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3 4 The Care of Patients with an Abdominal Aortic Aneurysm: 5 The Society for Vascular Surgery Practice Guidelines 6
7 Elliot L. Chaikof, MD, PhD,1,* Ronald L. Dalman, MD,2 Mark K. Eskandari, MD,3 8 Benjamin M. Jackson, MD,4 W. Anthony Lee, MD,5 M. Ashraf Mansour, MD,6 9 Tara M. Mastracci, MD,7 Matthew Mell, MD,2 M. Hassan Murad, MD, MPH,8 10 Louis L. Nguyen, MD, MBA, MPH,9 11 Gustavo S. Oderich, MD,10 Madhukar S. Patel, MD, MBA, ScM, 1,11 12 Marc Schermerhorn, MD, MPH,1 and Benjamin W. Starnes, MD12 13 14 1Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, 15 2Department of Surgery, Stanford University, Palo Alto, CA, 16 3Department of Surgery, Northwestern University, Chicago, IL, 17 4Department of Surgery, University of Pennsylvania, Philadelphia, PA, 18 5Christine E. Lynn Heart & Vascular Institute, Boca Raton Regional Hospital, Boca Raton, FL, 19 6Department of Surgery, Spectrum Health Medical Group, Grand Rapids, MI, 20 7The Royal Free Hospital, London, UK, 21 8Evidence-based Practice Center, Mayo Clinic, Rochester, MN 22 9Department of Surgery, Brigham and Women’s Hospital, Boston, MA, 23 10Department of Surgery, Mayo Clinic, Rochester, MN, 24 11Department of Surgery, Massachusetts General Hospital, Boston, MA, 25 12Department of Surgery, University of Washington, Seattle, WA 26 27 28 29 30 31 32 *Address correspondence to: 33 Elliot L. Chaikof, M.D., Ph.D. 34 Department of Surgery 35 Harvard Medical School 36 Beth Israel Deaconess Medical Center 37 110 Francis St, Suite 9F 38 Boston, MA 02115 39 Tel: (617) 632-9581 40 E-mail: [email protected] 41 2
Table of Contents
SUMMARY OF GUIDELINES FOR THE CARE OF PATIENTS WITH AN 6 ABDOMINAL AORTIC ANEURYSM DEFINITION OF THE PROBLEM 19 Purpose of these guidelines 19 Methodology and evidence 19 Literature search and evidence summary 20 GENERAL APPROACH TO THE PATIENT 21 History and risk factors for abdominal aortic aneurysms 21 Physical examination 24 Assessment of medical comorbidities 25 Preoperative evaluation of cardiac risk 25 Preoperative coronary revascularization 27 Perioperative medical management of coronary artery disease 29 Pulmonary disease 30 Renal insufficiency 31 Diabetes mellitus 34 Hematologic disorders 35 Biomarkers and heritable risks for an abdominal aortic aneurysm 36 Biomarkers for the presence and expansion of an aortic aneurysm 36 Genetic markers identifying risk of aortic aneurysm 37 Aneurysm imaging 38 Modalities for aneurysm imaging 38 Prediction of aneurysm expansion and rupture risk 40 Recommendations for aneurysm screening 41 Recommendations for aneurysm surveillance 45 Recommendations for imaging the symptomatic patient 47 TREATMENT OF THE PATIENT WITH AN AAA 47 The decision to treat 47 Medical management during the period of AAA surveillance 50 Timing for intervention 51 Assessment of operative risk and life expectancy 53
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Endovascular aneurysm repair 55 Considerations for percutaneous repair 55 Infrarenal fixation 56 Suprarenal fixation 56 Management of the internal iliac artery 57 Management of associated vascular disease 59 Perioperative outcomes of elective EVAR 60 Incidence of 30-day and in-hospital mortality 60 Perioperative morbidity 61 Endoleak 62 Access site complications 62 Acute limb thrombosis 63 Post-implantation syndrome 63 Ischemic colitis 63 Role of elective EVAR in the high-risk and unfit patient 63 Open surgical repair 64 Indications 64 Surgical approach 65 Aortic clamping 66 Graft type and configuration 68 Maintenance of pelvic circulation 70 Management of associated intra-abdominal vascular disease 71 Management of associated intra-abdominal nonvascular disease 72 Perioperative outcomes of open AAA repair 72 The patient with a ruptured aneurysm 74 Preoperative management and considerations for patient transfer 74 Systems of care and time goals for intervention 76 Initial operative management 78 Role of EVAR 79 Management of postoperative complications 80 Abdominal compartment syndrome 80 Ischemic colitis 80 Multi-system organ failure 81 Special considerations 81
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Inflammatory aneurysm 81 Horseshoe kidney 81 Aortocaval fistula 82
ANESTHETIC CONSIDERATIONS AND PERIOPERATIVE MANAGEMENT 82 Choice of anesthetic technique and agent 82 Anesthetic considerations in the patient with a ruptured aneurysm 84 Antibiotic prophylaxis 84 Intraoperative fluid resuscitation and blood conservation 85 Cardiovascular monitoring 86 Maintenance of body temperature 88 Role of the intensive care unit 88 Nasogastric decompression and perioperative 89 Prophylaxis for deep vein thrombosis 90 Postoperative blood transfusion 91 Perioperative pain management 92 POSTOPERATIVE AND LONG-TERM MANAGEMENT 93 Late outcomes 93 Endoleak 93 Type I endoleak 93 Type II endoleak 94 Type III endoleak 95 Type IV endoleak 95 Endotension 95 Device migration 96 Limb occlusion 97 Graft infection 99 Incisional hernia 102 Para-anastomotic aneurysm 102 Recommendation for postoperative surveillance 104 Surveillance imaging modality 105 Surveillance outcomes 105 Summary 105 COST AND ECONOMIC CONSIDERATIONS IN ANEURYSM REPAIR 107
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CARE OF THE PATIENT WITH AN AAA: AREAS IN NEED OF FUTURE 109 RESEARCH REFERENCES 112 APPENDIX: SEARCH STRATEGY 189 42
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44 SUMMARY OF GUIDELINES FOR THE CARE OF PATIENTS WITH AN ABDOMINAL 45 AORTIC ANEURYSM 46 Physical examination
In patients with a suspected or known abdominal aortic aneurysm, we recommend performing physical examination that includes an assessment of femoral and popliteal arteries.
In patients with a popliteal or femoral artery aneurysm, we recommend evaluation for an abdominal aortic aneurysm. Level of recommendation Strong Quality of evidence High
Assessment of medical comorbidities
In patients with active cardiac conditions, including unstable angina, decompensated heart failure, severe valvular disease, or significant arrhythmia, we recommend cardiology consultation prior to EVAR or OSR. Level of recommendation Strong Quality of Evidence High
In patients with significant clinical risk factors, such as coronary artery disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic renal insufficiency and an unknown or poor functional capacity (MET < 4) who are to undergo OSR or EVAR, we suggest noninvasive stress testing. Level of recommendation Weak Quality of evidence Moderate
We recommend a preoperative resting 12-lead ECG in all patients undergoing EVAR or OSR within 30 days of planned treatment. Level of recommendation Strong Quality of evidence High
We recommend echocardiography prior to planned operative repair in patients with dyspnea of unknown origin or worsening dyspnea. Level of recommendation Strong Quality of evidence High
We suggest coronary revascularization prior to aneurysm repair in patients with acute ST- or non-ST elevation MI, unstable angina, or stable angina with left main coronary artery or three- vessel disease. Level of recommendation Weak Quality of evidence Moderate
We suggest coronary revascularization prior to aneurysm repair in patients with stable angina and two-vessel disease that includes the proximal left descending artery and either ischemia on non-invasive stress testing or reduced LV function (EF < 50%). Level of recommendation Weak Quality of evidence Moderate
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In patients who may need aneurysm repair in the subsequent 12 months and in whom percutaneous coronary intervention is indicated, we suggest a strategy of balloon angioplasty or bare metal stent placement, followed by four to six weeks of dual-antiplatelet therapy. Level of recommendation Weak Quality of evidence High
We suggest deferring elective aneurysm repair for 30 days after bare metal stent placement or coronary artery bypass surgery, if clinical circumstances permit. As an alternative, EVAR may be performed with uninterrupted continuation of dual-antiplatelet therapy. Level of recommendation Weak Quality of evidence Moderate
We suggest deferring open aneurysm repair for at least 6 months after drug-eluting coronary stent placement or, alternatively, performing EVAR with continuation of dual-antiplatelet therapy. Level of recommendation Weak Quality of evidence Moderate
In patients with a drug-eluting coronary stent requiring open aneurysm repair, we recommend discontinuing P2Y12 platelet receptor-inhibitor therapy 10 days preoperatively with continuation of aspirin. The P2Y12 inhibitor should be restarted as soon as possible after surgery. The relative risks and benefits of perioperative bleeding and stent thrombosis should be discussed with the patient. Level of recommendation Strong Quality of evidence Moderate
We suggest continuation of beta-blocker therapy during the perioperative period, if part of an established medical regimen. Level of recommendation Weak Quality of evidence Moderate
If a decision was made to start beta-blocker therapy (due to the presence of multiple risk factors such as coronary artery disease, renal insufficiency, and diabetes); we suggest initiation well in advance of surgery to allow sufficient time to assess safety and tolerability. Level of recommendation Weak Quality of evidence Moderate
We suggest preoperative pulmonary function studies, including room air arterial blood gases, in patients with a history of symptomatic COPD, long-standing tobacco use, or inability to climb one flight of stairs. Level of recommendation: Weak Quality of evidence Low
We recommend smoking cessation for at least two weeks prior to aneurysm repair. Level of recommendation Strong Quality of evidence Low
We suggest administration of pulmonary bronchodilators for at least two weeks prior to aneurysm repair in patients with a history of COPD or abnormal pulmonary function testing. Level of recommendation Weak Quality of evidence Low
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We suggest holding angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists on the morning of surgery and restarting these agents after the procedure once euvolemia has been achieved. Level of recommendation Weak Quality of evidence Low
We recommend preoperative hydration in non-dialysis dependent patients with renal insufficiency prior to aneurysm repair. Level of recommendation Strong Quality of evidence High
We recommend pre- and post-procedure hydration with normal saline or 5% dextrose/sodium bicarbonate for patients at increased risk of contrast-induced nephropathy undergoing EVAR. Level of recommendation Strong Quality of evidence High
We recommend holding metformin at the time of contrast administration among patients with an eGFR of < 60 mL/min or up to 48 hours before contrast administration, if the eGFR is < 45 mL/min. Level of recommendation: Strong Quality of evidence Low
We recommend restarting metformin no sooner than 48 hours after contrast administration as long as renal function has remained stable (< 25% increase in creatinine above baseline). Level of recommendation: Strong Quality of evidence Low
We recommend perioperative transfusion of packed red blood cells if the hemoglobin level is less than 7 g/dL. Level of recommendation Strong Quality of evidence Moderate
We suggest hematologic assessment if the preoperative platelet count is less than 150,000/μL. Level of recommendation Weak Quality of evidence Low
Aneurysm imaging
We recommend using ultrasound, when feasible, as the preferred imaging modality for aneurysm screening and surveillance. Level of recommendation Strong Quality of evidence High
We suggest that the maximum aneurysm diameter derived from CT imaging should be based on an outer-wall to outer-wall measurement perpendicular to the path of the aorta. Level of recommendation Good Practice Statement Quality of evidence Ungraded
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We recommend a one-time ultrasound screening for abdominal aortic aneurysms in men or women 65-75 years of age with a history of tobacco use. Level of recommendation Strong Quality of evidence High
We suggest ultrasound screening for AAA in first-degree relatives of patients who present with an AAA. Screening should be performed in first degree relatives who are between 65-75 years of age or in those over 75 years of age and in good health. Level of recommendation Weak Quality of evidence Low
We suggest a one-time ultrasound screening for abdominal aortic aneurysms in men or women over 75 years of age with a history of tobacco use and in otherwise good health who have not previously received a screening ultrasound. Level of recommendation Weak Quality of evidence Low
If initial ultrasound screening identified an aortic diameter > 2.5 cm but less than 3 cm, we suggest re-screening after 10 years. Level of recommendation Weak Quality of evidence Low
We suggest surveillance imaging at three-year intervals for patients with an abdominal aortic aneurysm between 3.0 and 3.9 cm. Level of recommendation Weak Quality of evidence Low
We suggest surveillance imaging at 12-month intervals for patients with an abdominal aortic aneurysm of 4.0 to 4.9 cm in diameter. Level of recommendation Weak Quality of evidence Low
We suggest surveillance imaging at six-month intervals for patients with an abdominal aortic aneurysm between 5.0 and 5.4 cm in diameter. Level of recommendation Weak Quality of evidence Low
We recommend a CT scan to evaluate patients suspected to have AAA presenting with recent onset abdominal or back pain, particularly in the presence of a pulsatile epigastric mass or significant risk factors for AAA. Level of recommendation Strong Quality of evidence Moderate
The decision to treat
We suggest referral to a vascular surgeon at the time of initial diagnosis of an aortic aneurysm. Level of recommendation Good Practice Statement Quality of evidence Ungraded
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We recommend repair for the patient who presents with an AAA and abdominal or back pain that is likely attributed to the aneurysm. Level of recommendation Strong Quality of evidence Low
We recommend elective repair for the patient at low or acceptable surgical risk with a fusiform AAA that is ≥ 5.5 cm. Level of recommendation Strong Quality of evidence High
We suggest elective repair for the patient who presents with a saccular aneurysm. Level of recommendation Weak Quality of evidence Low
We suggest repair in women with abdominal aortic aneurysm between 5.0 cm and 5.4 cm in maximum diameter. Level of recommendation Weak Quality of evidence Moderate
In patients with a small aneurysm (4.0 cm to 5.4 cm) who will require chemotherapy, radiation therapy, or solid organ transplantation, we suggest a shared-decision making approach to decide about treatment options. Level of recommendation Weak Quality of evidence Low
Medical management during the period of AAA surveillance
We recommend smoking cessation to reduce the risk of AAA growth and rupture. Level of recommendation Strong Quality of evidence Moderate
We suggest not administering statins, doxycycline, roxithromycin, ACE-inhibitors, or angiotensin receptor blockers for the sole purpose of reducing the risk of AAA expansion and rupture. Level of recommendation Weak Quality of evidence Low
We suggest not administering beta-blocker therapy for the sole purpose of reducing the risk of AAA expansion and rupture. Level of recommendation Strong Quality of evidence Moderate
Timing for intervention
We recommend immediate repair for patients who present with a ruptured aneurysm. Level of recommendation Strong Quality of evidence High
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Should repair of a symptomatic AAA be delayed to optimize co-existing medical conditions, we recommend that the patient be monitored in an ICU-setting with blood products available. Level of recommendation Strong Quality of evidence Low
Assessment of operative risk and life expectancy
We recommend informing patients contemplating open repair or EVAR of their VQI perioperative mortality risk score. Level of recommendation Weak Quality of evidence Low
Endovascular aneurysm repair
We recommend preservation of flow to at least one internal iliac artery. Level of recommendation Strong Quality of evidence High
We recommend using FDA approved branch endograft devices in anatomically suitable patients to maintain perfusion to at least one internal iliac artery. Level of recommendation Strong Quality of evidence High
We recommend staging bilateral internal iliac artery occlusion by at least one to two weeks if required for EVAR. Level of recommendation Strong Quality of evidence High
We suggest renal artery or superior mesenteric angioplasty and stenting for selected patients with symptomatic disease prior to EVAR or OSR. Level of recommendation Weak Quality of evidence Low
We suggest prophylactic treatment of an asymptomatic, high-grade stenosis of the SMA in the presence of a meandering mesenteric artery based off of a large IMA, which will be sacrificed during the course of treatment. Level of recommendation Weak Quality of evidence Low
We suggest preservation of accessory renal arteries at the time of EVAR or OSR if the artery is 3 mm or larger in diameter or supplies more than one-third of the renal parenchyma. Level of recommendation Weak Quality of evidence Low
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Perioperative outcomes of elective EVAR
We suggest that elective EVAR be performed at centers with a volume of at least 10 EVAR cases each year and a documented perioperative mortality and conversion rate to OSR of 2% or less. Level of recommendation Weak Quality of evidence Low
Role of elective EVAR in the high-risk and unfit patient
We suggest informing high-risk patients of their VQI perioperative mortality risk score in order to make an informed decision to proceed with aneurysm repair. Level of recommendation Weak Quality of evidence Low
Open surgical repair
We recommend a retroperitoneal approach for patients requiring open surgical repair of an inflammatory aneurysm, horseshoe kidney, or an aortic aneurysm in the presence of a hostile abdomen. Level of recommendation Strong Quality of evidence Low
We suggest a retroperitoneal exposure or a transperitoneal approach with a transverse abdominal incision for patients with significant pulmonary disease requiring open surgical repair. Level of recommendation Weak Quality of evidence Low
We recommend a thrombin inhibitor, such as Bivalirudin or Argatroban as an alternative to heparin for patients with a history of heparin-induced thrombocytopenia. Level of recommendation Strong Quality of evidence Moderate
We recommend straight tube grafts for open surgical repair of AAA in the absence of significant disease of the iliac arteries. Level of recommendation Strong Quality of evidence High
We recommend performing the proximal aortic anastomosis as close to the renal arteries as possible. Level of recommendation Strong Quality of evidence High
We recommend that all portions of an aortic graft be excluded from direct contact with the intestinal contents of the peritoneal cavity. Level of recommendation Strong Quality of evidence High
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We recommend reimplantation of a patent inferior mesenteric artery (IMA) under circumstances that suggest an increased risk of colonic ischemia. Level of recommendation Strong Quality of evidence High
We recommend preserving blood flow to at least one hypogastric artery in the course of OSR. Level of recommendation Strong Quality of evidence High
We suggest concomitant surgical treatment of other visceral arterial disease at the time of open surgical repair in symptomatic patients who are not candidates for catheter-based intervention. Level of recommendation Weak Quality of evidence Moderate
We suggest concomitant surgical repair of an AAA and co-existent cholecystitis or an intraabdominal tumor in patients who are not candidates for EVAR or staged intervention. Level of recommendation Weak Quality of evidence Low
Perioperative outcomes of open AAA repair
We suggest that elective OSR for AAA be performed at centers with an annual volume of at least 10 open aortic operations of any type and a documented perioperative mortality of 5% or less. Level of recommendation Weak Quality of evidence Low
The patient with a ruptured aneurysm
We suggest a door-to-intervention time of < 90 minutes, based on a 30-30-30 minute framework, for the management of the patient with a ruptured aneurysm. Level of recommendation Good Practice Statement Quality of evidence Ungraded
An established protocol for the management of ruptured AAA is essential for optimal outcomes. Level of recommendation Good Practice Statement Quality of evidence Ungraded
We recommend implementing hypotensive hemostasis with restriction of fluid resuscitation in the conscious patient. Level of recommendation Strong Quality of evidence Moderate
We suggest that patients with ruptured AAA who require transfer for repair, be referred to a facility with an established rupture protocol and suitable endovascular resources. Level of recommendation Good Practice Statement Quality of evidence Ungraded
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If anatomically feasible, we recommend EVAR over open repair for treatment of a ruptured AAA. Level of recommendation Strong Quality of evidence Low
Choice of anesthetic technique and agent
We recommend general endotracheal anesthesia for patients undergoing open aneurysm repair. Level of recommendation Strong Quality of evidence High
Antibiotic prophylaxis
We recommend intravenous administration of a first generation cephalosporin or, in the event of penicillin allergy, vancomycin, within 30 minutes prior to open surgical repair or EVAR. Prophylactic antibiotics should be continued for no more than 24 hours. Level of recommendation Strong Quality of evidence High
We recommend that any potential sources of dental sepsis be eliminated at least 2 weeks before implantation an aortic prosthesis. Level of recommendation Good Practice Statement Quality of evidence Ungraded
Intraoperative fluid resuscitation and blood conservation
We recommend using cell salvage or an ultrafiltration device if large blood loss is anticipated. Level of recommendation Strong Quality of evidence Moderate
If the intraoperative hemoglobin is less than 10 gm/dL and blood loss is ongoing, we recommend transfusion of packed blood cells along with fresh frozen plasma and platelets in a ratio of 1:1:1. Level of recommendation Strong Quality of evidence Moderate
Cardiovascular monitoring
We suggest using pulmonary artery catheters only if the likelihood for a major hemodynamic disturbance was high. Level of recommendation Strong Quality of evidence Moderate
We recommend central venous access and arterial line monitoring in all patients undergoing open aneurysm repair. Level of recommendation Strong Quality of evidence Moderate
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We recommend postoperative ST-segment monitoring for all patients undergoing open aneurysm repair and for those patients undergoing EVAR who are at high cardiac risk. Level of recommendation Strong Quality of evidence Moderate
We recommend postoperative troponin measurement for all patients with ECG changes or chest pain after aneurysm repair. Levels of recommendation Strong Quality of evidence High
Maintenance of body temperature
We recommend maintaining core body temperature at or above 36°C during aneurysm repair. Levels of recommendation Strong Quality of evidence High
Role of the intensive care unit
We recommend postoperative management in an intensive care unit for the patient with significant cardiac, pulmonary or renal disease, as well as for those requiring postoperative mechanical ventilation or who developed a significant arrhythmia or hemodynamic instability during operative treatment. Level of recommendation Strong Quality of evidence High
Nasogastric decompression and perioperative
We recommend optimization of preoperative nutritional status prior to elective open aneurysm repair, if repair will not be unduly delayed. Level of recommendation Strong Quality of evidence High
We recommend using nasogastric decompression intraoperatively for all patients undergoing open aneurysm repair, but postoperatively, only for those patients with nausea and abdominal distention. Level of recommendation Strong Quality of evidence High
We recommend parenteral nutrition if a patient is unable to tolerate enteral support seven days after aneurysm repair. Level of recommendation Strong Quality of evidence High
Prophylaxis for deep vein thrombosis
We recommend thromboprophylaxis that includes intermittent pneumatic compression and early ambulation for all patients undergoing OSR or EVAR. Level of recommendation Strong Quality of Evidence High
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We suggest thromboprophylaxis with unfractionated or low molecular weight heparin for patients undergoing aneurysm repair at moderate to high risk for venous thromboembolism and low risk for bleeding. Level of recommendation Weak Quality of evidence Low
Postoperative blood transfusion
In the absence of ongoing blood loss, we suggest a threshold for blood transfusion during or after aneurysm repair at a hemoglobin concentration of 7 gm/dL or below. Level of recommendation Weak Quality of evidence Low
Perioperative pain management
We recommend multimodality treatment, including epidural analgesia, for postoperative pain control after open surgical repair of an abdominal aortic aneurysm. Level of recommendation Strong Quality of evidence High
Late outcomes
We recommend treatment of Type I endoleaks. Level of recommendation Strong Quality of Evidence Moderate
We suggest treatment of Type II endoleaks associated with aneurysm expansion. Level of recommendation Weak Quality of Evidence Low
We recommend surveillance of Type II endoleaks not associated with aneurysm expansion. Level of recommendation Strong Quality of Evidence Moderate
We recommend treatment of Type III endoleaks. Level of recommendation Strong Quality of Evidence Moderate
We suggest no treatment of Type IV endoleaks. Level of recommendation Weak Quality of Evidence Low
We recommend open repair if endovascular intervention fails to treat a Type I or III endoleak with ongoing aneurysm enlargement. Level of recommendation Strong Quality of Evidence Moderate
We suggest open repair if endovascular intervention fails to treat a Type II endoleak with ongoing aneurysm enlargement. Level of recommendation Weak Quality of Evidence Low
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We suggest treatment for ongoing aneurysm expansion, even in the absence of a visible endoleak. Level of recommendation Weak Quality of Evidence Low
We recommend that follow-up of patients after aneurysm repair include a thorough lower extremity pulse exam or ABI. Level of recommendation Strong Quality of evidence Moderate
We recommend a prompt evaluation for possible graft limb occlusion if patients develop new onset lower extremity claudication, ischemia, or a reduction in ABI after aneurysm repair. Level of recommendation Strong Quality of evidence High
We recommend antibiotic prophylaxis to prevent graft infection prior to any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, including scaling and root canal procedures, for any patient with an aortic prosthesis, whether placed by open surgical repair or EVAR. Level of recommendation Strong Quality of evidence Moderate
We suggest antibiotic prophylaxis prior to respiratory tract procedures, gastrointestinal or genitorurinary procedures, dermatological or musculoskeletal procedures, for any patient with an aortic prosthesis, if the potential for infection exists or the patient is immunocompromised. Level of recommendation Good practice statement Quality of evidence Ungraded
After aneurysm repair, we recommend prompt evaluation for possible graft infection if a patient presents with generalized sepsis, groin drainage, pseudoaneurysm formation, or ill-defined pain. Level of recommendation Strong Quality of evidence High
We recommend prompt evaluation for possible aortoenteric fistula in a patient presenting with gastrointestinal bleeding after aneurysm repair. Level of recommendation Strong Quality of evidence High
In patients presenting with an infected graft in the presence of extensive contamination with gross purulence, we recommend extra-anatomic reconstruction followed by excision of all graft material along with aortic stump closure covered by an omental flap. Level of recommendation Strong Quality of evidence Moderate
In patients presenting with an infected graft with minimal contamination, we suggest in situ reconstruction with cryopresevered allograft. Level of recommendation Weak Quality of evidence Moderate
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In a stable patient presenting with an infected graft, we suggest in situ reconstruction with femoral vein after graft excision and debridement. Level of recommendation Weak Quality of evidence Moderate
In unstable patients with infected graft, we recommend in situ reconstruction with a silver or antibiotic impregnated graft, cryopreserved allograft, or a PTFE graft. Level of recommendation Strong Quality of evidence Moderate
Recommendation for postoperative surveillance
We recommend surveillance during the first year after EVAR using contrast enhanced CT at one month and in the absence of an endoleak or sac enlargement, contrast enhanced CT or color duplex sonographic imaging at 12 months. Level of recommendation Strong Quality of evidence Moderate
If a Type II endoleak is observed one month after EVAR, we suggest postoperative surveillance with contrast enhanced CT and color duplex sonographic imaging at six months. Level of recommendation Weak Quality of evidence Moderate
If neither endoleak nor AAA enlargement is observed one year after EVAR, we suggest color Duplex ultrasonography when feasible, or CT imaging if ultrasound is not possible, for annual surveillance. Level of recommendation Weak Quality of evidence Low
If a Type II endoleak is associated with an aneurysm sac that is shrinking or stable in size, we suggest color Duplex ultrasonography for continued surveillance at 6 month intervals for 24 months and then annually thereafter. Level of recommendation Weak Quality of evidence Low
If a new endoleak is detected, we suggest evaluation for a Type I or Type III endoleak. Level of recommendation Weak Quality of evidence Low
We suggest non-contrast CT imaging of the entire aorta at five-year intervals after open repair or EVAR. Level of recommendation Weak Quality of evidence Low
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48 DEFINITION OF THE PROBLEM
49 Purpose of these guidelines
50 The Clinical Practice Council of the Society for Vascular Surgery charged a writing
51 committee with the task of updating practice guidelines, initially published in 20031 and
52 subsequently updated in 20092, for surgeons and physicians who are involved in the
53 preoperative, operative, and postoperative care of patients with abdominal aortic aneurysms
54 (AAA). This document provides recommendations for evaluating the patient, including risk of
55 aneurysm rupture and associated medical co-morbidities, guidelines for intervention,
56 intraoperative strategies, perioperative care, long-term follow-up, and treatment of late
57 complications. Decision making related to the care of patients with AAA is complex.
