular or open surgical repair for elective treatment of AAA should be individualized with appropriate consideration of:○Anatomic suitability for endovascular aneurysm repair (EVAR).○Comorbidities and physical fitness.○Life expectancy.○Compliance with postoperative surveillance.○Patient preference. •If anatomically feasible, EVAR is recommended for treatment of a ruptured AAA (grade 1C), with a suggested door-to-intervention time of less than 90 minutes (Good Practice Standard) (Fig).1Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B.M. Lee W.A. Mansour M.A. 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.e72Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar•Open surgical repair (OSR) should be considered for elective treatment of AAA when:○The aortic anatomy does not meet recommended indications for use for commercially available EVAR devices.○The estimated life expectancy exceeds 10 to 15 years.2Patel R. Sweeting M.J. Powell J.T. Greenhalgh R.M. EVAR trial investigatorsEndovascular 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: 2366-2374Abstract Full Text Full Text PDF PubMed Scopus (539) Google Scholar •Observational studies report short- and mid-term survival benefit for patients with a ruptured AAA treated by EVAR as compared with OSR,3Wang L.J. Locham S. Al-Nouri O. Eagleton M.J. Clouse W.D. Malas M.B. Endovascular repair of ruptured abdominal aortic aneurysm is superior to open repair: propensity-matched analysis in the Vascular Quality Initiative.J Vasc Surg. 2020; 72: 498-507Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar but caution is required in inferring causality.•The perioperative survival benefit associated with EVAR for ruptured AAA has not been supported by randomized, controlled trials.•EVAR for elective AAA treatment is associated with decreased mortality and morbidity, and faster recovery, but a greater incidence of late reintervention and without a late survival benefit as compared with OSR.4Paravastu S.C. Jayarajasingam R. Cottam R. Palfreyman S.J. Michaels J.A. Thomas S.M. Endovascular repair of abdominal aortic aneurysm.Cochrane Database Syst Rev. 2014; : CD004178PubMed Google Scholar •The implementation of a treatment algorithm for the management of ruptured AAA is associated with a significant decrease in 30-day mortality.5Starnes B.W. Quiroga E. Hutter C. Tran N.T. Hatsukami T. Meissner M. et al.Management of ruptured abdominal aortic aneurysm in the endovascular era.J Vasc Surg. 2010; 51: 9-17Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar•Healthcare systems should consider the implementation of a structured, multidisciplinary triage protocol for the emergent management of ruptured AAA or rapid transfer to an EVAR-capable facility, if there are no contraindications to transfer (Figure). •Several scoring systems claim accurate predictions of thirty day mortality after ruptured AAA.6Hansen S.K. Danaher P.J. Starnes B.W. Hollis Jr., H.W. Garland B.T. Accuracy evaluations of three ruptured abdominal aortic aneurysm mortality risk scores using an independent dataset.J Vasc Surg. 2019; 70: 67-73Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar•The validation of a risk assessment tool to predict treatment futility for ruptured AAA would inform:○Patient-centered communication and shared decision-making.○Cost-effective allocation of healthcare resources.•The Vascular Study Group of Northern New England risk calculator predicts in-hospital mortality after elective AAA repair and has been externally validated.○The Vascular Study Group of Northern New England risk calculator should be implemented routinely to facilitate patient-centered communication and shared decision-making, particularly for those patients with a calculated high mortality risk and limited life expectancy.7Eslami M.H. Rybin D.V. Doros G. Siracuse J.J. Farber A. External validation of Vascular Study Group of New England risk predictive model of mortality after elective abdominal aorta aneurysm repair in the Vascular Quality Initiative and comparison against established models.J Vasc Surg. 2018; 67: 143-150Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar