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The Care of Patients with an Abdominal Aortic Aneurysm: the Society for Vascular Surgery Practice Guidelines

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The Care of Patients with an Abdominal Aortic Aneurysm: the Society for Vascular Surgery Practice Guidelines The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines Elliot L. Chaikof, MD, PhD,a David C. Brewster, MD,b Ronald L. Dalman, MD,c Michel S. Makaroun, MD,d Karl A. Illig, MD,e Gregorio A. Sicard, MD,f Carlos H. Timaran, MD,g Gilbert R. Upchurch Jr, MD,h and Frank J. Veith, MD,i Atlanta, Ga, Boston, Mass, Palo Alto, Calif, Pittsburgh, Penn, Rochester, NY, St. Louis, Mo, Dallas, Tex, Ann Arbor, Mich, and Cleveland, Ohio DEFINITION OF THE PROBLEM rupture and patient specific factors influence anticipated Purpose of these guidelines life expectancy, operative risk, and the need to intervene. Careful attention to the choice of operative strategy, as The Clinical Practice Council of the Society for Vascu- influenced by anatomic features of the AAA, along with lar Surgery charged a writing committee with the task of optimal treatment of medical co-morbidities is critical to updating practice guidelines, initally published in 2003, for achieving excellent outcomes. Moreover, appropriate surgeons and physicians who are involved in the preopera- postoperative patient surveillance and timely interven- tive, operative, and postoperative care of patients with tion in the case of a late complication is necessary to 1 abdominal aortic aneurysms (AAA). This document minimize subsequent aneurysm-related death or mor- provides recommendations for evaluating the patient, bidity. All of these clinical decisions are determined in an including risk of aneurysm rupture and associated med- environment where cost-effectiveness will ultimately dic- ical co-morbidities, guidelines for selecting surgical tate the ability to provide optimal care to the largest or endovascular intervention, intraoperative strategies, possible segment of the population. Currently available perioperative care, long-term follow-up, and treatment clinical data sets have been reviewed in formulating these of late complications. recommendations. However, an important goal of this Decision making related to the care of patients with document is to clearly identify those areas where further AAA is complex. Aneurysms present with varying risks of clinical research is necessary. From the Department of Surgery, Emory University,a the Department of Methodology and evidence b Surgery, Massachusetts General Hospital, the Department of Surgery, A comprehensive review of the available clinical evi- Stanford University,c the Department of Surgery, University of Pitts- burgh,d the Department of Surgery, University of Rochester,e the Depart- dence in the literature was conducted in order to generate a ment of Surgery, Washington University-St. Louis,f the Department of concise set of recommendations. The strength of any given Surgery, University of Texas-Southwestern,g the Department of Surgery, recommendation and the quality of evidence was scored h University of Michigan, and the Department of Vascular Surgery, Cleve- based on the GRADE system (Table I).2 When the bene- land Clinic Foundation.i Submitted as a Supplement to the Journal of Vascular Surgery. fits of an intervention outweighed its risks, or, alternatively, Dr Chaikof received research (principal investigator) and educational sup- risks outweighed benefits, a strong recommendation was port (program director) from WL Gore, and research and educational noted. However, if benefits and risks were less certain, support (program director) from Medtronic and Cook, Inc. Dr Makaroun either because of low quality evidence or because high received research and educational support (program director) from WL Gore, Cook Inc, Medtronic, Cordis, BSCI, Abbott, Bolton, and Lom- quality evidence suggests benefits and risks are closely bard. In the last two years, Dr. Makaroun had consulting agreements with balanced, a weak recommendation was recorded. The WL Gore, Medtronic, Cook, Inc and Cardiomems. Dr Illig received quality of evidence that formed the basis of these recom- proctoring, travel expenses and honoraria from Cook, Inc, speaking and mendations was scored as high, moderate, or low. Not all travel expenses from Cook, Inc and WL Gore and also, University of Rochester Department of Vascular Surgery has received unrestricted randomized controlled trials are alike and limitations may educational grant support from Cook, Inc, WL Gore, Medtronic, and compromise the quality of their evidence. In addition, if Boston Scientific. Dr Timaran received fees for consulting and speaking there is a large magnitude of effect, the quality of evidence from W.L. Gore and Associates, Inc. Dr Veith is a stockholder in Vascular derived from observational studies may be high. Thus, Innovation, a company that may in the future make aortic endografts. Nothing in this article was influenced by their ownership. quality of evidence was scored as high when additional Reprint requests: Elliot L. Chaikof, MD, PhD, Emory University, 101 research is considered very unlikely to change confidence in Woodruff Circle, Rm 5105, Atlanta, GA 30322 (e-mail: echaiko@ the estimate of effect; moderate when further research is emory.edu). likely to have an important impact in the estimate of effect; 0741-5214/$36.00 Copyright © 2009 by the Society for Vascular Surgery. or low when further research is very likely to change the doi:10.1016/j.jvs.2009.07.002 estimate of the effect. 