58 Aneurysms present with varying risks of rupture and patient specific factors influence
59 anticipated life expectancy, operative risk, and the need to intervene. Careful attention to the
60 choice of operative strategy, as influenced by anatomic features of the AAA, along with optimal
61 treatment of medical co-morbidities is critical to achieving excellent outcomes. Moreover,
62 appropriate postoperative patient surveillance and timely intervention in the case of a late
63 complication is necessary to minimize subsequent aneurysm-related death or morbidity. All of
64 these clinical decisions are determined in an environment where cost-effectiveness will
65 ultimately dictate the ability to provide optimal care to the largest possible segment of the
66 population. Currently available clinical data sets have been reviewed in formulating these
67 recommendations. However, an important goal of this document is to clearly identify those
68 areas where further clinical research is necessary.
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70 Methodology and evidence
71 A comprehensive review of the available clinical evidence in the literature was
72 conducted in order to generate a concise set of recommendations. The strength of any given
73 recommendation and the quality of evidence was graded based on the GRADE approach.3
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74 The quality of evidence derived from randomized trials has an initial rating of high whereas
75 evidence derived from observational studies has an initial rating of low. GRADE domains are
76 then used to modify this initial rating; these domains include risk of bias, consistency of the
77 results across studies, directness of the populations and interventions of the studies to the
78 question at hand, precision of the estimates of effect and the size of the observed effect. When
79 the benefits of an intervention outweighed its risks, or, alternatively, risks outweighed benefits, a
80 strong recommendation was noted. However, if benefits and risks were less certain, either
81 because of low quality evidence or because high quality evidence suggests benefits and risks
82 are closely balanced, a weak recommendation was recorded. Guideline developers used the
83 terms “we recommend” to denote strong recommendations, whereas for weak
84 recommendations they used the less definitive wording “we suggest.” Thus, quality of
85 evidence was rated as high when additional research is considered very unlikely to change
86 confidence in the estimate of effect; moderate when further research is likely to have an
87 important impact in the estimate of effect; or low when further research is very likely to change
88 the estimate of the effect. On occasions, the guideline committee made good practice
89 statements; which are ungraded recommendations advising about performing certain actions
90 considered by surgeons to be essential for patient care and supported by only indirect evidence.
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92 Literature search and evidence summary
93 Three systematic reviews were conducted to support this guideline. Two focused on
94 evaluating the best modalities and optimal frequency for post EVAR surveillance. A third
95 umbrella systematic review (overview of reviews) was focused on identifying the best available
96 evidence on the diagnosis and management of AAA. The date range of this search was from
97 1996 to September 19th, 2016 and included Ovid Medline In-Process & Other Non-Indexed
98 Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials,
99 Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was
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100 designed and conducted by an experienced librarian with input from the guideline
101 methodologist. Controlled vocabulary supplemented with keywords was used to search for
102 meta-analyses and randomized controlled trials of diagnosis and therapy for abdominal aortic
103 aneurysm. The actual strategy is available as Appendix. This search yielded 1,206 references;
104 from which 29 evidence synthesis reports (systematic reviews and meta-analyses) were used to
105 grade the quality of evidence (Table 1) in various topics that relate to AAA such as screening,
106 diagnosis, surveillance and treatment.
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108 GENERAL APPROACH TO THE PATIENT
109 History and Risk Factors for Abdominal Aortic Aneurysm
110 The risk of an abdominal aortic aneurysm (AAA), as well as aneurysm enlargement and
111 rupture, for each patient and related family members, can be largely determined by a thorough
112 medical, family and social history. Abdominal aortic ultrasound screening studies obtained in the
113 United States between 2003 and 2008 were analyzed from more than three million men and
114 women, from diverse racial, ethnic and socioeconomic backgrounds.4 Participants completed a
115 36-item questionnaire on demographic and medical, social and family history information, as
116 well as self-reported weight and height.
117 These data were used to generate a multivariable model for risk, which confirmed age
118 as the most significant risk factor for development of an abdominal aortic aneurysm with a
119 significant increase in risk between the ages of 65 to 69 years (Odds Ratio (OR) 5.4) and 75 to
120 79 years (OR 14.5). Consistent with prior estimates,5-9 an abdominal aortic aneurysm was more
121 likely among men (OR 5.7) and less common in Hispanic (OR 0.7), African American (OR 0.7)
122 and Asian Americans (OR 0.7).
123 This study also confirmed the close epidemiologic association of cigarette smoking and
124 aneurysmal disease. A smoking history of < 0.5 pack per day for up to 10 years carried a
125 significant increased risk of an abdominal aortic aneurysm (OR 2.6), which increased in a dose-
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126 dependent manner such that smoking more than 1 pack per day for greater than 35 years was
127 associated with a 12-fold increased risk (OR 12.1). Reduced risk was noted for smoking
128 cessation, diabetes mellitus, eating fruits and vegetables more than 3 times a week, and
129 exercise more than once a week. The protective effects of healthy diet and physical activity
130 have been confirmed in other reports.10-12 Increasing risk has also been noted with increased
131 salt intake,13 high blood pressure, concomitant peripheral arterial disease and cerebrovascular
132 disease, and a family history of abdominal aortic aneurysm (Table 2).4
133 Given the prevalence of abdominal aortic aneurysm-related risk factors in the United
134 States, the prevalence of abdominal aortic aneurysm, as defined by an aortic diameter greater
135 than 3 cm, was estimated at 1.4% among those between 50 and 84 years of age, or 1.1 million
136 adults. Importantly, these findings largely concur, and expand upon, prior prevalence and
137 association estimates derived from more homogenous populations such male military
138 veterans.14 First degree relatives of patients with an abdominal aortic aneurysm have an
139 approximately 20% likelihood of developing an AAA.15, 16
140 The association between cigarette smoking and AAA disease deserves special
141 emphasis.17 More than 90% of patients with abdominal aortic aneurysm have smoked
142 cigarettes at some point in their lifetime, and AAA is second only to lung cancer in epidemiologic
143 association to cigarette smoking – more closely associated than either cerebrovascular or
144 coronary artery disease.18 For patients with early aneurysmal disease, a recent meta-analysis
145 concluded that smoking increased the rate of aneurysm enlargement by 35%.19 Current
146 smokers are over seven times more likely to have an aneurysm than nonsmokers, with duration
147 of smoking the most important variable. Each year of smoking increases the relative risk of
148 developing an aneurysm by 4%.20 The decades-long decline in per capita cigarette
149 consumption in American adults has been paralleled by a similar decline in deaths from
150 ruptured AAA (Figure 1).21
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151 Estimates of the incidence of death from ruptured abdominal aortic aneurysm have
152 declined by more than 50% in the last twenty years, likely due to multiple factors including
153 declining cigarette consumption, increased public awareness of AAA disease, improved surgical
154 outcomes and access to treatment afforded by endovascular repair techniques, and general
155 improvement in management of cardiovascular disease risk factors.22-24 However, in countries
156 where cigarette consumption remains high or is increasing, aneurysm-related mortality
157 continues to increase.25 Although the risk of inhaled, vaporized nicotine from e-cigarettes and
158 similar nicotine delivery devices has yet to be determined, multiple investigations suggest that
159 exposure to nicotine alone may promote the development and progression of an abdominal
160 aortic aneurysm.26-28
161 Risk factors for rupture are also relevant when evaluating and managing patients with a
162 known or suspected abdominal aortic aneurysm. In the U.K. Small Aneurysm Trial, the annual
163 risk of rupture was 2.2%. Factors significantly and independently associated with rupture
164 included female gender, large initial aneurysm diameter, low forced expiratory volume in one
165 second (FEV1), current smoking history, and elevated mean blood pressure.29, 30 Multiple
166 studies have suggested that women are at greater risk for rupture,31, 32 as are patients receiving
167 immunomodulatory therapy following major organ transplantation.33-35 Women who smoke are
168 at high risk for an abdominal aortic aneurysm. In a recent Swedish population study, women
169 with a history of smoking of more than a 20 pack-years were nearly twice as likely to develop
170 AAA as men with a similar smoking history.36 However, the risk of AAA following smoking
171 cessation declines more rapidly in women than men.36 Increased aortic mural calcification has
172 also been suggested as a risk factor for rupture.37
173 Rupture risk for those unfit for repair in the ADAM trial was 9% per year for patients with
174 aortic diameters between 5.5 and 5.9 cm, 10% for aneurysms between 6.0 and 6.9 cm, and
175 33% for those ≥ 7.0 cm.38 More recent experience suggests that rupture estimates based on
176 aortic diameter may need revision downward. Pooled analysis from natural history studies and
24
177 control arms of interventional trials indicate that current rupture risk for AAAs between 5.5 and
178 7.0 cm in diameter may be as low as 5.3% per year and for AAA > 7.0 cm, 6.3% per year.
179 Among asymptomatic patients, the risk of death from causes other than AAA, regardless of
180 aneurysm diameter, was higher than the risk of death from aneurysm rupture.39
181 Careful review of the surgical history is also essential for accurate and timely recognition
182 of AAA disease. Cholecystitis, appendicitis, or pancreatitis may mimic the presentation of a
183 symptomatic aneurysm. In addition, the nature and extent of previous abdominal surgery may
184 influence the operative approach. When a pulsatile mass is discovered in a patient following
185 prior open surgical repair (OSR) of an AAA, the presence of an anastomotic pseudoaneurysm,40
186 iliac artery aneurysm,41 or suprarenal aortic aneurysm42 should be considered. Abdominal or
187 back pain after endovascular aneurysm repair (EVAR) should also prompt evaluation of
188 potential aneurysm expansion or rupture.43-45
189 Physical examination
190 An abdominal aortic aneurysm is generally defined as an enlargement of the abdominal
191 aorta to ≥ 3.0 cm in diameter. The abdominal aorta begins at the diaphragm, typically at the
192 12th thoracic vertebra, and lays in the retroperitoneum just anterior and slightly left of the
193 vertebral column. With increasing age, the aorta elongates and enlarges, so the location of a
194 pulsatile mass on physical examination can be variable in location. At the level of the umbilicus
195 and fourth lumbar vertebra, the aorta bifurcates into the right and left common iliac arteries. The
196 focused exam for an aortic aneurysm should be directed at the upper abdominal quadrants.
197 Physical examination has only a moderate sensitivity for detecting AAA, depending on
198 the extent of abdominal girth and aneurysm size.46 The common iliac arteries may also become
199 aneurysmal and palpable in the lower abdominal quadrants. A number of theories have been
200 proposed to explain the predilection of aneurysmal degeneration to the abdominal aorta and
201 common iliac arteries, but none are definitive.47 Palpation does not precipitate rupture and the
25
202 concern for a symptomatic aneurysm should not preclude thorough examination. An abdominal
203 aneurysm is common (37-40%) in patients with popliteal artery aneurysms48-50, as are the
204 presence of concurrent distal arterial aneurysms in patients with an AAA.51-53
205 206 207 In patients with a suspected or known abdominal aortic aneurysm, we recommend performing 208 physical examination that includes an assessment of femoral and popliteal arteries. 209 210 In patients with a popliteal or femoral artery aneurysm, we recommend evaluation for an 211 abdominal aortic aneurysm. 212 213 Level of recommendation Strong 214 Quality of evidence High 215 216
217 Assessment of medical comorbidities
218 Preoperative evaluation of cardiac risk. Despite improvements in cardiovascular risk
219 factor management, five-year survival following successful aneurysm repair remains under
220 70%.54-56 Cardiovascular and pulmonary disease remain the leading causes of early and late
221 death following OSR or EVAR.57 EVAR is associated with a three-fold reduction in perioperative
222 mortality when compared to propensity-matched patients undergoing elective OSR,58 including
223 even younger patients with fewer co-morbidities.59 60 For both patients with advanced chronic
224 renal insufficiency61 and oxygen-dependent COPD,62 EVAR outcomes are superior to those
225 achieved with contemporary OSR, particularly when performed under local or regional
226 anesthesia. However, despite the reduced risk as compared to OSR, EVAR remains an
227 intermediate to high-risk procedure.
228 Given the risk associated with either OSR or EVAR, it is essential to evaluate the overall
229 operative risk associated with either method of repair. The first step should be to determine
230 whether an active cardiovascular condition exists (Table 3), which would mandate further
231 assessment and management prior to planned aneurysm repair. In the absence of an active
232 cardiovascular condition, further testing, as dictated by functional capacity and cardiovascular
26
233 risk factors, is indicated only if the results will change the planned treatment approach.
234 Functional capacity can be estimated from a simple activity assessment (Table 4). Patients
235 capable of moderate physical activities, such as climbing two flights of stairs or running a short
236 distance (metabolic activity unit (MET) ≥ 4) will not benefit from further testing. Those who do
237 not function at this level or in whom physical reserve cannot be assessed will benefit from
238 cardiac testing, if it will change operative management.63 Recent studies suggest that low
239 anaerobic threshold (< 10 mL O2/kg/min) during exercise testing, as a measure of aerobic
240 capacity, is predictive of cardiovascular complications, as well as early and late death after
241 aortic aneurysm repair.64-66
242 All patients should be evaluated with a 12-lead ECG within 30 days of planned repair.
243 Although resting LV function, as determined by an echocardiogram, does not predict
244 postoperative MI or death, echocardiography is recommended for those patients with dyspnea
245 of unknown origin or worsening dyspnea in the setting of a history of congestive heart failure.
246 247 248 In patients with active cardiac conditions, including unstable angina, decompensated heart 249 failure, severe valvular disease, or significant arrhythmia, we recommend cardiology 250 consultation prior to EVAR or OSR. 251 252 Level of recommendation Strong 253 Quality of Evidence High 254 255 256 In patients with significant clinical risk factors, such as coronary artery disease, congestive 257 heart failure, cerebrovascular disease, diabetes mellitus, chronic renal insufficiency and an 258 unknown or poor functional capacity (MET < 4) who are to undergo OSR or EVAR, we suggest 259 noninvasive stress testing. 260 261 Level of recommendation Weak 262 Quality of evidence Moderate 263 264 265 We recommend a preoperative resting 12-lead ECG in all patients undergoing EVAR or OSR 266 within 30 days of planned treatment. 267 268 Level of recommendation Strong 269 Quality of evidence High 270
27
271 272 We recommend echocardiography prior to planned operative repair in patients with dyspnea of 273 unknown origin or worsening dyspnea. 274 275 Level of recommendation Strong 276 Quality of evidence High 277 278
279 Preoperative coronary revascularization. A meta-analysis of 22 studies examining
280 more than 13,000 patients with coronary artery disease (CAD) identified an abdominal aortic
281 aneurysm in 8.4% of patients.67 Routine coronary artery revascularization in patients with stable
282 cardiac symptoms and absent left main coronary artery disease or severe aortic stenosis does
283 not alter the risk of MI, death, or long-term survival among patients undergoing elective vascular
284 surgery.68, 69 Coronary revascularization is indicated for acute coronary syndrome with or
285 without ST-segment elevation, unstable angina, stable angina in the presence of left main
286 coronary artery or three-vessel disease, as well as for two-vessel disease, including the
287 proximal left anterior descending artery and either ischemia on non-invasive testing or reduced
288 LV function.
289 The risk for perioperative stent thrombosis for both bare-metal stents (BMS) and drug-
290 eluting stents (DES) in the coronary arteries is highest in the first 4 to 6 weeks after
291 implantation. Surgery should be delayed for 14 days after coronary angioplasty and 30 days
292 after a BMS, if dual-antiplatelet therapy cannot be continued through the perioperative period.
293 Likewise, OSR should not be performed within 6 months following implantation of a drug-eluting
294 stent, if cessation of dual antiplatelet therapy is required.70 This recommendation assumes the
295 use of newer generation drug eluting stents in patients with stable ischemic heart disease. Thus
296 percutaneous EVAR should be considered the operative method of choice if aneurysm
297 treatment becomes necessary within 6 months after placement of a drug-eluting stent, as dual
298 antiplatelet therapy can typically be continued using this approach.
