Timing of repair. Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men. A thoughtful discussion of individual risks should take place in every case, but in many patients, even the elderly, repair of a large asymptomatic AAA is indicated. 5
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Our patient should have repeat imaging of his AAA in six months and regular surveillance afterward to monitor for growth every six months. When the AAA is >5.5 cm or if it grows >1 cm a year, he should be evaluated for EVAR or open repair.
The current USPSTF guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 with a history of smoking. If an AAA >3 cm is found, the patient should undergo regular USG screening every six months. The AAA should be repaired if >5.5 cm or symptomatic, via either an endoscopic or open approach.
Dr. Best is a hospitalist at University of Washington Medicine at Harborview and associate program director of the internal-medicine residency program at the University of Washington, Seattle. Dr. Carpenter is a fellow in the division of geriatrics at the University of California at San Franscisco.
- Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8, 92-102.
- Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-1172.
- Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002;287:2968-2972
- Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J Vasc Surg. 2003;37:280-284.
- Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson SG. Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. British Journal of Surgery. 2011;98:609-618.
- Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230(3):289-297.
- Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117:1883-1889.
- The Propranolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002:35:72-79.
- Ruhani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012. Sep 12;9:CD009536. doi: 10.1002/14651858.
- The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863-1871.
- De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889.
- Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.
- Biancari F, Catania A, D’Andrea V. Elective endovascular vs. open repair of abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42:571-576.
- Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008;358:464-474.
- Cosford PA, Leng GC, Tomas J. Screening for abdominal aortic aneurysm. Cochrane Database for Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858.CD002945.pub2.
- Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012, Issue 3. Art. No.:CD001835. DOI: 10.1002/14651858.CD001835.pub3.
- The UK Small Aneurysm Trial Participants. Final 12-year follow-up of surgery versus surveillance in the UK small aneurysm trial. Brit J Surg. 2007;94:702-708.
- U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005.