Watchful waiting in cases of small abdominal aortic aneurysms— appropriate for all patients?

Abstract

Watchful waiting programs are imperfect and highly reliant on the motivation levels and means of the individual patients. Watchful waiting is reasonable among compliant patients with abdominal aortic aneurysms, inasmuch as fewer than half will meet the criteria for intervention within a mean of 3 years. Approximately one fourth of these patients will have medical contraindications to abdominal aortic aneurysm repair during follow-up, and many of these will die of causes other than abdominal aortic aneurysm rupture. In our experience, one third of candidates for watchful waiting programs are unable to participate and are at risk of rupture. These patients need special attention so that the reasons for their noncompliance can be determined, and they may be candidates for earlier intervention.

ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients

“…The success of watchful waiting is predicated on patient cooperation, however. In a similar study of 101 patients with aneurysms measuring less than 5.0 cm in diameter, Valentine et al encountered no ruptures among patients who complied with their follow-up program compared with a 10% rupture rate among those who did not (1217). If continued surveillance is recommended, measures should be taken to control hypertension and to discourage smoking, because these risk factors are associated with accelerated rates of aneurysm growth (936,961).…”

ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)

“…The success of watchful waiting is predicated on patient cooperation, however. In a similar study of 101 patients with aneurysms measuring less than 5.0 cm in diameter, Valentine et al encountered no ruptures among patients who complied with their follow-up program compared with a 10% rupture rate among those who did not (1217). If continued surveillance is recommended, measures should be taken to control hypertension and to discourage smoking, because these risk factors are associated with accelerated rates of aneurysm growth (936,961).…”

Cost-Benefit Analysis of Second-Generation Antipsychotics and Placebo in a Randomized Trial of the Treatment of Psychosis and Aggression in Alzheimer Disease

“…Although placebo is not a real-world treatment, it is a relevant experimental condition for this cost-benefit analysis inasmuch as it represents an approach to agitation and psychosis in AD involving general support without active pharmacotherapy. Watchful waiting has become an increasingly important clinical option in diseases such prostate 17 and other forms of cancer [18][19][20] and depression 21,22 as well as in surgical conditions such as abdominal aortic aneurysm 23 and inguinal hernia. 24 It can only be subject to double-blind experimental evaluation through a "placebo" control.…”