28
299 In summary, a recommendation for percutaneous or surgical intervention for coronary
300 artery disease should follow established clinical practice guidelines, regardless of the need for
301 aneurysm repair.63 While simultaneous open aneurysm repair and CABG has been reported for
302 select symptomatic patients with critical coronary artery disease,71-74 if anatomically feasible,
303 EVAR under local anesthesia would be a preferred option.
304 305 306 307 We suggest coronary revascularization prior to aneurysm repair in patients with acute ST- or 308 non-ST elevation MI, unstable angina, or stable angina with left main coronary artery or three- 309 vessel disease. 310 311 Level of recommendation Weak 312 Quality of evidence Moderate 313 314 We suggest coronary revascularization prior to aneurysm repair in patients with stable angina 315 and two-vessel disease that includes the proximal left descending artery and either ischemia on 316 non-invasive stress testing or reduced LV function (EF < 50%). 317 318 Level of recommendation Weak 319 Quality of evidence Moderate 320 321 322 In patients who may need aneurysm repair in the subsequent 12 months and in whom 323 percutaneous coronary intervention is indicated, we suggest a strategy of balloon angioplasty or 324 bare metal stent placement, followed by four to six weeks of dual-antiplatelet therapy. 325 326 Level of recommendation Weak 327 Quality of evidence High 328 329 330 We suggest deferring elective aneurysm repair for 30 days after bare metal stent placement or 331 coronary artery bypass surgery, if clinical circumstances permit. As an alternative, EVAR may 332 be performed with uninterrupted continuation of dual-antiplatelet therapy. 333 334 Level of recommendation Weak 335 Quality of evidence Moderate 336 337 338 We suggest deferring open aneurysm repair for at least 6 months after drug-eluting coronary 339 stent placement or, alternatively, performing EVAR with continuation of dual-antiplatelet therapy. 340 341 Level of recommendation Weak 342 Quality of evidence Moderate 343 344
29
345 In patients with a drug-eluting coronary stent requiring open aneurysm repair, we recommend 346 discontinuing P2Y12 platelet receptor-inhibitor therapy 10 days preoperatively with continuation 347 of aspirin. The P2Y12 inhibitor should be restarted as soon as possible after surgery. The 348 relative risks and benefits of perioperative bleeding and stent thrombosis should be discussed 349 with the patient. 350 351 Level of recommendation Strong 352 Quality of evidence Moderate 353 354 355 Perioperative medical management of coronary artery disease. The initiation of
356 beta-blockade prior to non-cardiac surgery has been associated with an increased risk of stroke
357 and all-cause mortality.75-77 The use of an alpha-2 agonist is no longer recommended to prevent
358 cardiac events, nor are calcium channel blockers, such as diltiazem and verapamil, given their
359 potential to impair myocardial function in patients with reduced left ventricular function.
360 Continuation of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers is
361 based on individual clinical circumstances.63
362 Aspirin reduces adverse cardiovascular events among patients with coronary artery
363 disease and can be continued during the perioperative period.78 Both warfarin and the new oral
364 anticoagulants (non-vitamin K antagonist oral anticoagulants) should be discontinued at least 5
365 days and 2 days, respectively, prior to major surgery.79 The need for low molecular weight
366 heparin as a bridge depends on the indication for anticoagulation.
367 368 369 We suggest continuation of beta-blocker therapy during the perioperative period, if part of an 370 established medical regimen. 371 372 Level of recommendation Weak 373 Quality of evidence Moderate 374 375 376 If a decision was made to start beta-blocker therapy (due to the presence of multiple risk factors 377 such as coronary artery disease, renal insufficiency, and diabetes); we suggest initiation well in 378 advance of surgery to allow sufficient time to assess safety and tolerability. 379 380 Level of recommendation Weak 381 Quality of evidence Moderate 382
30
383 Pulmonary disease. Between 7 and 11% of patients with COPD have an AAA.29 The
384 prevalence of chronic obstructive pulmonary disease (COPD) in patients presenting with
385 ruptured AAA has largely been attributed to cigarette smoking as a common risk factor.31
386 Common genetic, inflammatory and remodeling pathways may also be present that predispose
387 patients to both conditions.80 Several studies have reported that COPD is an independent
388 predictor of mortality after open repair5, 81 with the severity of pulmonary disease and the
389 capacity to optimize preoperative respiratory function influencing outcome.82 EVAR is better
390 tolerated than OSR, particularly if EVAR is performed under local anesthesia.83, 84 However,
391 patients with severe COPD exhibit increased in-hospital mortality, pulmonary complications,
392 major adverse events, and decreased 5-year survival whether treated with open repair or
393 EVAR.62
394 If COPD is suspected or present, room air arterial blood gases and standard pulmonary
395 function testing should be performed prior to surgery. In the setting of oxygen-dependent
396 COPD, pulmonary consultation should be obtained for assessment of prognosis and
397 optimization of medical therapy. Smoking cessation prior to aneurysm repair and administration
398 of pulmonary bronchodilators for at least two weeks is recommended. The diagnosis of an
399 aortic aneurysm can be a strong motivator for smoking cessation85 and efforts to begin smoking
400 cessation prior to surgery can result in long term benefits.86 Nicotine replacement87 and use of
401 nortriptyline and bupropion, alone or in combination, along with inpatient and outpatient
402 counseling have proven beneficial for smoking cessation.88
403 404 405 We suggest preoperative pulmonary function studies, including room air arterial blood gases, in 406 patients with a history of symptomatic COPD, long-standing tobacco use, or inability to climb 407 one flight of stairs. 408 409 Level of recommendation: Weak 410 Quality of evidence Low 411 412 413
31
414 We recommend smoking cessation for at least two weeks prior to aneurysm repair. 415 416 Level of recommendation Strong 417 Quality of evidence Low 418 419 420 We suggest administration of pulmonary bronchodilators for at least two weeks prior to 421 aneurysm repair in patients with a history of COPD or abnormal pulmonary function testing. 422 423 Level of recommendation Weak 424 Quality of evidence Low 425 426
427 Renal insufficiency. Preoperative renal insufficiency is an established risk factor for
428 poor outcome after aneurysm repair. Among patients with moderate renal dysfunction
429 (estimated glomerular filtration rate (eGFR) 30-60 mL/min), mortality and cardiovascular events
430 are more likely for patients treated by open surgical repair than by EVAR.61 However,
431 outcomes are uniformly poor in the presence of severe renal dysfunction (eGFR < 30 mL/min),
432 regardless of the type of repair. Outcomes are equally poor after EVAR or OSR for the patient
433 requiring dialysis with a 30-day mortality of 11% with Kaplan-Meier survival estimates of 66% at
434 1 year and 37% at three years.89 Median survival was two years.89
435 Significant declines in renal mass and eGFR have been documented after OSR and
436 EVAR, even in the setting of age-adjusted normal renal function prior to surgery.90 For
437 example, acute and chronic kidney injury have been noted after complex EVAR with snorkel or
438 renal stent placement, with an increased risk among women.91 Even transient postoperative
439 renal dysfunction is associated with an increase in mortality, morbidity, and the need for
440 additional intensive care unit support.92
441 Several strategies have been recommended to minimize renal injury after EVAR or
442 OSR. Hydration with either normal saline or sodium bicarbonate is recommended to ensure
443 euvolemia.93 Similarly, given the association of angiotensin-converting enzyme inhibitors and
444 angiotensin receptor antagonists with hypotension on induction of anesthesia, these
445 medications should be held the morning of surgery and restarted after the patient is
32
446 euvolemic.94, 95 While the administration of many agents have been evaluated, none have
447 proven of value in limiting renal injury after AAA repair. Antioxidants, such as mannitol, prior to
448 or during OSR have demonstrated no benefit.96 Likewise, fenoldopam, dopamine, atrial
449 natriuretic peptide, diuretics, as well as anti-platelet and anti-inflammatory agents are of no
450 value in the prevention or treatment of acute kidney injury.97 Lastly, remote ischemic
451 preconditioning (RIPC) has been studied as a strategy for reducing the risk of renal dysfunction.
452 However, systematic review and meta-analysis of the current literature does not confirm the
453 efficacy of this technique in patients undergoing major vascular surgery.98-101
454 Contrast-induced nephropathy (CIN) is defined as a 25% increase in serum creatinine,
455 or an absolute increase of 0.5 mg/dL, two to seven days following contrast administration.
456 Patients with renal disease (eGFR ≤ 45 mL/min/1.73 m2), diabetes, congestive heart failure,
457 ejection fraction < 40%, hypertension, anemia, advanced age, proteinuria, and gout are at
458 increased risk for CIN.102 Gadolinium is not a safe alternative to iodinated contrast, given the
459 risk for nephrogenic systemic fibrosis in patients with a GFR of < 30 mL/min/1.73 m2.
460 There is a linear relationship between the volume of contrast administered and the onset
461 and severity of CIN. For every 100 mL of contrast infused during coronary artery interventions,
462 there is a 12% increase in the risk for CIN.103 Pre-procedural hydration may be beneficial, but
463 fenoldapam, dopamine, atrial natriuretic peptide, theophylline and calcium channel blockers are
464 not.104 Pre-procedural administration of oral N-acetylcysteine is recommended for at-risk
465 patients, given its low cost, safety profile, and mild protective effect. However, a randomized
466 trial of N-acetylcysteine did not reduce the incidence of CIN after EVAR.105 Recent evidence
467 suggests that statin therapy may be of benefit in preventing CIN. For example, two studies
468 suggest that initiating high dose statin therapy two days prior to contrast exposure, and
469 continuing for three days afterward, may reduce the risk for CIN undergoing coronary
470 interventions.106, 107 A recent meta-analysis concluded that the administration of statins along
471 with N-acetylcysteine and intravenous saline had clinically important and statistically significant
33
472 benefits as a prevention strategy for CIN when compared to the use of N-acetylcysteine and
473 saline alone.108
474 Contrast agents with osmolality of > 780 mOsm/kg display increased nephrotoxicity.
475 Additional nephroprotection through further reduction in osmolality was suggested by a study
476 comparing iohexol (Omnipaque, a low-osmolar agent; 600 – 800 mOsm/kg) with iodixanol
477 (Visipaque, an iso-osmolar agent; 290 mOsm/kg).109 However, rates of CIN for iopamidol
478 (Isovue-370, 796 mOsm/kg, non-ionic) are similar to iodixanol, which suggests that other
479 physiochemical properties, apart from osmolarity, are important determinants of CIN.110
480 Likewise, several randomized trials of ionic and nonionic contrast agents have demonstrated no
481 difference in CIN.111
482 In summary, minimizing the volume of any type of contrast agent is essential to reducing
483 the risk of CIN, and all nephrotoxic drugs should be stopped at least 48 hours before contrast
484 administration. Patients at increased risk for CIN should be hydrated prior to and after EVAR.
485 Normal saline at 1 mL/kg/h can be administered for 6 to 12 hours prior to and after the
486 procedure. Alternatively, D5W/sodium bicarbonate can be administered at 3 mL/kg/h for 1 hour
487 prior to EVAR and at 1 mL/kg/h for six hours afterwards. Peri-procedural N-acetylcysteine may
112 488 be of benefit to reduce CIN. Additional strategies to limit contrast load include use of CO2,
489 intravascular or Duplex ultrasound113, or fusion imaging.114
490 491 492 We suggest holding angiotensin-converting enzyme inhibitors and angiotensin receptor 493 antagonists on the morning of surgery and restarting these agents after the procedure once 494 euvolemia has been achieved. 495 496 Level of recommendation Weak 497 Quality of evidence Low 498 499 500 We recommend preoperative hydration in non-dialysis dependent patients with renal 501 insufficiency prior to aneurysm repair. 502 503 Level of recommendation Strong 504 Quality of evidence High
34
505 506 We recommend pre- and post-procedure hydration with normal saline or 5% dextrose/sodium 507 bicarbonate for patients at increased risk of contrast-induced nephropathy undergoing EVAR. 508 509 Level of recommendation Strong 510 Quality of evidence High 511 512 513 Diabetes mellitus. Diabetic patients have increased operative mortality following AAA
514 repair with reduced survival two to five years following surgery, consistent with an increased
515 burden of cardiovascular disease.115 However, whether diabetes is a distinct risk factor for
516 major adverse events or death after OSR or EVAR is not well defined.116-120
517 Metformin is a first-line medication for the treatment of type 2 diabetes and prescribed
518 for over 100 million patients worldwide. Metformin is contraindicated if the eGFR is below 30
519 mL/min per 1.73 m2 due to risk the lactic acidosis, which carries a mortality of up to 50%.121
520 Given the risk of CIN after conventional or CT angiography and the association of metformin
521 with lactic acidosis among patients with renal insufficiency, an eGFR of less than 60 mL/min
522 should prompt the cessation of metformin either at the time of contrast administration or up to
523 48 hours before, if eGFR is less than 45 mL/min.122 Metformin should be restarted no sooner
524 than 48 hours after contrast administration as long as renal function has remained stable (less
525 than 25% increase in creatinine above baseline).122
526 527 528 We recommend holding metformin at the time of contrast administration among patients with an 529 eGFR of < 60 mL/min or up to 48 hours before contrast administration, if the eGFR is < 45 530 mL/min. 531 532 Level of recommendation: Strong 533 Quality of evidence Low 534 535 536 We recommend restarting metformin no sooner than 48 hours after contrast administration as 537 long as renal function has remained stable (< 25% increase in creatinine above baseline). 538 539 Level of recommendation: Strong 540 Quality of evidence Low 541
35
542 Hematologic disorders. The presence of an aortic aneurysm influences both platelet
543 count and function. Low platelet counts and high glycocalicin levels have been observed in
544 patients with an abdominal aortic aneurysm, which has been attributed to increased platelet
545 destruction within the aneurysm sac.123 While a threshold of platelet count below which elective
546 AAA repair should be deferred has not been addressed, further evaluation is warranted if the
547 platelet count is less than 150,000 platelets/μL. Following elective OSR, a platelet count of less
548 than 130,000/μL is associated with an increased risk of bleeding124. Platelet sequestration and
549 thrombocytopenia may occur after OSR, which may persist for several weeks, especially when
550 proximal clamping necessitates periods of renal or visceral ischemia.125 Matsumura and
551 colleagues suggested that a lower preoperative platelet count was an independent predictor of
552 two year mortality among patients undergoing both EVAR and OSR.126
553 Elevated levels of homocysteine, plasminogen activator inhibitor 1, and lipoprotein(a)
554 have been observed among patients with aortic aneurysms, but their role in aneurysm
555 progression is uncertain.127-129 Anticardiolipin antibodies, MTHFR C677T polymorphism,
556 prothrombin gene G20210A variant, and Factor V Leiden mutation are no more common in
557 patients with an aortic aneurysm.
558 559 560 We recommend perioperative transfusion of packed red blood cells if the hemoglobin level is 561 less than 7 g/dL. 562 563 Level of recommendation Strong 564 Quality of evidence Moderate 565 566 567 We suggest hematologic assessment if the preoperative platelet count is less than 150,000/μL. 568 569 Level of recommendation Weak 570 Quality of evidence Low 571 572
573
36
574 Biomarkers and heritable risks for an abdominal aortic aneurysm
575 Biomarkers for the presence and expansion of an aortic aneurysm. The
576 identification of circulating biomarkers for AAA disease remains an area of active investigation.
577 Such markers may assist in identifying new targets for pharmacotherapy, and may improve both
578 the diagnosis of AAA disease and monitoring the response to medical or surgical therapy.
579 Among biomarkers evaluated to date, fibrinogen, D-dimer, and IL-6 have been consistently
580 associated with the presence of AAA in multiple cross-sectional, case-controlled studies.130 A
581 meta-analysis has reported that fibrinogen, D-dimer and thrombin-anti-thrombin III complex
582 levels are increased in patients with AAA.131 Matrix metalloproteinase 9 (MMP-9), tissue inhibitor
583 of matrix metalloproteinase 1 (TIMP-1), interleukin 6 (IL-6), C-reactive protein (CRP), α1-
584 antitrypsin, triglycerides, lipoprotein (a) (Lp(a)), apolipoprotein A, and high-density lipoprotein
585 (HDL) are also differentially expressed in patients with AAA. While a linear correlation has been
586 noted between CRP and aortic diameter,132 this observation is at odds with at least one prior
587 report.133 A number of microRNAs (miRs) related to smooth muscle cell function and collagen
588 formation have also been suggested as possible AAA biomarkers.28, 134-137 At the current time,
589 none of these candidates has the sensitivity, specificity, or rigorous clinical validation to be
590 relied upon as a diagnostic or prognostic indicator for rupture risk.138, 139
591 Genetic markers identifying risk of aortic aneurysm. Genetic influences in AAA
592 disease, first suggested by Clifton,140 has been demonstrated by twin studies141 and by formal
593 segregation analyses.142 Genetic predisposition likely represents small contributions from a
594 large number of risk alleles with the effect dependent on the population under consideration, as
595 well as relevant environmental considerations, such as cigarette smoking.143 Most genomic
596 studies have investigated single nucleotide polymorphisms (SNPs) in genes related to AAA
597 pathogenesis. Potential AAA-related SNPs have been identified in genes encoding for ACE,
37
598 5,10-methyltetrahydrofolate reductase (MTHFR), angiotensin II type 1 receptor, interleukin-10,
599 MMP-3 and transforming growth factor beta receptor II.144
600 The use of genome-wide DNA linkage analyses relies on traditional proband and family
601 tree studies. Examination of families with two or more members with an AAA has identified
602 variations on chromosomes 4 and 19.144 Allelic variation at the q31 locus on chromosome 4
603 may influence endothelin signaling and respiratory epithelial response to injury, such as
604 cigarette smoking.145, 146 Several genome-wide association studies (GWAS) have also been
605 conducted for various cardiovascular diseases,147 at least three of which have focused on
606 AAA.148 A number of genetic loci have been implicated in AAA pathogenesis (Table 5).144 The
607 non-coding region of chromosome 9p21 has been identified as an important source of heritable
608 risk coronary and peripheral arterial disease, as well as AAA, independent of smoking,
609 hypertension and hyperlipidemia. The at-risk allele may mediate this effect by down regulating
610 the cell-cycle regulatory gene, CDKN2B.149 Epigenetic regulation of gene expression through
611 microRNA production and post-translation regulation of gene expression may also influence
612 inflammation, fibrosis, or other mechanisms relevant to AAA pathogenesis.150 151
613 Some monogenic diseases increase the risk of AAA, including mutations within the
614 COL3AI gene, associated with an autosomal dominant defect in type III collagen synthesis
615 present in patients with the Ehlers Danlos phenotype152, 153 or mutations in fibrillin 1, responsible
616 for Marfan Syndrome154. In Ehlers Danlos and Marfan Syndromes, isolated AAA is uncommon
617 in the absence of other arterial aneurysms or aortic dissection, respectively.
618
619 Aneurysm imaging
620 Modalities for aneurysm imaging. Among asymptomatic patients, ultrasound detects
621 the presence of an abdominal aortic aneurysm accurately, reproducibly, and efficiently.
622 Sensitivity and specificity approach 100%, but in 1% to 3% of patients, the aorta cannot be
623 visualized due to bowel gas or obesity.155, 156 Transabdominal ultrasound is ideal for screening
38
624 and surveillance,157 but insufficiently precise for procedural planning or more complex
625 morphological analyses.158-160
626 Computed tomographic (CT) imaging is more reproducible than ultrasound, with > 90%
627 of measurements within 2 mm of the initial reading.161 Both techniques suffer from a lack of
628 standardization in terms of determining the degree and rate of disease progression.162 An
629 aneurysm measured by standard axial CT is generally more than 2 mm larger in diameter than
630 when measured by ultrasound. Most commonly, the cross-sectional measurement obtained by
631 CT is not necessarily perpendicular to the path of the aorta, which presumably contributes to an
632 over-estimation of aneurysm size. There is also significant variability in reporting of aneurysm
633 diameter, particularly in research studies, which have included diameter measurements based
634 on outer-wall to outer-wall, inner-wall to inner-wall, and anterior outer-wall to posterior inner-
635 wall.163 Lack of precision of diameter measurements based on orthogonal rendering, as well as
636 path lengths and centerline measurements have been largely superseded by the adoption of
637 three-dimensional reformatting software and dedicated computer workstations to obtain curved
638 multiplanar reformatted images.164
639 The increasingly small size and low cost of portable ultrasound units and absence of
640 radiation or nephrotoxic contrast administration with ultrasound has made it the preferred
641 technique for aneurysm screening and surveillance.165-167 For operative planning, however, CT
642 remains an essential tool, given its precision, reproducibility, resolution, capacity for complete
643 anatomic examination, and data conversion into numerous reformatting and measurement
644 programs. It bears noting that plain abdominal films and catheter-based digital subtraction
645 angiography have low sensitivity for the detection of AAA. The luminal contour of the
646 aneurysmal aorta visualized by angiography may be obscured by accumulated mural thrombus,
647 particularly in the case of larger aneurysms.
648 Ultrasound has become a mainstay of emergency medical practice and used with
649 increasing accuracy and facility in the differential diagnosis of abdominal pain. High sensitivity
39
650 and specificity have been reported in detecting non-ruptured aneurysms167, 168 and use of
651 bedside ultrasound significantly reduces time to diagnosis and treatment.169, 170 However,
652 regions of the retroperitoneum may not be well visualized in non-fasting patients or those with
653 ileus or excessive intestinal gas.171
654 The accuracy of CT imaging for diagnosis of symptomatic and ruptured AAA has also
655 improved due to advances in coordinated timing and appropriate dosage of contrast, as well as
656 through the use of multi-detector arrays and post-image processing. Timed contrast boluses
657 greatly increases the sensitivity and specificity of CT imaging.172 With modern equipment and
658 imaging techniques, false positive CT interpretation is very low173 and radiographic findings of
659 rupture are well-characterized.174
660 661 662 We recommend using ultrasound, when feasible, as the preferred imaging modality for 663 aneurysm screening and surveillance. 664 665 Level of recommendation Strong 666 Quality of evidence High 667 668 669 We suggest that the maximum aneurysm diameter derived from CT imaging should be based 670 on an outer-wall to outer-wall measurement perpendicular to the path of the aorta. 671 672 Level of recommendation Good Practice Statement 673 Quality of evidence Ungraded 674
675 Prediction of aneurysm expansion and rupture risk. A significant unmet need in the
676 assessment of AAA disease is a determination of rupture risk. Maximum AAA diameter
677 remains the most widely used and validated criteria for prediction of rupture risk. The adoption
678 of maximum diameter as a measure of rupture risk was based, in part, on a retrospective review
679 of 24,000 consecutive autopsies performed over 23 years at a single institution.175 Of the 473
680 non-resected AAA identified in this series, 118 were ruptured. Approximately 40% of AAA
681 greater than 5 cm in diameter were ruptured. However, 40% of AAA between 7 and 10 cm were
682 not ruptured, while 13% of AAA less than 5 cm in size were ruptured.175 Thus, a variety of
40
683 potentially more sensitive predictors of rupture risk have been proposed, including AAA
684 expansion rate,30, 38, 176, 177 wall stiffness,178-180 wall tension,181 and peak AAA wall stress.182-184
685 Hall and colleagues have suggested that rupture is imminent above a critical aortic wall
686 stress, predicted by the Law of Laplace and maximum AAA diameter.181 Several other
687 investigators subsequently demonstrated that wall stress is highly dependent on AAA shape
688 rather than diameter alone.182-188 With ultrasound-based assessment, determination of peak
689 wall stress may soon be translatable to real-time patient assessment.189 Modeling by
690 computational fluid dynamics has suggested that intraluminal hemodynamic conditions also
691 influence AAA growth, remodeling, and risk of rupture.190-194
692 The peak wall rupture index considers both peak wall stress and residual wall strength
693 and has been proposed as more predictive than estimates of peak wall stress alone.195-197
694 Further analyses have also incorporated the influence of intraluminal hemodynamic conditions
695 on wall stress/strength indices through fluid structure interaction simulations.198, 199 The value of
696 CT-determined intraluminal thrombus volume200 201, as well as PET-CT imaging in predicting
697 rupture risk remains uncertain.202 203 The utility of PET imaging may require the development of
698 AAA-specific radiotracer agents.204
699 Beyond an assessment of rupture risk, there is a clear role for imaging-based criteria for
700 the prediction of disease progression. As revealed in surveillance studies, many small AAAs do
701 not enlarge.205 Molecular imaging of pathologic processes characteristic of aortic degeneration,
702 including angiogenesis,206 matrix disruption,207 activated macrophage localization,208 and
703 proteolysis209 are being translated to the clinic210-213 and may help to identify those patients with
704 an increased likelihood of disease progression.