2S JOURNAL OF VASCULAR SURGERY Volume 50, Number 8S Chaikof et al 3S Table I. Criteria for strength of a recommendation and Table II. Risk factors for aneurysm development, grading quality of evidence expansion, and rupture Strength of a recommendation Symptom Risk factors Strong Benefits Ͼ Risks AAA development ● Tobacco use Risks Ͼ Benefits ● Hypercholesterolemia Weak ● Hypertension Benefits ϳ Risks ● Male gender Quality of evidence precludes accurate assessment of risks ● Family history (male predominance) and benefits AAA expansion ● Advanced age Grading quality of evidence ● Severe cardiac disease High ● Previous stroke Additional research is considered very unlikely to change ● Tobacco use confidence in the estimate of effect ● Cardiac or renal transplant Moderate ● Further research is likely to have an important impact on in AAA rupture Female gender ● 2 the estimate of effect FEV1 ● Low Larger initial AAA diameter ● Further research is very likely to change the estimate of the Higher mean blood pressure ● effect Current tobacco use (length of time smoking ϾϾ amount) Adapted from Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, ● Cardiac or renal transplant Hylek EM, Phillips B, et al. Grading strength of recommendations and ● Critical wall stress – wall strength quality of evidence in clinical guidelines. Chest 2006;129:174-81. relationship AAA, Abdominal aortic aneurysm. GENERAL APPROACH TO THE PATIENT History aneurysm diameter, low forced expiratory volume in one The medical history is helpful in determining the pa- second (FEV1), current smoking history, and elevated tient’s risk of developing an AAA. Even in the absence of mean blood pressure.14-16 Women are two to four times clinical symptoms, knowledge of the risk factors for devel- more likely to experience rupture than men.14-17 Aneu- oping an AAA may facilitate early diagnosis. The Aneurysm rysms in transplant patients also appear to have high expan- Detection and Management Veterans Affairs Cooperative sion and rupture rates.18 Study Group (ADAM) trial found a number of factors to be Prior surgical history is crucial to exclude certain disease associated with increased risk for AAA: advanced age, processes, such as appendicitis or cholecystitis, that may greater height, coronary artery disease (CAD), atheroscle- mimic the presentation of a symptomatic aneurysm. In rosis, high cholesterol levels, hypertension, and, in particu- addition, the nature and extent of previous abdominal lar, smoking.3 Indeed, aortic aneurysms occur almost ex- surgery may influence operative approach. When a pulsatile clusively in the elderly. In a 2001 study, the mean age of abdominal mass is discovered in a patient who has previ- patients undergoing repair for AAA in the United States ously undergone open surgical repair (OSR) of an AAA, the was 72 years.4-8 Men outnumber women by a factor of 4 to presence of an anastomotic pseudoaneurysm,19 iliac artery 6to1.4-8 Family members are also at significant risk with aneurysm,20 or suprarenal aortic aneurysm should be con- 12% to 19% of those undergoing aneurysm repair having a sidered. Likewise, complaints of abdominal or back pain in a first-degree relative with an AAA.9-11 In a recent nation- patient with a prior history of endovascular aortic aneurym wide survey conducted in Sweden, the relative risk of repair (EVAR) requires the treating physician to exclude an developing AAA for first-degree relatives was approxi- endoleak with attendant aneurysm expansion or rupture.21-24 mately double that of persons without a family history of AAA.12 Neither the gender of the index person nor the Physical examination first-degree relative influenced the risk of AAA. An AAA is An abdominal aortic aneurysm has been defined as “a over seven times more likely to develop in a smoker than a pulsating tumor that presents itself in the left hypochon- nonsmoker, with the duration of smoking, rather than total driac or epigastric regions.”25 The abdominal aorta begins number of cigarettes smoked, being the key variable (Table at the level of the diaphragm and the 12th thoracic vertebra II).13 The risk for developing an AAA is lower in women, and runs in the retroperitoneal space just anterior
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