Abdominal aortic aneurysm surgery: Difference between revisions
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* ''Endovascular repair'' first became practical in the 1990's and although it is now an established alternative to open repair, its role is yet to be clearly defined. It is generally indicated in older, high-risk patients or patients unfit for open repair. However, endovascular repair is feasible for only a proportion of AAA's, depending on the morphology of the aneurysm. The main advantage over open repair is that the peri-operative period has less impact on the patient (less time in intensive care, less time in hospital overall, earlier return to normal activity). Disadvantages of endovascular repair include a requirement for more frequent ongoing hospital reviews, and a higher chance of further procedures being required. According to the latest studies, the EVAR procedure doesn't offer any overall survival benefit.<ref name="pmid16782510">Rutherford RB. Randomized EVAR Trials and Advent of Level I Evidence: A Paradigm Shift in Management of Large Abdominal Aortic Aneurysms? ''Semin Vasc Surg'' 2006; '''19''':69-74. PMID 16782510</ref> Regarding unruptured aneurysms, EVAR is associated with lower operative mortality than open repair but unknown long-term mortality<ref name="pmid17502634">{{cite journal |author=Lederle FA, Kane RL, MacDonald R, Wilt TJ |title=Systematic review: repair of unruptured abdominal aortic aneurysm |journal=Ann. Intern. Med. |volume=146 |issue=10 |pages=735-41 |year=2007 |pmid=17502634 |doi=}}</ref> | * ''Endovascular repair'' first became practical in the 1990's and although it is now an established alternative to open repair, its role is yet to be clearly defined. It is generally indicated in older, high-risk patients or patients unfit for open repair. However, endovascular repair is feasible for only a proportion of AAA's, depending on the morphology of the aneurysm. The main advantage over open repair is that the peri-operative period has less impact on the patient (less time in intensive care, less time in hospital overall, earlier return to normal activity). Disadvantages of endovascular repair include a requirement for more frequent ongoing hospital reviews, and a higher chance of further procedures being required. According to the latest studies, the EVAR procedure doesn't offer any overall survival benefit.<ref name="pmid16782510">Rutherford RB. Randomized EVAR Trials and Advent of Level I Evidence: A Paradigm Shift in Management of Large Abdominal Aortic Aneurysms? ''Semin Vasc Surg'' 2006; '''19''':69-74. PMID 16782510</ref> Regarding unruptured aneurysms, EVAR is associated with lower operative mortality than open repair but unknown long-term mortality<ref name="pmid17502634">{{cite journal |author=Lederle FA, Kane RL, MacDonald R, Wilt TJ |title=Systematic review: repair of unruptured abdominal aortic aneurysm |journal=Ann. Intern. Med. |volume=146 |issue=10 |pages=735-41 |year=2007 |pmid=17502634 |doi=}}</ref> | ||
==ACC/ AHA Guidelines - Recommendations for surgery of Abdomino-thoracic surgery (DO NOT EDIT)== | |||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
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|bgcolor="LightGreen" | '''1.''' For patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
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|bgcolor="LightGreen" |'''2.''' For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
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|bgcolor="LightGreen" |'''3.'''For patients with thoracoabdominal aneurysms, in whom endovascular stent graft options are limited and surgical morbidity is elevated, elective surgery is recommended if the aortic diameter exceeds 6.0 cm, or less if a connective tissue disorder such as Marfan or Loeys-Dietz syndrome is present ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' | |||
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|bgcolor="LightGreen" |'''4.''' For patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease, an additional revascularization procedure is recommended''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B]])'' | |||
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=== Pre-Operative Assessment === | === Pre-Operative Assessment === | ||
* The ADAM trial suggested that the "biological age," as reflected by the condition of the vital organs such as the lungs, kidneys, heart was more important than the chronological age as a determinant of operative outcome. <cite>ADAMref4</cite> | * The ADAM trial suggested that the "biological age," as reflected by the condition of the vital organs such as the lungs, kidneys, heart was more important than the chronological age as a determinant of operative outcome. <cite>ADAMref4</cite> | ||
Revision as of 20:59, 9 October 2012
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Abdominal Aortic Aneurysm Microchapters |
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Differentiating Abdominal Aortic Aneurysm from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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Abdominal aortic aneurysm surgery On the Web |
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Directions to Hospitals Treating Abdominal aortic aneurysm surgery |
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Risk calculators and risk factors for Abdominal aortic aneurysm surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Surgery and Device Based Therapy
2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) - Recommendations for Management of Abdominal Aortic Aneurysm (DO NOT EDIT)
| Class I |
| 1. Open or endovascular repair of infrarenal AAAs and/or common iliac aneurysms is indicated in patients who are good surgical candidates. (Level of Evidence: A) |
| 2. Periodic long-term surveillance imaging should be performed to monitor for endoleak, confirm graft position, document shrinkage or stability of the excluded aneurysm sac, and determine the need for further intervention in patients who have undergone endovascular repair of infrarenal aortic and/or iliac aneurysms. (Level of Evidence: A) |
| Class IIa |
| 1.Open aneurysm repair is reasonable to perform in patients who are good surgical candidates but who cannot comply with the periodic long-term surveillance required after endovascular repair. (Level of Evidence:C) |
| Class IIb |
| 1.Endovascular repair of infrarenal aortic aneurysms in patients who are at high surgical or anesthetic risk as determined by the presence of coexisting severe cardiac, pulmonary, and/or renal disease is of uncertain effectiveness. (Level of Evidence:B) |
Indications for Surgery
The treatment options for asymptomatic AAA are immediate repair, surveillance with a view to eventual repair, and conservative. There are currently two modes of repair available for an AAA: open aneurysm repair (OR), and endovascular aneurysm repair (EVAR).