705 Gender-specific rupture indicators have been evaluated given the increased risk for
706 rupture in women at any given aortic diameter. A recent computational study of patient-specific
707 anatomy using finite element analysis was unable to identify significant differences in peak wall
708 stress and peak wall rupture indices between men and women.214 Although aneurysm diameter
41
709 remains a well-established parameter for clinical decision-making, a retrospective analysis has
710 suggested that aneurysm diameter indexed to body size (aortic size index (ASI) = aneurysm
711 diameter (cm)/BSA (m2)) may represent a superior predictor of rupture risk for women.215
712 Recommendations for aneurysm screening. Aneurysm screening has been
713 motivated by a desire to reduce AAA-related mortality and prolong life expectancy. Overall, the
714 probability of AAA in the general population is very low, but significantly increased when certain
715 risk factors are present.4 Four randomized clinical trials that included 127,891 men and 9,342
716 women between 65 and 79 years of age provide evidence that ultrasound screening is effective
717 in reducing aneurysm-related mortality.216-221 This benefit begins within 3 years of testing and
718 persists for up to 15 years.222 In addition, screening is associated with a reduced risk for AAA
719 rupture and emergency surgery.222
720 The MASS group, the largest of the four randomized clinical trials, reported that over 13
721 years there was a 42% reduction in AAA-related mortality and a small reduction in all-cause
722 mortality. It was estimated that 216 men needed to be invited to screening to save one death
723 over 13 years. Of those aneurysms that did rupture, roughly half had an initial baseline
724 diameter of 2.5 to 2.9 cm at initial screening.223
725 Screening for AAA in women is more controversial. Since few women were included in
726 these trials, a decrease in AAA-related mortality or incidence of rupture could not be
727 identified.224 Although AAA prevalence is lower in women, the rate of rupture and overall life
728 expectancy are higher, which suggest that screening may be more cost-effective in women.225
729 In 2005 the U.S. Preventative Services Task Force (USPSTF) recommended a one time
730 screening by abdominal ultrasonography for men aged 65 to 75 with a history of smoking.226 In
731 2014, the USPSTF updated their 2005 recommendations to include one time ultrasound
732 screening for men aged 65 to 75 who have ever smoked (grade B) and selective screening of
733 65 to 75 year old men who have never smoked (grade C). Screening was not recommended for
42
734 women aged 65 to 75 who have never smoked (grade D) and evidence was insufficient to
735 recommend for or against screening in women aged 65 to 75 who had a smoking history.227
736 The USPSTF recommendations are based on the assumption that 6 to 7% of men with a
737 smoking history in the 65 to 75 year old age group will have an AAA. In the absence of a
738 smoking history, the prevalence drops to 2%. The prevalence of AAA is 0.8% in a similar age
739 group of women who have a past history of smoking, but for women who are current smokers
740 the prevalence is 2%. In women who have never smoked, AAA prevalence is less than
741 0.60%.227
742 In 2007, following passage of the SAAAVE (Screening Abdominal Aortic Aneurysms
743 Very Efficiently) amendment in 2006, the U.S. Centers for Medicare and Medicaid Services
744 began offering one time screening by ultrasonography for men aged 65 to 75 if they had
745 smoked ≥ 100 cigarettes in their lifetime, and men and women with a family history of AAA
746 disease, as part of their “Welcome to Medicare” physical examination. As originally mandated,
747 the screening could only be ordered by the primary care physician, within 6 months of the
748 activation of Medicare benefits.226 However, by 2012 it was apparent that fewer than 3% of
749 abdominal ultrasound claims were for SAAAVE-specific AAA screening, and although
750 abdominal ultrasounds in the affected age groups had increased, there was no discernible effect
751 on AAA rupture or all-cause mortality.228 Subsequent Medicare eligibility guidelines have been
752 modified to allow additional physician specialists to order the tests and increase the window of
753 eligibility.
754 Many additional opportunities exist to improve screening and surveillance practices in
755 the United States. Currently, 40% of operative repairs in Medicare beneficiaries are performed
756 late in the course of the disease, suggesting that a prior screening opportunity had been
757 missed.229 A significant portion of patients present with rupture despite known AAA status.229 In
758 an analysis of a cohort of more than 3 million individuals, it was suggested that small changes in
759 recommended eligibility requirements, such as accounting for the impact of accumulated
43
760 cardiovascular risk factors, would improve the screening yield for women, non-smokers, and
761 other groups traditionally considered at lower risk.4
762 Effective use of the electronic health record to improve screening of target populations
763 has been demonstrated by Kaiser Permanente of Southern California.230 “Best practice alerts”
764 for AAA screening criteria were integrated into the electronic health record and reduced the
765 percentage of unscreened patients within their 3.6 million subscriber system from 52% to 20%
766 within 15 months. These alerts were directed to nursing staff when patients checked in for any
767 visit with any provider. Automatic screening orders were then entered that clinicians would sign
768 when visit specific relevant orders were completed. Patients who had undergone any type of
769 cross-sectional abdominal imaging in the prior ten years (>54,000) were excluded from the alert
770 system.230
771 In addition to the United States, government-sponsored screening programs have been
772 implemented in the U.K. and Sweden and the results reflect the changing epidemiology of
773 aneurysmal disease. In Sweden the screening yield was less than half that expected, despite
774 widespread participation.231 Similarly, in the first three years of the U.K. National Abdominal
775 Aortic Aneurysm Screening Program AAA detection rate was only 1.6%, less than 50% of that
776 expected based on the results of the prior MASS cohort.232 However, cost-effectiveness
777 calculations derived from MASS (£7,600/life-year gained) suggest that AAA screening in
778 England and other European countries will remain cost-effective even with prevalence rates as
779 low as 1%.233-235
780 Other challenges to efficient implementation of screening include identifying and
781 excluding patients who have had prior abdominal cross-sectional imaging studies, accounting
782 for increasing longevity, the potential needs for late rescreening,236 and selective screening to
783 optimize yield at minimal cost.237 Reducing all-cause mortality and enhancing yield might be
784 increased by integrating AAA screening with concurrent echocardiograms238 or blood pressure
44
785 and peripheral vascular disease testing.239 Ensuring full participation for all patient groups at
786 risk remains an ever-present challenge.240, 241
787 788 789 We recommend a one-time ultrasound screening for abdominal aortic aneurysms in men or 790 women 65-75 years of age with a history of tobacco use. 791 792 Level of recommendation Strong 793 Quality of evidence High 794 795 We suggest ultrasound screening for AAA in first-degree relatives of patients who present with 796 an AAA. Screening should be performed in first degree relatives who are between 65-75 years 797 of age or in those over 75 years of age and in good health. 798 799 Level of recommendation Weak 800 Quality of evidence Low 801 802 803 We suggest a one-time ultrasound screening for abdominal aortic aneurysms in men or women 804 over 75 years of age with a history of tobacco use and in otherwise good health who have not 805 previously received a screening ultrasound. 806 807 Level of recommendation Weak 808 Quality of evidence Low 809 810 If initial ultrasound screening identified an aortic diameter > 2.5 cm but less than 3 cm, we 811 suggest re-screening after 10 years. 812 813 Level of recommendation Weak 814 Quality of evidence Low 815
816 Recommendations for aneurysm surveillance. The optimal frequency for
817 surveillance following recognition of early-stage AAA disease has not been defined by
818 randomized clinical study. Some authors have suggested that there is no need to follow
819 patients with an initial aortic diameter less than 3 cm given their low risk for rupture.220, 242
820 However, in a 12 year analysis of 1,121 men aged 65 or older, 13.8% of aortas with an initial
821 diameter of 2.6 to 2.9 cm exceeded 5.5 cm at 10 years. Among patients with an aortic diameter
822 between 3.0 and 3.4 cm, 2.1% had reached 5.5 cm at three years, and of those with a diameter
45
823 between 3.5 and 3.9 cm, 10.5% exceeded 5.5 cm or required surgery within two years. Rupture
824 occurred in 1.4%.
825 Two randomized controlled trials, the U.K. Small Aneurysm Trial,243 and the US Veterans
826 Affairs Aneurysm Detection and Management Trial,244 as well as a follow-up study of patients
827 detected in the U.K. MASS trial,218 demonstrated that a policy of surveillance until aneurysm
828 diameter exceeds 5.5 cm was safe and associated with a rupture rate of 1% per year. While
829 aortic size was defined by the maximum external aortic diameter, the surveillance frequency
830 differed among these studies.
831 In an analysis of expansion rates of 1,743 participants in the U.K. Small Aneurysm Trial,
832 AAA growth rate increased with aneurysm size and among current smokers, was lower in those
833 with low ankle-brachial index and diabetes, and was unaffected by lipids and blood pressure.245
834 Combining the results of 18 surveillance studies with similar imaging and assessment protocols,
835 the RESCAN collaborators identified a pooled growth rate across all studies of 2.2 mm per year,
836 with no significant difference between men and women. When estimates were pooled using
837 random-effects meta-analysis, following further adjustment for all demographics, medical and
838 drug history, rates of aneurysm enlargement were significantly increased in smokers and
839 decreased in those with diabetes (Figures 2A and 2B). Pooled meta-analysis failed to identify
840 the effects of any class of drug on aneurysm expansion.19 After adjustment for initial aneurysm
841 diameter, medical history and demographics, a strong association was noted between smoking
842 and rupture (HR 2.02, 95% CI 1.33 - 3.06, p = 0.001), and a far higher risk for women than men
843 (HR 3.76, 95% CI 2.58 - 5.47, p < 0.001). Rupture risk was increased in older participants,
844 those enrolled in earlier studies, those with lower BMI and higher mean arterial or pulse
845 pressure. The effect of any class of drug was difficult to evaluate based on the low incidence of
846 rupture.19
847 Thompson and associates performed a meta-regression of growth estimates based on
848 aneurysm diameter (Figure 3) and time to a 10% probability of attaining an aortic diameter of
46
849 5.5 cm (Figure 4).246 Integrating cost-effectiveness data, the authors proposed
850 recommendations for surveillance intervals based on aortic size. Several years was
851 recommended for men with an initial AAA diameter between 3.0 and 4.0 cm range, whereas an
852 interval of one year was recommended for AAAs between 4.0 and 4.9 cm and six months for
853 those between 5.0 and 5.4 cm. However, the presence of diabetes, female sex, and current
854 smoking history were not accounted by the model or considered within this set of
855 recommendations.246 The increased risk of aneurysm rupture in women and patients with a
856 smoking history has confounded attempts at standardizing surveillance intervals.
857 858 859 We suggest surveillance imaging at three-year intervals for patients with an abdominal aortic 860 aneurysm between 3.0 and 3.9 cm. 861 862 Level of recommendation Weak 863 Quality of evidence Low 864 865 866 867 We suggest surveillance imaging at 12-month intervals for patients with an abdominal aortic 868 aneurysm of 4.0 to 4.9 cm in diameter. 869 870 Level of recommendation Weak 871 Quality of evidence Low 872 873 We suggest surveillance imaging at six-month intervals for patients with an abdominal aortic 874 aneurysm between 5.0 and 5.4 cm in diameter. 875 876 Level of recommendation Weak 877 Quality of evidence Low 878 879
880 Recommendations for imaging the symptomatic patient. In patients with abdominal
881 or back pain, ultrasound imaging is recommended to determine if an AAA is present and to
882 evaluate for the presence of other causes of abdominal or back pain. If an aneurysm is
883 detected, the patient should have a CT aortogram with timed intravenous contrast injection, if
884 not contraindicated, to exclude rupture and facilitate operative planning. A patient presenting
885 with a large AAA and back or abdominal pain should be referred for treatment, as soon as an
47
886 aneurysm is recognized, regardless of evidence for rupture, symptom evolution, or if a CT scan
887 has been completed. If hemodynamic compromise is present or evolves during the process of
888 evaluation, further imaging studies should be abandoned as care is escalated.
889 890 891 We recommend a CT scan to evaluate patients suspected to have AAA presenting with recent 892 onset abdominal or back pain, particularly in the presence of a pulsatile epigastric mass or 893 significant risk factors for AAA. 894 895 Level of recommendation Strong 896 Quality of evidence Moderate 897 898 899
900 TREATMENT OF THE PATIENT WITH AN ABDOMINAL AORTIC ANEURYSM
901 The decision to treat. It is recognized that the majority of patients will be asymptomatic
902 at the time of diagnosis of an AAA. Less frequently, the first presentation of an unrecognized
903 AAA may, in fact, be a symptomatic aneurysm manifested by abdominal or back pain or even
904 rupture. Should this be the case, prompt treatment is recommended.
905 Most AAAs are fusiform rather than saccular and current recommendations for treatment
906 of asymptomatic fusiform AAA rests primarily on the maximum transverse diameter as
907 measured on ultrasound, computed tomography, or magnetic resonance imaging. Conventional
908 arteriography can easily underestimate the true diameter by not accounting for luminal
909 thrombus.
910 There is general agreement that small aneurysms, less than 4.0 cm in maximum
911 diameter, are at low risk of rupture and should be monitored whereas an aneurysm greater than
912 5.4 cm in diameter should be repaired in an otherwise healthy patient. Elective repair is also
913 recommended for patients who present with a saccular aneurysm and while size guidelines are
914 currently lacking due to their infrequent presentation, repair is generally recommended at a
915 smaller diameter.
48
916 Some controversy exists regarding treatment strategies for patients who present with an
917 AAA between 4.0 and 5.4 cm. In the United Kingdom Small Aneurysm Trial (UKSAT)247 and the
918 Aneurysm Detection and Management (ADAM) Trial,248 the 30-day operative mortality in the
919 immediate surgery groups (5.5% UKSAT, 2.1% ADAM) led to an early disadvantage in survival.
920 The investigators found no statistically significant difference in long-term survival between the
921 immediate open surgical repair and surveillance groups. Currently nearly 80% of all AAAs are
922 treated by EVAR in the United States.249, 250 Given the less invasive nature of EVAR, two
923 studies re-evaluated the appropriateness of intervention for small aneurysms. The Comparison
924 of Surveillance versus Aortic Endografting for Small Aneurysm Repair (CAESAR)251 and Positive
925 Impact of Endovascular Options for Treating Aneurysms Early (PIVOTAL)252 trials compared
926 immediate EVAR or surveillance for AAA between 4.1 and 5.4 cm (CAESAR) and 4.0 and 5.0
927 cm (PIVOTAL) and found no survival benefit for early EVAR, but neither trial was designed to
928 determine whether immediate EVAR might be beneficial or harmful for specific AAA size ranges
929 or age subgroups. A Cochrane Database Review253 of these four studies demonstrated no
930 advantage to immediate repair by open surgery or EVAR for small AAA (4.0 - 5.5 cm).
931 Patients with an asymptomatic fusiform AAA greater than 5.4 cm should be considered
932 for repair and surveillance is recommended for smaller aneurysms. An individualized approach
933 may be appropriate for patients with an AAA greater than 5.4 cm, but who are of advanced age
934 or have significant co-morbid conditions. Alternatively, young, healthy patients, particularly
935 women, with an AAA between 5.0 and 5.4 cm or those with rapid expansion of small fusiform
936 AAAs may benefit from early repair.246, 254-256
937 938 939 940 We suggest referral to a vascular surgeon at the time of initial diagnosis of an aortic aneurysm. 941 942 Level of recommendation Good Practice Statement 943 Quality of evidence Ungraded 944 945
49
946 We recommend repair for the patient who presents with an AAA and abdominal or back pain 947 that is likely attributed to the aneurysm. 948 949 Level of recommendation Strong 950 Quality of evidence Low 951 952 953 We recommend elective repair for the patient at low or acceptable surgical risk with a fusiform 954 AAA that is ≥ 5.5 cm. 955 956 Level of recommendation Strong 957 Quality of evidence High 958 959 960 We suggest elective repair for the patient who presents with a saccular aneurysm. 961 962 Level of recommendation Weak 963 Quality of evidence Low 964 965 966 We suggest repair in women with abdominal aortic aneurysm between 5.0 cm and 5.4 cm in 967 maximum diameter. 968 969 Level of recommendation Weak 970 Quality of evidence Moderate 971 972 973 In patients with a small aneurysm (4.0 cm to 5.4 cm) who will require chemotherapy, radiation 974 therapy, or solid organ transplantation, we suggest a shared-decision making approach to 975 decide about treatment options. 976 977 978 Level of recommendation Weak 979 Quality of evidence Low 980 981
982 Medical management during the period of aneurysm surveillance. In the presence
983 of a small aortic aneurysm, several approaches have been proposed to prevent further
984 enlargement.18 Smoking cessation is the most important intervention for a patient with an
985 aneurysm.246, 255, 257-259 Hemodynamic control with propranolol has not been shown to inhibit
986 aneurysm expansion.260, 261 Despite the benefits of statins in cardiovascular disease, their ability
987 to limit aneurysm expansion is lacking.262-265 Angiotensin-converting enzyme (ACE) inhibitors
988 and Losartan, an angiotensin receptor antagonist, decrease the rate of AAA expansion in mice,
50
989 but clinical investigations have reported conflicting results.266, 267 Clinical trials of beta-adrenergic
990 receptor blockade demonstrate no effect on the rate of aneurysm progression.261, 268 Likewise,
991 beta-blockade, lipid-lowering agents, and angiotensin receptor blockade do not appear to alter
992 rupture risk, but an increased risk of rupture has been reported for patients who recently
993 discontinue ACE inhibitors.269
994 Some have suggested that serological evidence of Chlamydophili pneumonia infection
995 may be associated with AAA expansion,270 but a prospective randomized trial demonstrated that
996 azithromycin had no effect aneurysm enlargement.271 Doxycycline can inhibit matrix
997 metalloproteases in plasma and aneurysm tissue and, thus, has been proposed as an agent to
998 limit AAA growth. 272, 273 However, a randomized trial of low dose doxycycline (100 mg once
999 daily) demonstrated no reduction in aneurysm growth during an 18 month period.274 An ongoing
1000 NIH trial is examining the effectiveness of a higher dose of doxycycline (100 mg twice daily).
1001 In summary, during the surveillance period, patients should be counseled to cease
1002 smoking if tobacco products are being used. Patients should be encouraged to seek
1003 appropriate medical management for hypertension, hyperlipidemia, diabetes, and other
1004 atherosclerotic risk factors. A statin and ACE inhibitor should be considered, given the broad
1005 potential benefits to cardiovascular disease and acceptable safety profile. Insufficient data
1006 currently exist to recommend use of doxycycline or roxithromycin. Patients should be counseled
1007 that moderate physical activity does not precipitate rupture or influence AAA growth rate.12, 275
1008 1009 1010 We recommend smoking cessation to reduce the risk of AAA growth and rupture. 1011 1012 Level of recommendation Strong 1013 Quality of evidence Moderate 1014 1015 1016 We suggest not administering statins, doxycycline, roxithromycin, ACE-inhibitors, or angiotensin 1017 receptor blockers for the sole purpose of reducing the risk of AAA expansion and rupture. 1018 1019 Level of recommendation Weak 1020 Quality of evidence Low
51
1021 We suggest not administering beta-blocker therapy for the sole purpose of reducing the risk of 1022 AAA expansion and rupture. 1023 1024 Level of recommendation Strong 1025 Quality of evidence Moderate 1026 1027 1028 1029 Timing of intervention. A patient with a known abdominal aortic aneurysm or pulsatile
1030 mass on abdominal exam who presents without hemodynamic instability and acute onset of
1031 back or abdominal pain should undergo an immediate CT scan to determine if rupture has
1032 occurred. While a ruptured AAA represents a surgical emergency, the timing of aneurysm
1033 repair for patients with a symptomatic but non-ruptured aneurysm represents a clinical dilemma.
1034 Under select circumstances, it may be appropriate to delay intervention for several hours to
1035 ensure conditions for successful repair, including optimizing anesthetic support, as well as blood
1036 product or device availability. If such an approach is elected, the patient should be closely
1037 monitored in an intensive care unit.
1038 A more frequent concern is the timing for treatment of an asymptomatic, large abdominal
1039 aortic aneurysm, greater than 5.4 cm in diameter. In the ADAM trial, rupture risk was estimated
1040 at 10% per year for aneurysms between 5.5 and 6.9 cm diameter, but over 33% per year when
1041 aneurysms were 7 cm or larger in diameter.38 Recent reports, however, suggest that
1042 contemporary rupture rates may be lower than previously estimated. For example, a pooled
1043 analysis from natural history studies and control arms from interventional trials, calculated a
1044 rupture risk of 6.3% per year for aneurysms larger than 7 cm in diameter.39 In general, should a
1045 patient be considered a surgical candidate, repair of a large aneurysm should not be unduly
1046 delayed. Pertinent preoperative assessment should be conducted in a timely manner in order to
1047 optimize outcomes, especially for patients with associated co-morbid conditions. Given the risk
1048 of rupture, both patient and family need to understand and accept the rationale for any delay
1049 related to further evaluation.
