Two treatment modalities are available for the management of nonruptured abdominal aortic aneurysm (nrAAA):
- Open surgery (OAR).
- Endovascular aneurysm elimination (EVAR).
For patients with acceptable periprocedural risk, EVAR and OAR should be recommended equally, assuming anatomic feasibility of EVAR. Level of evidence 1a/grade of recommendation A. [S3 guideline]
Indication asymptomatic AAA Recommendation. For the treatment of asymptomatic AAA [according to S3 guideline].
- Regular surveillance should be the first-line management strategy of choice for asymptomatic AAA of 4.0-5.4 cm. Evidence grade 1a/recommendation grade A.
- Patients with an infrarenal or juxtarenal AAA ≥ 5.5 cm should be referred for elective AAA management. Evidence grade 1a/Recommendation grade A.
- AAA treatment can be considered in patients with infrarenal or juxtarenal AAA 5.0-5.4 cm. Level of evidence 3b/grade of recommendation 0.
- In women, invasive care should be considered when the maximum aortic diameter reaches 5.0 cm. Evidence grade 3b/Recommendation grade B.
- If AAA size increases >10 mm/year, an indication for conventional surgery or EVAR should be considered regardless of AAA diameter. Evidence grade 1a/Recommendation grade A.
1st order
- Interventional procedure (see below EVAR) with insertion of a stent prosthesis (“vascular support”) or conventional surgery with opening of the abdomen and suturing in of a vascular prosthesis:
- Patients who have been denied open aneurysm repair (OAR) because of age and comorbidities (concomitant diseases) may be treated with endovascular aneurysm repair (EVAR), a minimally invasive procedure.
- In patients with low-risk profiles, the two methods, EVAR and open surgery, compete.
- After endovascular treatment, to detect complications (endoleaks or stent migration), regular monitoring of the stent prosthesis is recommended. Stent prosthesis open rates are 93-98%.
Note [S3 guideline]:
- Preprocedural initiation of statin therapy should be considered in patients undergoing vascular surgery, ideally at least 2 weeks before surgery. Evidence level 2a/recommendation level B.
- In patients with cardiovascular comorbidity, antiplatelet therapy should be recommended for patients with AAA. Evidence level 2a/recommendation grade B.
Treatment of ruptured abdominal aneurysm (rAAA) [S3 guideline].
RAAA is defined by unequivocal evidence of blood or contrast outside the aortic wall, detected, for example, by preprocedural CT, intraoperative angiography, or during surgery. Patients with confirmed rupture of an AAA should receive immediate invasive care. Evidence level 2b/recommendation level A.
Further references
- Later surgery worsens survival: In England (men: 63.8 mm; women: 61.7 millimeters mm), abdominal aortic aneurysm surgery is performed significantly later than in the United States (men: 58.2 mm; women: 56.3 millimeters mm), with the consequence of a mortality (death rate) three times higher than in the United States: odds ratio 3.60 (3.55-3.64).
- Endovascular aneurysm elimination (EVAR; endovascular aneurysm repair) using stent-graft (“vascular stent”) systems is known to be associated with significantly lower perioperative mortality (mortality in the time surrounding the surgical procedure) than open surgery. This survival advantage persisted for about three years, after which the survival rates in both groups equalized, as long-term results (observation period: max. 8 years) of a large study could prove.
- Abdominal aortic aneurysm (AAA): comparison of endovascular aneurysm repair (EVAR) versus aneurysm repair (OAR):
- 30-day mortality: EVAR approximately 1.5% versus OAR approximately 4.7%.
- After 3 years: mortality rate for both procedures approximately 19.9%; re-interventions: EVAR 6.6% versus OAR 1.5%.
- Abdominal aortic aneurysms (BAA): open surgery (OAR) was superior to EVAR in the long term in a long-term study. This is attributed to the fact that vascular prostheses are more prone to complications in the long term.After six months, no mortality benefits of EVAR were detectable. In the further course, mortality (mortality) continued to increase in this collective and reached the significance level in about the eighth year. After a mean of 12.7 years, all-cause mortality was 25% higher after EVAR (adjusted hazard ratio 1.25; 1.00-1.56). Aneurysm-related mortality was even almost 6-fold higher (adjusted hazard ratio 5.82; 1.64-20.65).
- This contrasts with a long-term US study in which endovascular aneurysm elimination achieved equally good results as open surgery. During the first 4 years of follow-up, mortality (death rate) was higher after open surgery; between the fourth and eighth years, mortality was higher in the stent-provided patients (provision by vascular bridge); thereafter, the trend reversed, and now the mortality rate is slightly lower in the vascular stent group.