- Conservative treatment is indicated in patients where repair carries a high risk of mortality and also in patients where repair is unlikely to improve life expectancy. The two mainstays of the conservative treatment are smoking cessation and blood pressure control.
- Surveillance is indicated in small aneurysms, where the risk of repair exceeds the risk of rupture. As an AAA grows in diameter the risk of rupture increases. Although some controversy exists around the world, most vascular surgeons would not consider repair until the aneurysm reached a diameter of 5cm. The threshold for repair varies slightly from individual to individual, depending on the balance of risks and benefits when considering repair versus ongoing surveillance. The size of an individual's native aorta may influence this, along with the presence of comorbitities that increase operative risk or decrease life expectancy.
- Open repair (operation) is indicated in young patients as an elective procedure, or in growing or large, symptomatic or ruptured aneurysms. Open repair has been the mainstay of intervention from the 1950's until recently.
- Endovascular repair first became practical in the 1990's and although it is now an established alternative to open repair, its role is yet to be clearly defined. It is generally indicated in older, high-risk patients or patients unfit for open repair. However, endovascular repair is feasible for only a proportion of AAA's, depending on the morphology of the aneurysm. The main advantage over open repair is that the peri-operative period has less impact on the patient (less time in intensive care, less time in hospital overall, earlier return to normal activity). Disadvantages of endovascular repair include a requirement for more frequent ongoing hospital reviews, and a higher chance of further procedures being required. According to the latest studies, the EVAR procedure doesn't offer any overall survival benefit.[1] Regarding unruptured aneurysms, EVAR is associated with lower operative mortality than open repair but unknown long-term mortality[2]
ACC/ AHA Guidelines - Recommendations for surgery of Abdomino-thoracic surgery (DO NOT EDIT)
| Class I |
| 1. For patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended (Level of Evidence: B) |
| 2. For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible(Level of Evidence: B) |
| 3.For patients with thoracoabdominal aneurysms, in whom endovascular stent graft options are limited and surgical morbidity is elevated, elective surgery is recommended if the aortic diameter exceeds 6.0 cm, or less if a connective tissue disorder such as Marfan or Loeys-Dietz syndrome is present (Level of Evidence: C) |
| 4. For patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease, an additional revascularization procedure is recommended(Level of Evidence:B) |
Pre-Operative Assessment
- The ADAM trial suggested that the "biological age," as reflected by the condition of the vital organs such as the lungs, kidneys, heart was more important than the chronological age as a determinant of operative outcome. ADAMref4
- Patients with poor renal and pulmonary function have worse operative outcomes
- Chronic obstructive pulmonary disease
- Elevated creatinine concentrations
- Electrocardiographic evidence of ischemia
- Aortic factors implicated in postoperative morbidity and mortality include:
- Extensive atheromatous disease
- Mural calcification
- Thrombosis
- Juxtarenal extension of aneurysm
- Inflammatory aortic aneurysms
- The increased risk resulted from:
- Longer suprapenal clamping time
- Need for complex dissection
- Increased hemodynamic stresses
References
- ↑ Rutherford RB. Randomized EVAR Trials and Advent of Level I Evidence: A Paradigm Shift in Management of Large Abdominal Aortic Aneurysms? Semin Vasc Surg 2006; 19:69-74. PMID 16782510
- ↑ Lederle FA, Kane RL, MacDonald R, Wilt TJ (2007). "Systematic review: repair of unruptured abdominal aortic aneurysm". Ann. Intern. Med. 146 (10): 735–41. PMID 17502634.
Acknowledgements
The content on this page was first contributed by: C. Michael Gibson M.S., M.D. Template:WH Template:WS