52
1050 Whether a recent surgical procedure, such as an abdominal colectomy, coronary artery
1051 bypass, or prostatectomy, can increase the likelihood of aneurysm rupture remains an unsettled
1052 question.71, 276 It has been suggested that inflammation and the induction of a catabolic state
1053 may result in enhanced collagen proteolysis with an increased risk of rupture. However, animal
1054 studies have not found evidence of increased aortic collagenase activity277 nor has this notion
1055 been supported by a prospective clinical study.278 It seems unlikely that the risk of aneurysm
1056 rupture is substantially increased by an unrelated operation and that a several week delay to
1057 enable satisfactory recovery is acceptable prior to elective abdominal aortic aneurysm repair.
1058 In summary, the optimal timing of abdominal aortic aneurysm repair is based on clinical
1059 presentation and aneurysm status: 1) a ruptured abdominal aortic aneurysm requires emergent
1060 repair; 2) a symptomatic, non-ruptured aneurysm is best treated urgently; and 3) an
1061 asymptomatic abdominal aortic aneurysm can be treated electively following completion of
1062 preoperative assessment. Delay in the treatment of an asymptomatic, large abdominal aortic
1063 aneurysm should be minimized.
1064 1065 1066 We recommend immediate repair for patients who present with a ruptured aneurysm. 1067 1068 Level of recommendation Strong 1069 Quality of evidence High 1070 1071 1072 Should repair of a symptomatic AAA be delayed to optimize co-existing medical conditions, we 1073 recommend that the patient be monitored in an ICU-setting with blood products available. 1074 1075 Level of recommendation Strong 1076 Quality of evidence Low 1077 1078 1079 Assessment of operative risk and life expectancy. Several prediction models have
1080 been developed to estimate operative risk for open AAA repair and EVAR and hold the promise
1081 of better informing patients of their individual risk of perioperative mortality and provide
1082 surgeons a useful tool to ensure an informed discussion with patients and their families. Risk
53
1083 prediction models for aneurysm repair were first developed in the 1990s; largely derived from
1084 relatively small cohorts of several hundred patients treated by open surgical repair.279 The
1085 most well-known of this first generation of risk model were the Glasgow Aneurysm Score, the
1086 Leiden Score, and the Hardman Index. As one example, the Glasgow Aneurysm Score was
1087 developed from a cohort of 268 open AAA repairs, where 41% of patients presented with
1088 ruptured aneurysms and the overall mortality was 20%. The risk score accounted for age, the
1089 presence of shock, renal disease, and a history of myocardial or cerebrovascular disease.280
1090 The EUROSTAR collaborators suggested that the GAS could be used to estimate mortality for
1091 EVAR with 30 day mortality of 1.1% for GAS score < 74, 2.1% for GAS 74 to 84, and 5.3% for
1092 GAS > 84.281
1093 Over the past 7 years, a variety of new risk scoring schemes have been derived from
1094 an assessment of patients who have undergone either open repair or EVAR, in order to
1095 specifically account for the mortality risk associated with EVAR. Egarova used Medicare data
1096 to identify a EVAR patients with increased operative risk due to the presence of many of the
1097 same risk factors for mortality that had been previously identified among patients undergoing
1098 open repair, including age, renal failure, CHF, PAD, and liver disease.282 They found that only
1099 3.4% of Medicare patients undergoing EVAR had an operative risk > 5%, but a subset, which
1100 represented <1% of patients undergoing EVAR, was identified with a predicted mortality of >
1101 10%. In an analysis of Medicare patients undergoing open repair and EVAR, including a review
1102 of prior Medicare claims data to obtain a reliable assessment of pre-existing comorbidities,
1103 Schermerhorn found age, renal failure, heart failure, female sex, and peripheral or cerebral
1104 vascular disease to be predictive of perioperative mortality for either EVAR or open aneurysm
1105 repair (C-statistic 0.726).283 For the first time, a single scoring scheme was developed that
1106 could be applied to patients to assess risk for either EVAR or open surgical repair. Recently,
1107 Eslami and collaborators used the Vascular Study Group of New England (VSGNE) database to
1108 develop a new risk model, which included anatomic features, such as aneurysm diameter, neck
54
1109 length, and level of clamp placement that had not been incorporated in prior scoring schemes
1110 (C-statistic 0.822; Tables 6A and 6B).284 This model has since been validated using the
1111 Vascular Quality Initiative (VQI) database and has been recently endorsed by the VQI for risk
1112 stratification of patients under consideration for planned open repair or EVAR.
1113 The delivery of clinically appropriate care requires balancing operative risk with the
1114 likelihood of late survival. Patients with aortic aneurysms suffer higher rates of heart attacks,
1115 strokes, and major amputation and have an increase in five-year mortality compared with age-
1116 matched controls.56 Bahia and colleagues recently conducted a systematic review of long-term
1117 survival after aneurysm repair.56 Patients with large aneurysms, at greatest risk of rupture, also
1118 had significantly worse five-year survival. As one would anticipate, many of the same risk
1119 factors for perioperative death also impact life expectancy. One-year survival after hospital
1120 admission for heart failure is 60%. One-year survival after initiation of dialysis is 85%, but
1121 decreases for those with significant comorbidities to 60%. The three-year survival after initiating
1122 home oxygen therapy for COPD is 60%. In the EVAR-2 trial, patients with severe coronary
1123 artery disease, COPD, or poor renal function were considered ineligible for open repair. While
1124 the study has been criticized for its trial design, EVAR did not impact overall survival. Two year
1125 survival was 60% and five year survival was 35%.285 De Martino et al. assessed survival after
1126 EVAR within the VSGNE population using the EVAR-2 trial criteria.286 Five-year survival for
1127 patients with aneurysms smaller than 6.5 cm was 46% and for patients with aneurysms larger
1128 than 6.5 cm, five-year survival was 28%. In a recent study, those patients declined for AAA
1129 repair had a 2-year survival of 35%.287 Thus, for a patient with high operative risk and
1130 shortened life expectancy, rupture risk must be high to benefit from EVAR.
1131 1132 1133 We recommend informing patients contemplating open repair or EVAR of their VQI 1134 perioperative mortality risk score. 1135 1136 Level of recommendation Weak 1137 Quality of evidence Low 1138
55
1139 Endovascular aneurysm repair
1140 Endovascular aortic aneurysm repair has rapidly expanded as the preferred approach
1141 for treatment of AAA since the first report more than 25 years ago.288, 289 Since the introduction
1142 of EVAR, the annual number of deaths from intact and ruptured AAAs has significantly
1143 decreased in the United States. This has coincided with an increase in elective AAA repair and
1144 a decrease in the diagnosis and repair of ruptured AAAs.23
1145 Considerations for percutaneous repair. EVAR has evolved since its inception with
1146 the development lower profile delivery sheaths that are tapered, flexible, and coated for low-
1147 resistance introduction into the femoral arteries. Concomitantly, devices have been designed to
1148 facilitate percutaneous closure of femoral artery puncture sites of increasing dimension.
1149 Together, this has reduced the requirement for open surgical exposure of the femoral artery. A
1150 randomized study comparing open exposure and the percutaneous “preclose” technique using
1151 the Perclose ProGlide® (Abbott Vascular, Inc.) device demonstrated both safety and
1152 effectiveness.290 Following femoral artery access, systemic anticoagulation with 100 U/kg of
1153 intravenous heparin is recommended with a target activated clotting time ≥ 300 sec.
1154 Infrarenal fixation. EVAR requires non-aneurysmal proximal and distal attachment
1155 sites or sealing zones as dictated by device specific instructions for use. Most endografts that
1156 are dependent upon infrarenal fixation have required a proximal sealing zone of at least 15 mm
1157 in length, a neck diameter less than 32 mm, and a neck angulation of less than 60°. Several
1158 devices now report efficacy with shorter neck lengths and more severe levels of angulations.
1159 Use of devices outside recommended parameters increase the risk of device migration, delayed
1160 Type IA endoleaks, and aneurysm rupture.
1161 Suprarenal fixation. Suprarenal fixation has been proposed as a more effective
1162 means of proximal fixation when the morphologic features of the proximal aortic neck are
1163 unfavorable, including shortened neck length, severe angulation, reverse taper, barrel-shaped
1164 neck, circumferential mural thrombus, or extensive neck calcification. While concerns have
56
1165 been raised regarding the risks of renal or mesenteric embolization, occlusion, and end-organ
1166 ischemia, observational studies have documented the efficacy and safety of suprarenal
1167 fixation.291-295 Rates of renal dysfunction appear to be equivalent for endografts that utilize
1168 nitinol or stainless steel transrenal stents and not significantly different than that observed with
1169 infrarenal fixation.294 Although suprarenal fixation may produce a higher incidence of small renal
1170 infarcts, in most patients these do not appear to be clinically significant. The presence of renal
1171 dysfunction after EVAR with suprarenal fixation is likely multifactorial and transient in most
1172 patients.296 Nonetheless, renal artery occlusion and infarctions have been reported in patients
1173 with pre-existing renal artery occlusive disease and, while infrequent, visceral dysfunction and
1174 celiac or mesenteric artery occlusion may occur secondary to suprarenal fixation.297-300 One
1175 report showed no difference in renal function between the two device types, whereas another
1176 study demonstrates a reduction in renal function after the use of a suprarenal fixation device.301,
1177 302 A recent meta-analysis examining the renal complications after standard EVAR with
1178 suprarenal and infrarenal fixation demonstrated no difference in renal complications.303
1179 Management of the internal iliac artery. Exclusion of the hypogastric artery (HA) to
1180 prevent a type II endoleak is usually required when the aneurysm involves either the distal
1181 common iliac artery or the HA itself. 304-308 Several observational studies have revealed that
1182 unilateral embolization of the HA can be performed during EVAR with minimal adverse events
1183 as long as the contralateral HA is patent.305, 306 Although ipsilateral buttock claudication and
1184 erectile dysfunction have been reported to occur in up to 40% of patients after unilateral HA
1185 embolization, these symptoms tend to improve and abate over time.309 Indeed, one of the
1186 largest series of patients undergoing HA interruption during AAA repair revealed that persistent
1187 buttock claudication developed in 12% of unilateral and 11% of bilateral HA interruptions,
1188 whereas impotence occurred in 9% of unilateral and 13% of bilateral HA embolizations.310 In
1189 addition, the occurrence of these events is reduced if patency of the internal iliac artery
1190 bifurcation remains intact as illustrated in one small study using an Amplatzer vascular plug to
57
1191 occlude only the main trunk of the HA.311 A more recent report demonstrates no clinical
1192 difference between coils and plug embolization.312 Despite concerns about prolonged
1193 procedural time and increased amount of contrast, concomitant unilateral HA embolization
1194 during EVAR has been shown to be safe and effective, as compared to a staged approach.313
1195 Bilateral HA occlusion with endograft extension into both external iliac arteries is
1196 occasionally required in high-risk patients when there is no distal fixation zone in either common
1197 iliac artery or the aneurysm involves both common and internal iliac arteries. Although
1198 antegrade flow into at least one of HA should be maintained, if possible, bilateral HA
1199 embolization may be necessary in some situations. Initial concerns about life-threatening pelvic
1200 or colonic ischemia and neurologic deficits after bilateral HA interruption during EVAR may have
1201 been overestimated as several recent reports suggest that such devastating complications are
1202 exceedingly rare.305, 314-316 The risks associated with bilateral HA occlusion are restricted to
1203 more severe, persistent and frequent buttock claudication and erectile dysfunction.317
1204 Technical considerations that may reduce the incidence of adverse events when bilateral
1205 HA embolization is required include a staged approach, embolization of only the proximal main
1206 trunk of the HA, and preservation of collateral branches from the common and deep femoral
1207 arteries.305, 316 Alternative considerations to avoid bilateral HA embolization during EVAR include
1208 open or endovascular revascularization of at least one internal iliac artery.318, 319 FDA approved
1209 iliac branch graft devices have been developed or under review to maintain ipsilateral internal
1210 iliac perfusion.320-322 These devices have displayed satisfactory early outcomes and should be
1211 considered prior to embolization in appropriate circumstances.
1212 With the advent of endovascular repair techniques, the continued necessity of
1213 maintaining pelvic blood flow has been called into question. Several clinical series have used
1214 internal iliac artery embolization as an adjunct to extend the indications of EVAR in patients with
1215 aneurysms involving of the iliac bifurcation. Mehta and associates reported no mortality or
1216 increased morbidity in 48 patients who had interruption of both internal iliac arteries during open
58
1217 or endovascular aortic repair.314 However, buttock claudication and new onset erectile
1218 dysfunction were noted in 42% and 14% of the patients, respectively. The incidence of
1219 postoperative sexual dysfunction and buttock claudication varies widely in the literature, ranging
1220 from 16% to 50% for unilateral and 16% to 80% for bilateral internal iliac artery embolization,
1221 underscoring the difficulty of causal association in the setting of significant co-morbidities
1222 present in the older patient demographic at risk for AAA disease.323 Several endovascular
1223 techniques have been described to preserve internal iliac artery flow, including the development
1224 of commercially available aortoliac endografts that incorporate an iliac branch.324-327
1225 1226 1227 We recommend preservation of flow to at least one internal iliac artery. 1228 1229 Level of recommendation Strong 1230 Quality of evidence High 1231 1232 1233 We recommend using FDA approved branch endograft devices in anatomically suitable patients 1234 to maintain perfusion to at least one internal iliac artery. 1235 1236 Level of recommendation Strong 1237 Quality of evidence High 1238 1239 1240 We recommend staging bilateral internal iliac artery occlusion by at least one to two weeks if 1241 required for EVAR. 1242 1243 Level of recommendation Strong 1244 Quality of evidence High 1245 1246
1247 Management of associated vascular disease. Co-existence of other vascular disease
1248 with an AAA is common. Several series reporting observations of aortography have
1249 documented greater than 50% stenosis in 20-40% of renal arteries, 10-15% of celiac or superior
1250 mesenteric branches, and 20-30% of iliac vessels.328, 329
1251 The decision to intervene is based upon a consideration of severity of associated
1252 lesions; presumed natural history of the diseased vessel and end organ; and anticipated
59
1253 morbidity and mortality risk of combined repair. Prophylactic treatment of associated
1254 asymptomatic renal or mesenteric artery disease cannot be justified.330, 331 The exception may
1255 be the patient presenting with high grade stenosis of the superior mesenteric artery (SMA) and
1256 a meandering mesenteric artery that is based off of a large inferior mesenteric artery (IMA),
1257 which will be sacrificed during the course of treatment. A decision to repair each lesion should
1258 be based upon its own individual merits and indications. If endovascular treatment is judged to
1259 be beneficial, it is recommended that it be performed in a staged manner rather than
1260 concomitantly with the planned EVAR procedure. Iliac and femoral artery lesions may be
1261 treated at the time of EVAR to facilitate endograft delivery and to correct underlying pathology
1262 that may be contributing to lower extremity ischemic symptoms.
1263 Accessory renal arteries are present in 15 to 20% of patients and occasionally may arise
1264 from the aneurysm itself.328 Whether an accessory renal artery requires preservation is
1265 dependent on the size of the artery, its contribution to the renal parenchyma, and the presence
1266 of co-existing kidney disease. Renal infarction after occlusion of an accessory renal arteries is
1267 common, occurring in 84% of kidneys, but it is well tolerated in most patients, without significant
1268 impact on long-term glomerular filtration rate.332 Nonetheless, preservation should be
1269 considered for large accessory renal arteries (≥ 3 mm) or accessory renal arteries providing
1270 more than one-third of arterial flow to the kidney, particularly in the presence of pre-existing
1271 renal dysfunction.333, 334
1272 1273 1274 We suggest renal artery or superior mesenteric angioplasty and stenting for selected patients 1275 with symptomatic disease prior to EVAR or OSR. 1276 1277 Level of recommendation Weak 1278 Quality of evidence Low 1279 1280 1281 1282
60
1283 We suggest prophylactic treatment of an asymptomatic, high-grade stenosis of the SMA in the 1284 presence of a meandering mesenteric artery based off of a large IMA, which will be sacrificed 1285 during the course of treatment. 1286 1287 Level of recommendation Weak 1288 Quality of evidence Low 1289 1290 1291 We suggest preservation of accessory renal arteries at the time of EVAR or OSR if the artery is 1292 3 mm or larger in diameter or supplies more than one-third of the renal parenchyma. 1293 1294 Level of recommendation Weak 1295 Quality of evidence Low 1296 1297 1298
1299 Perioperative outcomes of elective EVAR
1300 Incidence of 30-day and in-hospital mortality. The UK EVAR-1, Dutch DREAM, US
1301 Veterans Affairs OVER, and French ACE multicenter randomized trials collectively randomized
1302 2,790 patients to EVAR or open repair.335-338 The two largest trials (EVAR-1 and OVER)
1303 demonstrated a statistically significant mortality benefit with EVAR and pooled analysis from all
1304 four trials confirmed the benefit of EVAR with a mortality of 1.4% as compared to 4.2% for open
1305 surgery (OR 0.3; 95%CI 0.22-0.50, p < 0.0001).339 A review of 79,932 Medicare patients
1306 confirmed that these results are representative of current outcomes with an overall mortality of
1307 5.2% for open repair and 1.6% for EVAR (OR 3.2; 95%CI 2.95-3.51).340 Outcomes after AAA
1308 repair are related to experience. While earlier studies341, 342 suggested that the minimum
1309 hospital threshold for optimal outcomes is 8 to 10 EVAR cases per year, a recent risk-adjusted
1310 analysis of 122,495 Medicare patients undergoing elective EVAR between 2001 and 2008
1311 observed that operative mortality is directly related to medical center volume.343 The odds ratio
1312 for elective perioperative mortality adjusted for surgeon volume was lowest for centers that
1313 perform at least 30 EVAR cases per year.
1314
1315
61
1316 1317 1318 We suggest that elective EVAR be performed at centers with a volume of at least 10 EVAR 1319 cases each year and a documented perioperative mortality and conversion rate to OSR of 2% 1320 or less. 1321 1322 Level of recommendation Weak 1323 Quality of evidence Low 1324 1325
1326 Perioperative morbidity. Estimated blood loss is significantly lower with EVAR than
1327 open repair.344 While major complications were not different in randomized controlled trials, in
1328 a review of Medicare patients, most major complications were lower with EVAR including
1329 pneumonia (3.8% vs. 12.9%, p < 0.001), acute renal failure (4.3% vs. 11.3%, p < 0.001), MI
1330 (2.5% vs. 5.2%, p < 0.001), and bowel ischemia (0.6% vs. 2.1%, p < 0.001). EVAR patients
1331 were also more likely to be discharged to home rather than to skilled nursing facility (95% vs.
1332 83%, p < 0.001). The need to convert from EVAR to open repair decreased over time (2.2% in
1333 2001 to 0.3% in 2008). Median length of stay was 2 days after EVAR as compared to 7 days
1334 after open repair (p < 0.001).
1335 Endoleak. Type IA endoleak is noted in 6% of procedures at the time of implantation
1336 and may be due to mural thrombus, calcification, angulation, neck tapering, or excessive graft
1337 under- or over-sizing.345-347 Initial management is angioplasty with a compliant balloon, followed
1338 by extension cuff placement. Additional maneuvers include placement of a Palmaz® balloon
1339 expandable stent or endo-stapling345, 348. Conversion to open repair is not recommended unless
1340 rupture or significant, uncorrectable, device maldeployment is noted. A Type IA endoleak may
1341 occasionally resolve after reversal of heparin and no longer be evident on postoperative CT
1342 imaging.349 A persistent Type IA endoleak may be treated by placement of a fenestrated
1343 device350, 351, proximal cuff extension with chimney grafts to the renal arteries352, 353, external
1344 banding, embolization with coils or glue, or conversion to open surgery. Insufficient data exist to
1345 recommend a particular strategy. A Type IB endoleak is treated initially by repeat balloon
62
1346 angioplasty and, as needed, by graft extension. Coil embolization of the hypogastric artery may
1347 be required when the graft is extended into the external iliac artery. A Type II endoleak is
1348 common at the time of implantation and is observed in 10 to 20% of patients at 1 month follow-
1349 up on CT imaging.354, 355 A Type II endoleak is not treated at the time of implantation. A Type III
1350 endoleak is treated by angioplasty of component overlap sites or by placement of an additional
1351 conduit.356 A Type IV endoleak is self-limited and treatment is not required.
1352 Access site complications. Early experience with EVAR using open femoral artery
1353 exposure were associated with a high rate of access site related complications (13%), including
1354 arterial dissection or perforation (1.4%), bleeding, hematoma, or false aneurysm (6.6%), arterial
1355 thrombosis (2.2%), embolization (1.1%), wound infection, skin necrosis, or lymphocele (1.4%),
1356 and amputation (0.1%).357 In a multicenter randomized control trial, percutaneous access was
1357 superior to open femoral artery excess with a shorter procedure time (107 vs. 141 min, p =
1358 0.004) and fewer access complications (6% vs. 10%, p = 0.005) with a 96% technical success
1359 rate.290 A systematic review and a recent NSQIP review also demonstrated a high technical
1360 success rate, shorter operative time (135 vs. 152 min), shorter length of stay (1 vs. 2 days), and
1361 fewer wound complications (1 vs. 2.1%, p = 0.02).358-361 Percutaneous access may not be
1362 appropriate for patients with small vessels, a high femoral artery bifurcation, or in the presence
1363 of calcification or a femoral aneurysm. In addition, a history of prior groin surgery with or
1364 without a vascular graft or patch and obesity may reduce success rates.362-366 Percutaneous
1365 access with large sheaths is improved by ultrasound guidance.362, 367-369
1366 Acute limb thrombosis. Early graft limb thrombosis may occur in 2% of patients due to
1367 the placement of a large limb in a small vessel, iliac tortuosity with graft kinking, inadequate
1368 angioplasty or stenting, arterial dissection, or injury at the access site.335, 336, 346, 370-372
1369 Post-implantation syndrome. A self-limited inflammatory state characterized by fever
1370 and elevated inflammatory markers may be observed after EVAR as a result of new thrombus
1371 formation within the excluded aneurysm sac.373-377
63
1372 Ischemic colitis. Colon ischemia due to occlusion of the inferior mesenteric or
1373 hypogastric arteries or embolization is rare after EVAR (< 1%).310, 340, 372, 378, 379 Circumflex
1374 femoral and circumflex iliac arteries should be preserved should hypogastric artery occlusion be
1375 planned. Suspected colonic ischemia should be assessed by endoscopy and, if confirmed,
1376 antibiotics administered and the patient maintained on intravenous fluids. Colectomy should be
1377 performed if full thickness necrosis is suspected.
