Clinical Decision Making for Endovascular Repair of Abdominal Aortic Aneurysm

Abstract

, MD, CM C ase 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-insulindependent (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?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 are associated with an increased prevalence of AAA include hypertension, hypercholesterolemia, and atherosclerotic diseases. 2-9 Initial development and subsequent growth of AAA is a complex interaction of many of these factors.The majority of patients with AAAs are asymptomatic. AAAs frequently are detected incidentally during imaging studies for another pathology. In people 60 years and older, AAAs are found in 4% to 8% of men and 1% to 3% of women. 7,10 -19 The incidence increases 2-to 5-fold in the presence of cardiovascular risk factors and a family history of aneurysm. 20,21 Each year, Ϸ15 000 people in the United States die from a ruptured abdominal aneurysm, rendering it the 15th leading cause of death in this country. 22 Thirty percent to 75% of patients with a ruptured AAA die before they ever reach a hospital. [23][24][25][26][27][28][29] Even with surgery, an average 48% (95% CI 46% to 50%) perioperative mortality rate is associated with a ruptured AAA repair. 30 The overall mortality rate in patients with ruptured AAA ranges from 67% to 89%. [23][24][25][26][27][28][29] Therefore, detection of AAAs before rupture and elective repair can prolong survival and decrease the periprocedural complication rate. Evidence suggests that screening patients for AAAs resulted in an Ϸ45% reduction in the incidence of ruptured AAA 16,18 and a 21% to 68% decrease in aneurysmrelated deaths. 13,15,16,18,31 These observations have led a group of experts to recommend screening of AAA for all men 60 to 85 years of age, all women 60 to 85 years of age with cardiovascular risk factors, and all men and women Ͼ50 years of age with a family history of AAA. 19 The primary goal in AAA treatment is to prolon...

Outcome and Survival of Patients Aged 75 Years and Older Compared to Younger Patients after Ruptured Abdominal Aortic Aneurysm Repair: Do the Results Justify the Effort?

“…For patients who undergo AAA repair, the 5-year survival rate is reduced compared to age and matched individuals (60-65%). 12 Excess mortality in this patient group is substantially attributable to associated comorbidities, particularly coronary artery disease. 9 However, repair of RAAA in the elderly generally requires a careful assessment of life expectancy and of the impact of repair-related complications in this specific high-risk subset of patients.…”

Effect of Crosslinker Length and Composition on the Hydrophobicity and Thermomechanical Response of Acrylate‐Based Shape‐Memory Polymers

“…Smart materials have been proposed as attractive options for various noninvasive endovascular applications 1, 2. Nitinol, a smart material alloy (SMA), is currently employed successfully in stenting applications due to its flexibility and shape‐memory ability 3, 4.…”

Compressive mechanical properties of the intraluminal thrombus in abdominal aortic aneurysms and fibrin-based thrombus mimics

“…AAAs are present in 4% to 8% of men over 60 and 1% to 3% of women over 60 [1]. The long time course of the disease results in the formation of an intraluminal thrombus (ILT) in most AAAs [2].…”