1378
1379 Role of elective EVAR in the high-risk and unfit patient
1380 The EVAR-2 trial compared EVAR to observation and found no benefit to EVAR for
1381 patients who were considered unfit for open repair due to a history of MI or cardiac
1382 revascularization, stable angina, valvular heart disease, significant arrhythmia, uncontrolled
285 1383 congestive heart failure, FEV1 < 1 L, or serum creatinine > 2.3 mg/dL. However, of those
1384 randomized to EVAR only 179 of 197 (91%) underwent surgery; 14 deaths and 9 ruptures
1385 occurred prior to surgery, which occurred at a median of 55 days after randomization.
1386 Operative mortality for those randomized to EVAR was 8.4% (6.4% for elective repair). Of 207
1387 patients randomized to observation, 70 (34%) crossed over to EVAR; 64 (31%) were repaired
1388 electively, with an operative mortality of 3%.
1389 Among the many lessons learned from EVAR-2 and other data, it is evident there is a
1390 subgroup of patients who are not fit for open repair, which are also at high risk for EVAR. It is
1391 this subgroup that may be identified using the VQI risk model and should be considered for non-
1392 operative management. There may also be patients who while high risk for open surgery are
1393 reasonable risk for EVAR. Additionally, as noted in one third of patients randomized to
1394 observation in EVAR-2, fitness may be improved by optimization of co-morbid disease to the
1395 extent that EVAR may then be considered.
1396
1397
64
1398 1399 1400 We suggest informing high-risk patients of their VQI perioperative mortality risk score in order to 1401 make an informed decision to proceed with aneurysm repair. 1402 1403 Level of recommendation Weak 1404 Quality of evidence Low 1405 1406
1407 Open surgical repair
1408 Indications. Open surgical repair of a AAA continues to be used for patients who do not
1409 meet the anatomical requirements for endovascular repair, including short or angulated landing
1410 zones, excessive thrombus, multiple large accessory renal arteries, or small and tortuous
1411 access vessels with concomitant occlusive disease. However, fenestrated, branched and the
1412 use of chimney or snorkel grafts has expanded the range of complex aortic anatomy potentially
1413 treatable by EVAR. Open surgical repair may be required for treatment of a persistent endoleak
1414 and aneurysm sac growth after EVAR or for treatment of a mycotic aneurysm or infected graft.
1415 Surgical approach. OSR can be performed using either a trans-peritoneal or left-flank
1416 retroperitoneal approach (Table 7). Indications for each type of approach are largely based on
1417 patient anatomy, comorbidities and surgeon preference. The trans-peritoneal approach is
1418 typically performed using a generous midline incision from the xyphoid process to the
1419 symphysis pubis. Extension of the incision alongside the xyphoid process releases rectus
1420 aponeurosis and facilitates exposure in the obese patient or in those with more proximal aortic
1421 disease. A mini-laparotomy (15 cm) has been used in select patients. A transperitoneal
1422 approach can be performed rapidly and is versatile, allowing assessment of intra-abdominal
1423 pathology and easy access to the visceral and iliac arteries. Transverse incisions just above the
1424 umbilicus also yield excellent exposure to the suprarenal aorta and bilateral iliac bifurcations.
1425 Proponents of the retroperitoneal approach claim various physiologic benefits, including
1426 significant reduction in fluid losses, cardiac stress, pulmonary complications, and ileus.
65
1427 However, prospective randomized studies have generated conflicting results.380, 381 The
1428 measurable benefits attributed to retroperitoneal exposure were primarily a shorter duration of
1429 ileus and earlier resumption of oral intake. Sieunarne reported no difference in a randomized
1430 comparison of transperitoneal and retroperitoneal approaches for infrarenal AAA repair, except
1431 for higher rates of incisional pain, bulge and hernias in the retroperitoneal group.382
1432 The retroperitoneal approach may be preferred for repair of a suprarenal aneurysm
1433 because exposure can be facilitated by division of the left diaphragmatic crura. However, in a
1434 majority of patients repair of juxtarenal and pararenal aneurysms can be performed using a
1435 transperitoneal approach with excellent outcomes.383, 384 Although some surgeons routinely
1436 ligate or divide the left renal vein to expose the suprarenal aorta in the course of using a
1437 transperitoenal approach, others do not.383, 384 An important indication for the retroperitoneal
1438 approach is the presence of a “hostile abdomen” due to prior intra-abdominal operations,
1439 radiation, incisional hernia, stoma, enterocutaneous fistula. In addition, a retroperitoneal
1440 approach can facilitate repair of an inflammatory aneurysm or aneurysm associated with a
1441 horseshoe kidney.385, 386
1442 1443 1444 We recommend a retroperitoneal approach for patients requiring open surgical repair of an 1445 inflammatory aneurysm, horseshoe kidney, or an aortic aneurysm in the presence of a hostile 1446 abdomen. 1447 1448 Level of recommendation Strong 1449 Quality of evidence Low 1450 1451 1452 1453 We suggest a retroperitoneal exposure or a transperitoneal approach with a transverse 1454 abdominal incision for patients with significant pulmonary disease requiring open surgical repair. 1455 1456 Level of recommendation Weak 1457 Quality of evidence Low 1458 1459
66
1460 Aortic clamping. Selection of the ideal clamp site and extent of reconstruction is based
1461 on analysis of cross-sectional aortic imaging including proximal aneurysm extension, iliac
1462 occlusive or aneurysmal disease, concomitant renal and mesenteric disease, anomalous
1463 venous anatomy, and presence of calcium, thrombus or atherosclerotic debris.
1464 The location of the clamp site should take into consideration the proximal extension of
1465 the aneurysm, as well as the structural integrity of the aortic wall. Ideally, the clamp site should
1466 be relatively free of thrombus, atherosclerotic debris or calcification. Other important
1467 considerations include presence of concomitant visceral aortic disease and unusual venous
1468 anatomy, such as a retro-aortic renal vein or left-sided vena cava. The aortic clamp should be
1469 placed in the most caudal position possible to avoid unnecessary renal and visceral ischemia,
1470 while allowing a safe anastomosis into healthy aortic wall. For repair of an infrarenal aortic
1471 aneurysm, the clamp is placed immediately below the level of the lowest renal artery, while the
1472 graft is anastomosed to a rim of normal aortic wall below the level of the clamp. Performing the
1473 proximal anastomosis within healthy aorta is important to minimize the risk of aneurysmal
1474 degeneration at or above the graft.
1475 The transperitoneal approach is typically performed using a midline incision from the
1476 xyphoid to the symphysis pubis or, in select cases, a mini-laparotomy incision. After placement
1477 of a self-retaining retractor, the transverse colon is retracted cephalad and the small bowel
1478 mesentery to the right side of the abdomen, splaying the retro-peritoneum and aortic aneurysm.
1479 The retroperitoneum is incised to the left side of the aorta, avoiding the IMA. The inferior
1480 mesenteric vein may need to be divided to avoid inadvertent traction injury or avulsion by fixed
1481 retractors used to assist in exposing the infrarenal aortic neck. The left renal vein may need to
1482 be mobilized and, if suprarenal clamp placement required, division of the gonadal, adrenal and
1483 lumbo-renal branches of the renal vein will facilitate its mobilization. Should division of the left
1484 renal vein be planned to optimize exposure of the aortic neck, the gonadal, adrenal, and lumbar
1485 branches should be preserved to provide collateral flow from the kidney. In the presence of
67
1486 significant mural thrombus at the level of the aortic neck, isolation and temporary occlusion of
1487 the renal arteries may be warranted to minimize the risk of renal artery embolization at the time
1488 of clamp placement.
1489 If the aneurysm extends above the renal arteries or significant aortic calcification is
1490 present, it may be preferable to clamp the supraceliac aorta.387, 388 Patients in which an aortic
1491 aneurysm required a suprarenal clamp have an increased risk of renal dysfunction and
1492 morbidity, but similar 30 day mortality, as compared to those in which an infrarenal clamp site
1493 was sufficient for repair an AAA.383, 384, 389 Visceral vessel control is not necessary as
1494 backbleeding is minimal following supraceliac aortic crossclamp application.
1495 The sequence of clamping should begin with the least diseased segment to avoid the
1496 risk of distal embolization. Typically the iliac arteries are clamped first, followed by the proximal
1497 aorta. Distal clamping is always at the level of the iliac arteries, since aneurysm disease usually
1498 extends to the aortic bifurcation even in patients with planned reconstruction using a tube graft.
1499 If the common iliac arteries are aneurysmal, the external iliac arteries need to be dissected and
1500 controlled separately. The internal iliac arteries may require balloon occlusion, if external
1501 clamping is not feasible.
1502 Systemic anticoagulation with 100 U/kg of intravenous heparin is recommended for
1503 elective aneurysm repair, irrespective of the location of the aortic clamp. Heparin administration
1504 may be omitted or used in lower doses in special circumstances of a ruptured aneurysm or
1505 other unusual situations. In these cases, the graft is vigorously flushed prior to restoration of
1506 blood flow, or limited amounts of heparinized saline may be instilled directly into the distal
1507 vessels after placement if the proximal aortic clamp. In patients with history of heparin-induced
1508 thrombocytopenia, a thrombin inhibitor, such as Bivalirudin or Argatroban may be used as an
1509 alterative.
1510
1511
68
1512 1513 1514 We recommend a thrombin inhibitor, such as Bivalirudin or Argatroban as an alternative to 1515 heparin for patients with a history of heparin-induced thrombocytopenia. 1516 1517 Level of recommendation Strong 1518 Quality of evidence Moderate 1519 1520
1521 Graft type and configuration. There is no significant difference in patency, durability,
1522 resistance to infection, or risk of degeneration or dilatation of currently used prosthetic materials.
1523 Differences in methods of fabrication of polyester grafts include knitted or woven, external or
1524 double velour, high or low porosity. Polyester grafts can be rendered impermeable by various
1525 biologic coatings, including collagen, gelatin or albumin. Graft impregnation with silver or
1526 Rifampin has been used to enhance resistance to infection. Routine use of Rifampin
1527 impregnated polyester grafts in which used gelatin-coated polyester grafts are soaked in
1528 Rifampin solution (1 mg/mL) for 15 to 30 minutes or silver impregnated grafts to limit the risk of
1529 device associated infection has not proven to be beneficial in prospective or multicenter
1530 studies.390-393
1531 Graft configuration can be a straight tube or bifurcated. The location of the distal
1532 anastomosis is at the aortic bifurcation, iliac or femoral artery. A tube graft is preferable when
1533 feasible due to shortened operative time, reduced blood loss and need for dissection,
1534 minimizing risk of inadvertent injury to the ureter, iliac veins, and autonomic nerves. In the era
1535 prior to widespread adoption of EVAR, approximately 40% to 50% of patients could be treated
1536 with a tube graft.394 In the Canadian Aneurysm Trial, graft configuration was straight in 39%,
1537 aorto-bi-iliac in 31%, aortobifemoral in 24%, and aorto-iliac and femoral in 7%.395 Bifurcated
1538 grafts are indicated when the distal aorta and common iliac arteries are aneurysmal, which
1539 occurs in one third of patients.396 In the presence of iliac aneurysmal disease, the distal
1540 anastomosis should be performed immediately proximal to the iliac bifurcation to reduce the risk
69
1541 of late aneurysmal degeneration. Patients with symptomatic aortoiliac occlusive disease may
1542 benefit from distal graft anastomosis to the distal external iliac or common femoral arteries.
1543 However, graft extension to the femoral arteries increases the risk of wound infection, limb
1544 thrombosis, and anastomotic aneurysm formation.395 Assuming normal iliac arteries have been
1545 selected for the distal anastomosis, the risk of progressive distal aneurysmal or occlusive iliac
1546 disease is relatively low.394, 397
1547 1548 1549 We recommend straight tube grafts for open surgical repair of AAA in the absence of significant 1550 disease of the iliac arteries. 1551 1552 Level of recommendation Strong 1553 Quality of evidence High 1554 1555 1556 We recommend performing the proximal aortic anastomosis as close to the renal arteries as 1557 possible. 1558 1559 Level of recommendation Strong 1560 Quality of evidence High 1561 1562 1563 We recommend that all portions of an aortic graft be excluded from direct contact with the 1564 intestinal contents of the peritoneal cavity. 1565 1566 Level of recommendation Strong 1567 Quality of evidence High 1568 1569
1570 Maintenance of pelvic circulation. Perfusion of the colon, rectum and pelvis is
1571 provided by a complex collateral network from the superior mesenteric artery (SMA) and IMA
1572 via the marginal artery of Drummond, the internal iliac arteries, and additional collaterals from
1573 the circumflex iliac, common and deep femoral arteries. Inadequate pelvic circulation can lead
1574 to sexual dysfunction, as well as hip and buttock claudication. Less frequently, colon or spinal
1575 ischemia may ensue. For example, in the Canadian Aneurysm Study, the risk of colon ischemia
1576 increased eight-fold (0.3% to 2.6%) when both internal iliac arteries were occluded compared to
70
1577 when at least one of the internal iliac arteries was preserved.395, 396 Thus, all efforts should be
1578 made to preserve perfusion to at least one internal iliac artery.
1579 Colonic ischemia following aortic repair is multifactorial in origin, but ligation of a patent
1580 IMA during reconstruction remains a risk factor.398 The IMA is occluded in 40% to 50% of the
1581 patients with aortic disease because of ostial atherosclerosis or mural thrombus. The value of
1582 routine re-implantation of a patent IMA has not been established, but selective re-implantation
1583 may be of value in the presence of compromised pelvic perfusion, particularly when the
1584 marginal artery is interrupted due to prior colectomy.379, 399 A prospective randomized study
1585 suggested that IMA re-implantation is beneficial in patients of advanced age and when intra-
1586 operative blood loss has been substantial.400 Likewise, re-implantation of the IMA should be
1587 considered in patients with underlying celiac and SMA occlusive disease, particularly in the
1588 presence of a large meandering artery. The IMA can be easily controlled prior to opening the
1589 aneurysm using a vessel loop and reimplantation to an aortic graft performed using a Carrel
1590 patch technique, in which a small button of aortic wall is dissected free from adherent thrombus
1591 and calcific debris. In the Canadian Aneurysm Trial, IMA re-implantation was used in 5% of the
1592 patients, but was associated with increased risk of postoperative bleeding.395 Preservation of
1593 antegrade flow into at least one of the internal iliac arteries is recommended, whenever
1594 possible. For patients treated by open surgical repair this can be usually achieved by distal
1595 anastomosis to the iliac bifurcation, end-to-side-anastomosis at the external iliac artery with
1596 retrograde flow into the internal iliac artery, or a separate bypass graft to the internal iliac artery.
1597 1598 1599 1600 We recommend reimplantation of a patent inferior mesenteric artery (IMA) under circumstances 1601 that suggest an increased risk of colonic ischemia. 1602 1603 Level of recommendation Strong 1604 Quality of evidence High 1605 1606 1607
71
1608 We recommend preserving blood flow to at least one hypogastric artery in the course of OSR. 1609 1610 Level of recommendation Strong 1611 Quality of evidence High 1612 1613
1614 Management of associated intra-abdominal vascular disease. Occlusive disease of
1615 the celiac and SMA is present in 10% of patients, whereas renal artery disease may occur in up
1616 to 40%. Since the morbidity and mortality of aortic repair is increased by concomitant renal or
1617 mesenteric reconstruction, such procedures are only indicated in the presence of symptomatic
1618 disease.
1619 Pearce and colleagues reported a 30-day mortality of 3% among 678 patients treated for
1620 abdominal aortic aneurysms with concomitant renal artery reconstruction.401 However,
1621 mesenteric artery reconstruction combined with aortic reconstruction carries higher mortality
1622 rate and should be avoided unless clinically indicated.402 Thus, should open AAA repair be
1623 required in the presence of renal or mesenteric artery disease, a staged approach with initial
1624 stenting should be pursued.
1625 1626 1627 We suggest concomitant surgical treatment of other visceral arterial disease at the time of open 1628 surgical repair in symptomatic patients who are not candidates for catheter-based intervention. 1629 1630 Level of recommendation Weak 1631 Quality of evidence Moderate 1632 1633 1634 1635 Management of associated intra-abdominal nonvascular disease. In the
1636 occurrence of an AAA and associated intra-abdominal pathology, the most life-threatening
1637 condition should be treated first. Simultaneous repair is avoided because of added morbidity
1638 and, in the case of genitourinary or gastrointestinal procedures, the risk of bacterial
1639 contamination of the prosthesis.
72
1640 Cholelithiasis is the most common abdominal pathology with a prevalence of 5% to 20%.
1641 Asymptomatic cholelithiasis should be left untreated since the risk of acute cholecystitis after
1642 elective AAA repair is <1%.403 In the presence of a large aneurysm, treatment of a colorectal
1643 tumor takes precedence in the presence of impending obstruction, bleeding or perforation.
1644 Otherwise, colon resection should be delayed for four to six weeks after AAA repair.404
1645 Simultaneous resection of ovarian or renal tumors may be considered if a staged minimally
1646 invasive treatment is not feasible.
1647 1648 1649 We suggest concomitant surgical repair of an AAA and co-existent cholecystitis or an 1650 intraabdominal tumor in patients who are not candidates for EVAR or staged intervention. 1651 1652 Level of recommendation Weak 1653 Quality of evidence Low 1654 1655
1656 Perioperative outcomes after open AAA repair. Factors affecting mortality of OSR
1657 include surgeon and hospital volume, urgency of the procedure, patient age, presence and
1658 severity of comorbidities and proximal aneurysm extension. Presence of symptomatic coronary
1659 artery disease, congestive heart failure, severe chronic pulmonary disease and advanced
1660 chronic kidney disease remain the most important predictors of mortality.340 There has been
1661 considerable variation in 30-day mortality rates in the literature, depending on the type of study
1662 reported and its design.405 Elective 30-day mortality for infrarenal AAA OSR in most
1663 contemporary large single-center institutional reports has ranged from 1% to 4%. 81, 406, 407
1664 Population-based studies, derived from state and national databases, indicate higher mortality
1665 rates of 4% to 8% across the entire spectrum of hospitals and health care organizations.5, 81, 117,
1666 395, 408-413 Recent multicenter, prospective, randomized trials have demonstrated 30-day
1667 mortality of 3% to 4.7%.344, 414, 415 Analyses of outcomes in Medicare beneficiaries indicates that
1668 OSR mortality, while improved in the last decade, remains higher than that associated with
73
1669 EVAR for every age category.340 Similarly, the morbidity of OSR is significantly higher compared
1670 to EVAR, particularly cardiac, pulmonary, renal, gastrointestinal and wound-related
1671 complications (Table 8). Finally, recent studies have shown that over 20% of the patients
1672 treated by OSR require reoperations for laparotomy-related complications within 8-years.340
1673 The impact of individual surgeon and hospital volume on outcomes of AAA OSR has
1674 been documented in several studies.117, 410, 416, 417 A review of national Medicare claims by
1675 Birkmeyer indicated that 30-day mortality was 8% for low volume hospitals (<17/year) compared
1676 to 4.4% in high volume hospitals (>79/year).416 Surgeon volume and prior dedicated vascular
1677 training also affect mortality of OSR. Dimick reported that elective AAA mortality was lowest
1678 when operations were performed by vascular surgeons (2.2%), as compared to cardiac
1679 surgeons (4%) and general surgeons (5.5%)(p < 0.001).418 Using a risk-adjusted analysis, high
1680 hospital volume, vascular surgery specialty, and high surgeon volume were independent
1681 predictors for lower risk of in-hospital mortality after elective AAA repair. In that study, absolute
1682 risk reduction for operations performed in high-volume hospitals and high-volume surgeons was
1683 30% and 40%, respectively. AAA repair performed by general surgeon increased risk of death
1684 by 76% compared to repair performed by vascular surgeon.418 A recent risk-adjusted analysis
1685 of 122,495 Medicare patients undergoing elective AAA repair between 2001 and 2008 notes
1686 that the mortality for open surgical repair is directly related to medical center volume.343 The
1687 odds ratio for elective perioperative mortality was lowest for centers that perform at least 18
1688 open repairs and was less than 5%.343
1689 Accurate assessment of open surgical expertise and the applicability of outcome data
1690 acquired in the pre-endovascular era will be areas of concern as the volume of OSR continues
1691 to decline in the United States with anticipated reduction in the prevalence of cigarette smoking
1692 and expanding options for complex endovascular aneurysm repair. Care should be taken in
1693 extrapolating current outcomes for OSR from data obtained before the widespread availability of
1694 endovascular devices.
74
1695 1696 1697 We suggest that elective OSR for AAA be performed at centers with an annual volume of at 1698 least 10 open aortic operations of any type and a documented perioperative mortality of 5% or 1699 less. 1700 1701 Level of recommendation Weak 1702 Quality of evidence Low 1703 1704
1705 The patient with a ruptured aneurysm
1706 Preoperative management and considerations for patient transfer. A ruptured
1707 abdominal aortic aneurysm represents a true surgical emergency. Documented rupture,
1708 particularly with associated hypotension, demands immediate transfer to an adequately
1709 equipped operating room for definitive repair without delay. Should aneurysm rupture occur,
1710 more than half of patients die prior to hospitalization or without treatment.
1711 Establishing a protocol or algorithm for urgent or emergent management of a patient with
1712 a ruptured abdominal aortic aneurysm is essential for optimizing outcomes.419 In the presence of
1713 a protocol, 30-day mortality was 18%, whereas in the absence of a protocol, 30-day mortality
1714 was 32%.420-422 Based on review of the literature, including existing guidelines endorsed in the
1715 United Kingdom423 and by the Western Vascular Society, an algorithm for the initial evaluation,
1716 diagnosis, immediate management, and triage of patients with a suspected ruptured abdominal
1717 aortic aneurysm is presented (Figure 5). An expedited evaluation consisting of the airway,
1718 breathing, and circulation (ABC) protocol, general assessment, and vital sign check should be
1719 initially performed by the emergency physician of any patient suspected of having a ruptured
1720 abdominal aortic aneurysm. Diagnosis in the emergency department is usually ascertained
1721 based on history and physical examination. Radiologic confirmation, either via bedside
1722 ultrasound imaging or a contrast-enhanced CT scan, can be obtained when an alternative
1723 diagnosis is more likely on clinical grounds. Optimization of the patients’ clinical condition in the
1724 pre-operative setting, while waiting for urgent transport to an operating room, may improve
75
1725 outcomes. Intravenous access should be established with two large bore peripheral
1726 intravenous lines, as central or arterial access is not immediately necessary. Permissive
1727 hypotension, or “hypotensive hemostasis,” which refers to restricting aggressive fluid
1728 resuscitation as long as the patient remains conscious and has a systolic blood pressure
1729 between 70 to 90 mm Hg, should be implemented to limit excessive hemorrhage.424-426
1730 Laboratory or imaging studies should only be obtained to confirm the diagnosis of ruptured
1731 abdominal aortic aneurysm. Other actions that may help improve outcomes are the immediate
1732 availability of blood and blood products, warming, and the avoidance of elective intubation.427
1733 With the increasing utilization of endovascular methods to treat patients presenting with
1734 a ruptured abdominal aortic aneurysm, vital resources, including advanced imaging, trained
1735 staff, and robust endovascular inventory must be available. In cases where transfer is not
1736 necessary, the vascular team should be notified as soon as a ruptured abdominal aortic
1737 aneurysm is suspected. It may be prudent, however, to transfer a patient to a higher level
1738 facility when such resources are unavailable.428, 429 Patients with good functional status and
1739 without severe co-morbidity should be transferred without delay. Further, patients previously
1740 declined elective surgery should be considered for transfer and treatment. Some patients
1741 experiencing a ruptured abdominal aortic aneurysm may not be medically fit to undergo open
1742 repair, while at the same time are not anatomically suitable for endovascular repair. The urge to
1743 offer endovascular repair to patients anatomically unsuitable for such repair should be strongly
1744 resisted.430 Pre-operative predictors of death after open repair include age > 76 years, serum
1745 creatinine of > 2.0 g/dL, pH < 7.2, and blood pressure < 70 mmHg at any time. While these risk
1746 factors require more robust validation, when all four are present, open repair is uniformly fatal.431
1747 As such, goals of care, medical comorbidities, and hemodynamics should be discussed with the
1748 receiving vascular surgeon if transfer is necessary. Ongoing cardiac arrest represents a
1749 contraindication for transfer given the unlikely survival of these patients.
76
1750 Direct physician-to-physician phone handoff is necessary for all patients being
1751 transferred. It is imperative that relevant imaging is transmitted, preferably using an electronic
1752 method.432 Little data exist to guide best management during this critical transfer time period.
1753 Patients should receive intravenous nitroglycerin, esmolol, sodium nitroprusside, and pain
1754 medication, as needed, to avoid hypertension and minimize the risk of uncontained rupture.
1755 Permissive hypotension is appropriate with limited resuscitation and should be maintained
1756 during transfer. Blood products are preferred to treat hypotension, but transfer should not be
1757 delayed if blood products are not readily available.433
1758 Systems of care and time goals for intervention. Timeliness of intervention for the
1759 patient with a ruptured abdominal aortic aneurysm impacts outcomes.434-436 A goal of door-to-
1760 intervention time of less than 90 minutes is recommended with time zero defined as the time of
1761 first medical contact and intervention defined as initial arterial access and placement of an aortic
1762 occlusion balloon (Figure 5). Given limited studies benchmarking time to intervention for a
1763 ruptured abdominal aortic aneurysm434, 436, this goal has been proposed based on those
1764 established by the 2004 American College of Cardiology (ACC) Foundation/American Heart
1765 Association guidelines for the management of ST-segment-elevation myocardial infarction
1766 (STEMI).437 For the patient necessitating transfer to a regional center, the adoption of a 30-30-
1767 30-minute framework is recommended as a benchmark. The initial period denotes the time
1768 from first medical contact with a patient suspected of having a ruptured aortic aneurysm,
1769 including immediate management, to the point when a decision is made to transfer the patient to
1770 a regional center if so required or the initiation of emergent in-house vascular surgery
1771 evaluation. The second period represents the time required for rapid transfer to a regional
1772 center, if needed, and includes, physician-physician phone handoff, transfer of images, if
1773 available, and in-transit care. The final period includes the time from evaluation by the in-house
1774 or receiving vascular surgery team to arterial access and placement of an aortic occlusion
1775 balloon. Checklists, such as those highlighting the essential tasks needed in order to facilitate
77
1776 transfer, as well as those that assist in coordinating care teams at the treating facility can be
1777 used to help meet these goals (Figures 6, 7). More importantly, and similar to STEMI
1778 management,438, 439 the establishment of systems of care will be necessary. With an organized
1779 regional transfer system, operative repair can be performed in over 95% of patients with a
1780 ruptured abdominal aortic aneurysm, with 67% survival.434 This requires effective coordination
1781 between established sending and receiving facilities with standardized communication, a
1782 reliable transport provider, patient management guidelines during transfer, and a streamlined
1783 process for operative repair. This goal should be considered the longest times acceptable for
1784 effective management of a patient with a ruptured aortic aneurysm and systems that are able to
1785 achieve even more rapid times should be encouraged.
1786 It should be noted that the benchmark of < 90 minute door-to-balloon time for the
1787 management of the patient with a STEMI was initially extremely challenging to meet.437 In 2004,
1788 the National Cardiovascular Data Registry reported that for patients requiring interhospital
1789 transfer, only 8.6% had total door-to-balloon times of less than 90 minutes with a median time of
1790 152 minutes.440 Nonetheless, the establishment of an ambitious time goal promoted the
1791 development of STEMI Systems of Care to decrease time to intervention and improve overall
1792 patient survival.441 The challenge faced by rural centers was recognized when the 2004
1793 AHA/ACC guidelines were issued. However, with rapid triage, transfer, and STEMI treatment
1794 programs, median total door-to-balloon times have been driven down for rural hospitals from a
1795 median of 189 minutes to 88 minutes.442
1796 1797 1798 We suggest a door-to-intervention time of < 90 minutes, based on a 30-30-30 minute 1799 framework, for the management of the patient with a ruptured aneurysm. 1800 1801 Level of recommendation Weak 1802 Quality of evidence Ungraded 1803 1804 1805 1806
78
1807 An established protocol for the management of ruptured AAA is essential for optimal outcomes. 1808 1809 Level of recommendation Good Practice Statement 1810 Quality of evidence Ungraded 1811 1812 1813 We recommend implementing hypotensive hemostasis with restriction of fluid resuscitation in 1814 the conscious patient. 1815 1816 Level of recommendation Strong 1817 Quality of evidence Moderate 1818 1819 1820 We suggest that patients with ruptured AAA who require transfer for repair, be referred to a 1821 facility with an established rupture protocol and suitable endovascular resources. 1822 1823 Level of recommendation Good Practice Statement 1824 Quality of evidence Ungraded 1825 1826 1827 1828 Initial operative management. Regardless of the nature of repair, proximal control of
1829 the aorta is a crucial aspect of the initial part of the procedure. Indications for an aortic occlusion
1830 balloon include circulatory collapse, hemodynamic instability, or anatomic limitations that
1831 prevent expeditious repair.427, 443 A femoral artery approach with use of a long sheath is
1832 preferred over a brachial approach. The sheath may be advanced into the supraceliac aorta to
1833 support the balloon and permit its removal after endograft placement.443
1834 In the hemodynamically unstable patient without preoperative CT imaging, evaluation of
1835 the proximal and distal sealing zones and device selection can be based on intraoperative
1836 angiography recognizing the inability to assess the extent of mural thrombus, or ideally, by
1837 intravascular ultrasound. Both bifurcated and aortouniliac endografts have been used for
1838 emergent EVAR.427, 444-446 While used less commonly, an aortouniliac device may be helpful in
1839 the treatment of an anatomically challenging AAA. The Nellix® Endovascular Aneurysm
1840 Sealing System (EVAS, Endologix, Inc.) has also been proposed for treatment of ruptured
1841 AAA.447, 448
79
1842 Role of EVAR. In an effort to improve outcomes for patients presenting with
1843 symptomatic or ruptured AAAs, the impact of urgent or emergent EVAR has been recently
1844 evaluated. An early randomized trial comparing EVAR and OSR for ruptured AAAs revealed
1845 that the suitability for endovascular repair was only 46%, but the rate of EVAR was lower
1846 (30%).449 Observational studies have revealed improved outcomes after emergent EVAR for
1847 ruptured AAAs, but significant selection bias and lack of uniform inclusion criteria and reporting
1848 standards confound these analyses.446The IMPROVE Trial was a multicenter randomized trial of
1849 EVAR and open repair for patients presenting with a ruptured AAA.450 Patients were
1850 randomized prior to obtaining CT imaging with 316 patients randomized to EVAR and 297
1851 patients to open repair. Thirty-day mortality was similar among patients treated with EVAR
1852 (35.4%) or open repair (37.4%). Secondary analyses demonstrated shorter length of stay and a
1853 higher proportion of patients discharged to home for those treated by EVAR. A potential
1854 limitation of this study was the application of an intent-to-treat analysis, which incorporated
1855 outcomes for those participants initially randomized to EVAR but whose anatomy required open
1856 repair to the EVAR group. Recently reported one-year outcomes demonstrated that EVAR was
1857 most cost effective when compared to open repair, but no survival benefit was observed.
1858 An analysis of national trends in the United States confirm that EVAR is being used with
1859 increasing frequency for the treatment ruptured AAA, with a decrease in associated mortality.451,
1860 452 Outcomes are superior when EVAR for a ruptured aneurysm is performed in teaching
1861 hospitals and high volume centers.451
1862 1863 1864 1865 If anatomically feasible, we recommend EVAR over open repair for treatment of a ruptured AAA. 1866 1867 Level of recommendation Strong 1868 Quality of evidence Moderate 1869 1870
1871
80
1872 Management of postoperative complications
1873 Abdominal compartment syndrome. Abdominal compartment syndrome is a well-
1874 recognized complication after both open surgical repair and EVAR for ruptured aneurysm and
1875 may occur in approximately 7% of patients.453 Use of an aortic occlusion balloon, coagulopathy,
1876 massive transfusion, and conversion to an aortouniliac device, are all predictors of abdominal
1877 compartment syndrome.454 Abdominal compartment syndrome typically occurs in the
1878 hemodynamically unstable patient with a large retroperitoneal hematoma. Diffuse visceral
1879 edema results in intra-abdominal hypertension and multiple system organ dysfunction, including
1880 oliguria, increased peak airway pressures, hypoxemia, hypercarbia, hypotension and decreased
1881 cardiac output. Early recognition and surgical decompression are necessary to improve
1882 survival455.
1883 Ischemic colitis. The incidence of colonic ischemia following repair of a ruptured AAA
1884 may occur in as many as one-in-five to one-in-three patients.456 Ischemic colitis following
1885 vascular surgery has been associated with mortality rates of 45-67% with recent reports
1886 demonstrating only modest improvement in outcomes.457 Delayed diagnosis with advanced
1887 ischemic colitis leading to perforation is associated with a mortality rate in excess of 90%458 and
1888 a retrospective review of 222 patients revealed that ischemic colitis was the most common
1889 cause of death after open repair of a ruptured aneurysm.459 Colonic ischemia is much less
1890 frequent after EVAR than OSR for ruptured aneurysm (23% vs. 42%), but the risk remains.379,
1891 457, 460 Prompt endoscopy is recommended when there is a suspicion for ischemic colitis to
1892 confirm the diagnosis and help guide management.
1893 Multi-system organ failure. Given the associated hemodynamic instability and
1894 ischemia-reperfusion injury among patients presenting with a ruptured aneurysm, multisystem
1895 organ failure (MSOF) may occur in 1% to 3% of patients after EVAR or open repair.461 462
1896 Once MSOF develops, organ dysfunction leads to a prolonged ICU stay, high resource
81
1897 consumption, and a 50-70% mortality rate.463 Dedicated ICU teams and regionalized care at
1898 high-volume centers have led to reduced mortality and decreased length of stay.464, 465
1899
1900 Special considerations
1901 Inflammatory aneurysm. An inflammatory aortic aneurysm occurs in between 5 to
1902 10% of patients.466 An inflammatory aortic aneurysm may not be readily apparent on CT
1903 imaging, but may be associated with retroperitoneal fibrosis467, 468 and displays a similar natural
1904 history to the more common degenerative aortic aneurysm.469, 470 An inflammatory aortic
1905 aneurysm is typically adherent to the duodenum, and less commonly, the ureters, renal vein and
1906 inferior vena cava.471 Should open repair be required, a retroperitoneal approach is
1907 recommended to avoid dissection of the duodenum. A systematic review of 999 patients with
1908 inflammatory aortic aneurysm confirmed that EVAR was associated with decreased mortality as
1909 compared to open repair.472-476 477
1910 Horseshoe kidney. A horseshoe kidney occurs in 0.25% of the general population and
1911 in 0.12% of patients presenting with an aortic aneurysm.478 Preoperative evaluation requires
1912 careful determination of the renal arterial anatomy, which can be highly variable with accessory
1913 renal arteries originating from the aorta, aneurysm sac and iliac arteries.479-481 If the main renal
1914 arteries are located proximal to the aneurysm, EVAR can be safely performed.482, 483 Small
1915 accessory renal arteries may be covered by EVAR.484, 485 In cases with anomalous blood
1916 supply, open surgical repair, preferably through a retroperitoneal approach, hybrid repair, or a
1917 fenestrated-branched EVAR may be considered.486, 487 488 Multiple renal arteries can be
1918 surgically re-implanted using a Carrel patch or through an inclusion technique.489 Should open
1919 repair be required and CT imaging reveal that the horseshoe kidney is associated with a very
1920 thin fibrous isthmus, a trans-peritoneal approach may be considered with division of the
1921 “isthmus”.490-492 A hybrid approach has been described using a bifurcated Dacron graft based
82
1922 off the external iliac artery to revascularize the horseshoe kidney, followed by EVAR.493, 494
1923 Likewise, repair has also been described using a fenestrated endograft and snorkel grafts.495, 496
1924 Aortocaval fistula. A ruptured aneurysm associated with an aortocaval fistula has been
1925 reported in 0.22% to 6% of patients.497 The triad of abdominal pain, a pulsatile mass, and an
1926 abdominal ‘machinery’ bruit is present in up to 80% of cases.498-501 Patients presenting with an
1927 abdominal aneurysm and high-output heart failure or a paradoxical pulmonary embolism should
1928 also be suspected of having an aortocaval fistula.502-506 Duplex imaging will reveal an arterial
1929 flow pattern in the inferior vena cava and CT imaging will demonstrate contrast in the inferior
1930 vena cava during the arterial phase.507-510 EVAR is preferred511-517 with expected resolution of
1931 preoperative heart failure and other physiologic disturbances.518-521 If open repair is required,
1932 venous bleeding should be anticipated and care taken to minimize the risk of pulmonary air
1933 embolism or embolism of thrombotic debris by placement of sponge sticks proximal and distal to
1934 the aortocaval fistula for control followed by direct suture repair of the defect.522, 523
1935 Since 2013, an additional 53 patients presenting with an aortocaval fistula have been
1936 added to the previously reported 250 cases.524 The majority have been successfully treated
1937 with EVAR alone, with occasional use of an Amplatzer® plug525 or additional placement of a
1938 covered stent in the inferior vena cava.526-529
1939
1940 ANESTHETIC CONSIDERATIONS AND PERIOPERATIVE MANAGEMENT
1941 Choice of anesthetic technique and agent. Open aneurysm repair requires general
1942 anesthesia, except in unusual circumstances, because of the required relaxation of the
1943 abdominal wall musculature and need for wide exposure of the aorta and its branches.530
1944 Insertion of monitoring lines prior to induction of anesthesia is appropriate if such monitoring
1945 devices improve the safety of induction. Infusion of an analgesic through an epidural catheter,
1946 by controlling pain fiber input, appears to lower the required dose of general anesthetic agents
1947 and may be associated with a shorter time to extubation.531 In addition, it has been postulated,
83
1948 but not proven that there is decreased hemodynamic lability and cardiac ischemia.532, 533
1949 Nonetheless, it has been difficult to demonstrate significant benefit to either intraoperative or
1950 postoperative epidural anesthesia and traumatic preoperative insertion of an epidural catheter
1951 with blood tinged cerebrospinal fluid may preclude subsequent heparin administration and
1952 require cancellation of the operative procedure. Use of epidural anesthesia with low dose
1953 inhalation anesthesia or in the awake patient has been advocated for patients with severe
1954 chronic obstructive pulmonary disease.534-536
1955 EVAR can be safely performed under general, epidural, or local anesthesia. While a
1956 number of retrospective studies suggest that the type of anesthetic influences operative time,
1957 length of hospital stay, and risk of morbidity, a mortality benefit has yet to be identified. In a
1958 retrospective analysis of nearly 4,000 patients in the EUROSTAR registry, local anesthesia was
1959 associated with shorter operative times, reduced ICU admission, shorter hospital stay, and
1960 fewer systemic complications.537 There was a modest advantage of epidural anesthesia as
1961 compared to general anesthesia. A recent review of the ACS NSQIP database demonstrated
1962 that general anesthesia was associated with longer hospital stay and increased pulmonary
1963 morbidity as compared to local or regional anesthesia.538 A meta-analysis of 13,459 patients
1964 undergoing EVAR, revealed that patients undergoing local anesthesia were older and had more
1965 severe cardiac and pulmonary disease, but experienced shorter operative times and hospital
1966 stays and suffered fewer complications.539 A limitation of this review was the inability to account
1967 for aneurysm anatomy and morphologic complexity, which may have influenced the selection of
1968 general anesthesia for repair.
1969 1970 1971 We recommend general endotracheal anesthesia for patients undergoing open aneurysm 1972 repair. 1973 1974 Level of recommendation Strong 1975 Quality of evidence High 1976 1977
84
1978 Anesthetic considerations in the patient with a ruptured aneurysm. Regardless of
1979 the choice of endovascular or open surgical repair, there is evidence to support the
1980 implementation of a standardized protocol for the efficient evaluation and treatment of ruptured
1981 aneurysm, including anesthetic management.427, 446 Notably, the surgical field should be initially
1982 draped and a transfemoral aortic balloon placed, especially if general anesthesia is required due
1983 to the likelihood of vasodilatation, hypotension and cardiovascular collapse. Permissive
1984 hypotension to maintain a systolic blood pressure of 80 mmHg limits volume overload and
1985 appears sufficient to maintain critical end organ perfusion.540 The use of local anesthesia for
1986 EVAR, most often, does not provide sufficient pain control for the patient experiencing
1987 significant abdominal or back pain.
1988 1989 Antibiotic prophylaxis. A Cochrane review confirms that prophylactic antibiotics,
1990 administered prior to incision, reduces the risk of wound infection and early graft infection in
1991 arterial reconstructive surgery.541 However, continuing antibiotics for more than 24 hours
1992 postoperatively was without added benefit. There was no advantage among first- or second-
1993 generation cephalosporins, penicillins with lactamase inhibitors, aminoglycosides, or
1994 vancomycin. We also recommend that any potential sources of dental sepsis be eliminated at
1995 least 2 weeks before implantation an aortic prosthesis.
1996 1997 1998 We recommend intravenous administration of a first generation cephalosporin or, in the event of 1999 penicillin allergy, vancomycin, within 30 minutes prior to open surgical repair or EVAR. 2000 Prophylactic antibiotics should be continued for no more than 24 hours. 2001 2002 Level of recommendation Strong 2003 Quality of evidence High 2004 2005 We recommend that any potential sources of dental sepsis be eliminated at least 2 weeks 2006 before implantation an aortic prosthesis. 2007 2008 Level of recommendation Good Practice Statement 2009 Quality of evidence Ungraded 2010 2011
85
2012 Intraoperative fluid resuscitation and blood conservation. Allogeneic blood
2013 transfusion remains associated with immunological and infectious risks. Although preoperative
2014 autologous blood donation avoids disease transmission and transfusion reaction, as well as
2015 stimulates erythropoiesis, limitations include limited availability of blood donation, increased
2016 expense, and potential waste of non-utilized blood.542 Intraoperative cell salvage assists in
2017 blood conservation, has been recommended if large blood loss is anticipated, and may be
2018 helpful where concerns of the safety of banked blood exist. 543-545 A prospective randomized trial
2019 of cell salvage in elective cardiac surgery did not lead to a reduction in exposure to allogeneic
2020 blood, but did reduce the number of transfused units.546 Various methods of cell salvage,
2021 including use of a cell saver or hemofiltration, have not been associated with meaningful
2022 differences in clinical outcomes.547 A Cochrane review of cell salvage used in a variety of
2023 surgeries demonstrated an overall reduction of less than 1 unit per patient with decreased
2024 likelihood of requiring an allogeneic blood transfusion, but no alteration in clinical outcome.548 A
2025 meta-analysis of cell salvage in open aneurysm repair, confirmed a reduced requirement for
2026 blood transfusion.549 In addition, one retrospective study has demonstrated that cell salvage
2027 was associated with improved survival among patients undergoing open repair of a ruptured
2028 aneurysm.550 Cell salvage is contraindicated in the presence of infection or malignancy.
2029 The benefit of maintaining a predefined hematocrit level during open surgical repair of
2030 aortic aneurysm is unknown, but preemptive transfusion in the setting of rapid ongoing blood
2031 loss is well-supported.551 In the trauma literature, plasma, platelets, and packed red blood cells
2032 in a 1:1:1 ratio and warm fresh whole blood instead of component therapy have each been
2033 advocated.433, 552, 553 However, retrospective studies have not consistently demonstrated a
2034 survival benefit to a lower ratio of red cell transfusion to plasma transfusion for patients
2035 undergoing open repair of a rupture aneurysm.550, 554 Further, withholding plasma and platelet
2036 transfusion until surgical repair is complete, is not supported by clinical evidence. Optimal blood
2037 replacement therapy during open repair has not been well defined nor indications established
86
2038 for administration of cryoprecipitate, plasma, and platelets.555 A retrospective study has
2039 suggested that administration of recombinant factor VIIa in the setting of intractable
2040 intraoperative and postoperative bleeding during vascular surgery has a survival benefit.556
2041 A Cochrane review of perioperative administration of crystalloid and colloid fluids for
2042 open abdominal aortic surgery did not identify a superior regimen.557 However, a recent
2043 prospective randomized study of elective open repair of abdominal aortic aneurysm concluded
2044 that a more restrictive perioperative fluid regimen reduces complications and length of hospital
2045 stay.558
2046 2047 2048 We recommend using cell salvage or an ultrafiltration device if large blood loss is anticipated. 2049 2050 Level of recommendation Strong 2051 Quality of evidence Moderate 2052 2053 2054 If the intraoperative hemoglobin is less than 10 gm/dL and blood loss is ongoing, we 2055 recommend transfusion of packed blood cells along with fresh frozen plasma and platelets in a 2056 ratio of 1:1:1. 2057 2058 Level of recommendation Strong 2059 Quality of evidence Moderate 2060 2061 2062 Cardiovascular monitoring. Central venous pressure and arterial line monitoring are
2063 suggested for all patients undergoing open surgical repair of an aortic aneurysm.559 However,
2064 multiple randomized trials have shown no measureable benefit to the routine use of pulmonary
2065 artery catheters in non-selected patients.560-563 While trans-esophageal echocardiography
2066 (TEE) is useful for those patients ‘at risk’ of major hemodynamic instability or in the unstable
2067 patient to assess volume status and cardiac function, routine use does not influence clinical
2068 outcomes.564, 565
2069 Perioperative myocardial infarction is associated with adverse short- and long-term
2070 outcomes and can be prevented by early recognition of myocardial ischemia.566-569 ECG
2071 monitoring, utilizing five leads, is recommended for both OSR and EVAR. Continuous 12-lead
87
2072 ECG or the monitoring of two leads instead of a single precordial lead has been shown to be a
2073 more sensitive indicator of myocardial ischemia.570 However, myocardial ischemia detection by
2074 TEE in the form of wall motion abnormalities precedes ST segment changes and is a more
2075 sensitive monitor for ischemia. While troponin measurement after vascular surgery has been
2076 advocated,571 routine measurement has not been associated with improved clinical outcomes.563
2077
2078 2079 2080 We suggest using pulmonary artery catheters only if the likelihood for a major hemodynamic 2081 disturbance was high. 2082 2083 Level of recommendation Strong 2084 Quality of evidence Moderate 2085 2086 2087 We recommend central venous access and arterial line monitoring in all patients undergoing 2088 open aneurysm repair. 2089 2090 Level of recommendation Strong 2091 Quality of evidence Moderate 2092 2093 2094 We recommend postoperative ST-segment monitoring for all patients undergoing open 2095 aneurysm repair and for those patients undergoing EVAR who are at high cardiac risk.. 2096 2097 Level of recommendation Strong 2098 Quality of evidence Moderate 2099 2100 2101 We recommend postoperative troponin measurement for all patients with ECG changes or chest 2102 pain after aneurysm repair. 2103 2104 Levels of recommendation Strong 2105 Quality of evidence High 2106 2107 2108 2109 Maintenance of body temperature. Maintenance of body temperature above 36°C
2110 during aneurysm repair appears to be beneficial with respect to hemodynamics, laboratory
2111 measures of clotting function, and metabolic acidosis.563, 572 Prospective randomized data
2112 supports the use of forced air warming blankets rather than circulating water mattresses.572 In
88
2113 addition, prospective studies support the use of low fresh flow rate anesthetic gases573 and the
2114 use of intravenous fluid and blood warmers to maintain normothermia.574
2115 2116 2117 We recommend maintaining core body temperature at or above 36°C during aneurysm repair. 2118 2119 Levels of recommendation Strong 2120 Quality of evidence High 2121 2122
2123 Role of the intensive care unit. Increasingly, the care of the postoperative patient is
2124 occurring in a step down unit or other monitored settings to best focus use of the intensive care
2125 unit on those patients in greatest need.575 Selective use of the intensive care unit after
2126 aneurysm surgery is most effective if preoperative criteria, such as preexisting significant
2127 coronary artery, pulmonary or renal disease, or intraoperative criteria, such as a significant
2128 arrhythmia, hemodynamic instability or requirement for postoperative mechanical ventilation are
2129 established.576 In a study of 230 patients undergoing aneurysm repair, 89% avoided admission
2130 to ICU by use of systematic preoperative evaluation to identify predictors of poor outcome.577
2131 Goal-directed therapy using non-invasive monitoring of cardiac output by esophageal
2132 Doppler or lithium indicator dilution and pulse power analysis (LiDCO) has been shown to
2133 improve short term outcomes.578, 579 Monitoring cardiac output with a defined treatment protocol
2134 has also been shown to be cost effective in the setting of major abdominal surgery.580 While
2135 studies focused on the care of patients with an aortic aneurysm have not been conducted,
2136 randomized trials have included patients with vascular disease.581.
2137 Fast track surgical pathways or ‘enhanced recovery’ pathways are being used
2138 increasingly to decrease length of stay and expedite discharge after abdominal surgery.
2139 Evaluation of a fast track surgery pathway in a 30 patient cohort undergoing open aneurysm
2140 repair was associated with an average length of stay of 3.6 days without readmission.582 The
2141 pathway included a limited retroperitoneal incision and specialized intraoperative retractors.582
89
2142 A recent trial confirmed benefit in 101 patients randomized to a fast track surgery care pathway,
2143 which included no bowel prep, reduced fasting, patient controlled anesthesia, as well as early
2144 mobilization and feeding. There was no difference in ICU length of stay, but time to full feeding
2145 (5 vs. 7 days, p < 0.001) was reduced along with the incidence of postoperative complication
2146 (16% vs. 36%, p = 0.039).
2147 2148 2149 We recommend postoperative management in an intensive care unit for the patient with 2150 significant cardiac, pulmonary or renal disease, as well as for those requiring postoperative 2151 mechanical ventilation or who developed a significant arrhythmia or hemodynamic instability 2152 during operative treatment. 2153 2154 Level of recommendation Strong 2155 Quality of evidence High 2156 2157 2158 Nasogastric decompression and perioperative nutrition. Routine nasogastric
2159 decompression is not recommended after aortic surgery. A Cochrane review examined 37
2160 studies involving 5,711 patients randomized to routine or selective nasogastric decompression
2161 after emergency or elective abdominal surgery.583 Selective decompression was associated
2162 with a decreased risk of pulmonary complications without untoward adverse effects.583
2163 Although postoperative malnutrition is uncommon after EVAR, given the anticipated short length
2164 of hospital stay,584 a risk for malnutrition exists for patients who undergo open aneurysm repair,
2165 particularly those with preexisting renal insufficiency.585 Early feeding reduces the likelihood of
2166 malnutrition, as demonstrated in a randomized trial of 128 patients undergoing colorectal and
2167 abdominal vascular surgery.586
2168 2169 2170 We recommend optimization of preoperative nutritional status prior to elective open aneurysm 2171 repair, if repair will not be unduly delayed. 2172 2173 Level of recommendation Strong 2174 Quality of evidence High 2175 2176
90
2177 We recommend using nasogastric decompression intraoperatively for all patients undergoing 2178 open aneurysm repair, but postoperatively, only for those patients with nausea and abdominal 2179 distention. 2180 2181 Level of recommendation Strong 2182 Quality of evidence High 2183 2184 2185 We recommend parenteral nutrition if a patient is unable to tolerate enteral support seven days 2186 after aneurysm repair. 2187 2188 Level of recommendation Strong 2189 Quality of evidence High 2190 2191
2192 Prophylaxis for deep vein thrombosis. Early mobilization and shorter length of stay
2193 has reduced the incidence of venous thromboembolism after aortic surgery relative to earlier
2194 eras of open aortic repair. Two studies using the NSQIP database determined that the 30-day
2195 incidence of venous thromboembolism after open aneurysm repair and EVAR were less than
2196 2% and 1%, respectively.587, 588 The risk of postoperative deep venous thrombosis (DVT)
2197 prophylaxis after open aneurysm repair was first highlighted by Olin et al. who performed
2198 postoperative venography in 50 consecutive patients.589 While most patients were
2199 asymptomatic, 21% had evidence of an acute DVT, predominantly within the calf veins.
2200 While venous thromboembolism risk stratification can be performed using the Caprini or
2201 similar scoring scheme, most patients undergoing aneurysm repair will be classified as
2202 moderate (Caprini Risk Score: 3-4) or high (Caprini Risk Score: >5) risk.590 For example, the
2203 majority of patients undergoing aneurysm repair will be 61 years of age or older (Caprini score
2204 of 2 points) with planned surgery of greater than 45 minutes (Caprini score of 2 points), These
2205 two factors alone yield a Caprini Risk Score of 4. Nonetheless, recommendations for
2206 thromboprophylaxis after aneurysm surgery are not well defined, given the lack of evidence for
2207 safety, particularly among patients undergoing open surgical repair, or effectiveness.591-598
2208
91
2209 2210 2211 We recommend thromboprophylaxis that includes intermittent pneumatic compression and early 2212 ambulation for all patients undergoing OSR or EVAR. 2213 2214 Level of recommendation Strong 2215 Quality of Evidence High 2216 2217 2218 We suggest thromboprophylaxis with unfractionated or low molecular weight heparin for patients 2219 undergoing aneurysm repair at moderate to high risk for venous thromboembolism and low risk 2220 for bleeding. 2221 2222 Level of recommendation Weak 2223 Quality of evidence Low 2224 2225 2226 Postoperative blood transfusion. A threshold for blood transfusion after OSR or
2227 EVAR has not been established. A number of studies suggest that anemia or a low hemoglobin
2228 level is associated with increased mortality after open AAA repair.82, 124 In a review of a
2229 statewide database, transfusion after major vascular procedures occurred in 25% of patients at
2230 a median hemoglobin level of 7.7 g/dL. Perioperative transfusion was independently associated
2231 with death, myocardial infarction, and pneumonia.599 A hemoglobin concentration of less than 7
2232 g/dL has been recommended as a transfusion threshold for a number of high risk conditions in
2233 both critical and ambulatory care.600 Given the prevalence of coronary artery disease among
2234 patients undergoing vascular surgery, blood transfusion for a hemoglobin concentration of less
2235 than 10 g/dL has been a common practice. However, a meta-analysis comparing transfusion
2236 thresholds of 7 to 8 g/dL and 9 to 10 g/dL did not discern a difference in outcome for patients
2237 undergoing either cardiac or vascular surgery.601 In this regard, motivated by a desire to reduce
2238 the established risks of blood transfusion, decrease blood utilization, and lower costs, a recent
2239 Cochrane analysis supports more restrictive guidelines for all patients, including those with
2240 cardiovascular disease.602 Therefore, on the basis of currently available evidence, in the
2241 absence of ongoing blood loss, transfusion during or after OSR or EVAR is recommended only
2242 if the hemoglobin concentration is at or below 7 g/dL.
92
2243 2244 2245 In the absence of ongoing blood loss, we suggest a threshold for blood transfusion during or 2246 after aneurysm repair at a hemoglobin concentration of 7 gm/dL or below. 2247 2248 Level of recommendation Weak 2249 Quality of evidence Low 2250
2251 Perioperative pain management. Central regional opioids, systemic opioid patient-
2252 controlled analgesia and peripheral regional techniques are recommended for pain
2253 management, including multimodal techniques such as central regional blockage with local
2254 anesthetics.603 The geriatric population warrants special consideration and incorporation of
2255 acetaminophen is recommended in the postoperative pain plan.603
2256 A Cochrane analysis reviewed 1,498 patients enrolled in 15 trials who were treated with
2257 either epidural or systemic opioid analgesia, most often after open aortic surgery.604 The method
2258 of pain control had no impact on 30 day mortality, but initial pain scores, the duration of
2259 ventilation, postoperative respiratory failure, gastrointestinal bleeding, ICU length of stay, and
2260 the incidence of MI were all reduced among patients treated with epidural analgesia.604, 605
2261 Epidural anesthesia may also be beneficial for patients with COPD.606 Complications after the
2262 placement of an epidural catheter are uncommon, but include epidural abscess and
2263 hematoma.607
2264 There is limited evidence that a pre-incisional transversus abdominis plane (TAP) block
2265 decreases the use of pain medication after major abdominal surgery.608, 609 A Cochrane review
2266 of 8 studies with 358 participants found TAP reduced opioid consumption in a subset of studies
2267 and had no impact on nausea, vomiting or sedation scores.610
2268 2269 2270 We recommend multimodality treatment, including epidural analgesia, for postoperative pain 2271 control after open surgical repair of an abdominal aortic aneurysm. 2272 2273 Level of recommendation Strong 2274 Quality of evidence High 2275
93
2276 2277 POSTOPERATIVE AND LONG-TERM MANAGEMENT
2278 Late outcomes
2279 Endoleak. Endoleak is defined as persistent blood flow in the aneurysm sac after
2280 EVAR. Endoleaks at the time of repair may be present in up to 25%.611-613 Although an
2281 endoleak may often resolve without intervention, some require immediate or delayed
2282 treatment to prevent aneurysm rupture. Additionally, some endoleaks develop months or
2283 years after EVAR. Thus, lifelong surveillance after EVAR is required. An endoleak may be
2284 identified by CT imaging or duplex ultrasound.614, 615 There are four main types of endoleak.347,
2285 616 Management depends on endoleak type and the associated risk of sac rupture.
2286 Type I endoleak. A type I endoleak occurs when there is an incomplete seal at the
2287 proximal aortic attachment site (type IA) or at the distal iliac attachment site (IB). A type IA
2288 endoleak most often occurs in the presence of a short or severely angulated neck, a reverse
2289 tapered neck, or when the attachment site contains considerable thrombus or calcification. A
2290 type I endoleak is associated with elevated sac pressure and an ongoing risk of rupture.617-619
2291 While a small endoleak may seal and can be observed, it is preferable that when
2292 identified at the time of repair, every attempt should be made to treat a type I endoleak before
2293 the conclusion of the procedure. Balloon molding of the proximal seal zone, placement of a
2294 proximal cuff, and endostaples have all been used with varying degrees of success.620
2295 Endostaples may reduce the risk of endograft migration and a type IA endoleak, but long-term
2296 data are limited.620, 621
2297 Other options for type IA endoleak treatment include embolization with coils or glue,622, 623
2298 proximal extension with a chimney approach,352 or conversion to a fenestrated endograft.351 A
2299 type IB endoleak is treated with distal extension of the iliac limb, if repeat angioplasty fails to
2300 eliminate the endoleak. It may be necessary to extend the endograft to the external iliac artery
94
2301 with coil occlusion of hypogastric artery. Conversion to open repair should be considered in the
2302 presence of a persistent type IA endoleak.624
2303 Type II endoleak. Persistent filling of the aneurysm sac from patent lumbar arteries or
2304 the inferior mesenteric artery (IMA) constitutes a type II endoleak.611-613 Type II endoleaks are
2305 the most common endoleak, present at the time of repair in up to one-fourth of patients. When
2306 identified at the time of the procedure, treatment is not indicated, as at least 50% will
2307 spontaneously resolve.617, 622, 623, 625 The incidence of type II endoleak at 6 months is 10% to
2308 15%.626-628 Factors that increase the risk of a persistent type II endoleak include a patent
2309 inferior mesenteric artery, number and diameter of patent lumbar arteries, especially L3 and L4
2310 lumbar arteries, and ongoing anticoagulation.629-632
2311 The fate of persistent type II endoleaks is variable. Aneurysm sac size may decrease in
2312 up to 25%,626, 633 remain stable in 50%-70%,634 or increase in up to 25% of patients. The
2313 delayed onset of a type II endoleak may also be noted 6 months or later after EVAR. A delayed
2314 type II endoleak may be associated with aneurysm sac expansion;635 however, expansion in sac
2315 diameter greater than 10 mm is uncommon.636
2316 Treatment of a type II endoleak includes embolization of the inferior mesenteric or lumbar
2317 arteries with coils or glue,623 direct trans-lumbar injection of the aneurysm sac,616 transcaval
2318 embolization,637, 638 or laparoscopic ligation of the inferior mesenteric and lumbar arteries,639 all
2319 with variable success rates. Up to 60% of treated aneurysms continue to expand requiring
2320 multiple procedures and in some cases explant with conversion to open repair.640, 641 Stent graft
2321 preservation with oversewing of the inferior mesenteric and lumbar arteries from within the sac
2322 has been reported.642-644 Type II endoleak remains a challenge to treat effectively.645
2323 Rupture from a type II endoleak is rare and more often related to an unrecognized type I
2324 endoleak. The decision to treat is based on the size and expansion (> 5 mm) of the aneurysm,
2325 type and size of patent inflow and outflow vessels, and the presence of symptoms.646, 647
2326 Selective intervention appears both safe and cost-effective.636, 648
95
2327 Type III endoleak. A type III endoleak occurs when there is incomplete seal between
2328 components or component separation and less frequently due to fabric erosion. The aneurysm
2329 sac becomes re-pressurized with an increased risk of rupture. All type III endoleaks should be
2330 treated. When the endoleak is present at the contralateral gate or between an iliac limb and an
2331 iliac extension, treatment entails bridging the gap with an appropriately sized limb.617, 618
2332 Type IV endoleak. A type IV endoleak is due to fabric porosity, which may be present
2333 at the time of repair. All type IV endoleaks seal spontaneously and do not require treatment.
2334 Endotension. Endotension is defined as sac enlargement without a discernable
2335 endoleak. It may be caused by blood flow that is undetectable at the limits of the imaging
2336 modality, pressure transmission through fabric,649, 650 or accumulation of a serous ultra-filtrate
2337 across a microporous fabric.612 Endotension is less common with the newer generation grafts.
2338 Management should be individualized, and may include observation, relining of low-porosity
2339 endografts, or rarely explantation and conversion to open repair.
2340 2341 2342 We recommend treatment of Type I endoleaks. 2343 2344 Level of recommendation Strong 2345 Quality of Evidence Moderate 2346 2347 2348 We suggest treatment of Type II endoleaks associated with aneurysm expansion. 2349 2350 Level of recommendation Weak 2351 Quality of Evidence Low 2352 2353 2354 We recommend surveillance of Type II endoleaks not associated with aneurysm expansion. 2355 2356 Level of recommendation Strong 2357 Quality of Evidence Moderate 2358 2359 2360 We recommend treatment of Type III endoleaks. 2361 2362 Level of recommendation Strong 2363 Quality of Evidence Moderate
96
2364 We suggest no treatment of Type IV endoleaks. 2365 2366 Level of recommendation Weak 2367 Quality of Evidence Low 2368 2369 2370 We recommend open repair if endovascular intervention fails to treat a Type I or III endoleak 2371 with ongoing aneurysm enlargement. 2372 2373 Level of recommendation Strong 2374 Quality of Evidence Moderate 2375 2376 2377 We suggest open repair if endovascular intervention fails to treat a Type II endoleak with 2378 ongoing aneurysm enlargement. 2379 2380 Level of recommendation Weak 2381 Quality of Evidence Low 2382 2383 2384 We suggest treatment for ongoing aneurysm expansion, even in the absence of a visible 2385 endoleak. 2386 2387 Level of recommendation Weak 2388 Quality of Evidence Low 2389 2390
2391 Device migration. Device migration most commonly presents as caudal migration of
2392 the proximal endograft. A delayed type IA endoleak will occur if the endograft migrates into the
2393 aneurysm sac. Rarely aortic remodeling will create forces that cause cranial migration of the
2394 distal landing zone and a resultant type IB endoleak. Device migration is a late event, typically
2395 occurring two or more years after implantation.651-653 Factors that predispose to migration
2396 include hostile neck anatomy, inadequate device fixation, and progressive aortic dilatation and
2397 elongation.651, 654-656
2398 Treatment for caudal device migration depends on anatomic considerations, including
2399 the quality of the aortic seal zone, as well as the distance between the renal arteries and the flow
2400 divider of the original endograft. Options include conversion to an aorto-unilateral iliac bypass
2401 with crossover femoral-femoral bypass and iliac occlusion or placement of an aortic extension
97
2402 cuff. However, the former approach has a lower risk of recurrent endoleak and rupture since
2403 treatment with an aortic cuff is often associated with continued risk of device migration.657
2404 Alternatives include proximal extension with a branched or fenestrated endograft.351 FEVAR for
2405 EVAR failure is technically complex because the existing endograft may interfere with rotational
2406 torque and visualization of the radio-opaque markers.
2407 Limb occlusion. Nearly 25% of all arterial re-interventions after open repair are due to
2408 limb occlusion, and are most common in patients with associated occlusive disease.658 Limb
2409 occlusion appears to be greater in women and in grafts extending to the femoral artery. Isolated
2410 limb occlusion usually presents with claudication, but occlusion of the entire graft may present
2411 with severe ischemia. On occasion, a patient may present before complete occlusion of the
2412 graft.
2413 Endografts are at a higher risk for limb thrombosis than bifurcated surgical grafts, as
2414 observed in the EVAR-1 trial.659 Endograft limbs can be narrowed by a calcified small aortic
2415 bifurcation or by tortuous, angulated, and diseased iliac arteries. Although device-dependent,
2416 the incidence of limb occlusion after EVAR is approximately 4%, with the majority of occlusions
2417 presenting within two months and nearly all within the first year after EVAR.370, 660, 661 Non-
2418 supported limbs are at especially high risk of limb occlusion.662 However, stented limbs may
2419 also occlude due to fabric in-folding and kinking between stents.660, 663 While the causes of
2420 endograft limb occlusion may be related to a number of factors, one of the most common
2421 reasons is compromised outflow. Occlusion of the internal iliac artery with or without extension
2422 of the endograft limb to the external iliac artery or unrecognized distal dissection may increase
2423 the risk of limb thrombosis.664, 665 Acute endograft limb occlusion often presents with worsening
2424 claudication rather than critical ischemia, provided the limb has been deployed proximal to the
2425 internal iliac artery, which facilitates collateral perfusion to the lower extremity.
2426 A stenotic limb, noted on Duplex or by a reduction in ankle-brachial index, can be treated
2427 by stent placement. An occluded limb after EVAR or open repair includes, can be treated by
98
2428 thrombectomy, pharmacolytic therapy with secondary endovascular or local surgical
2429 intervention, or by femoral-femoral or axillo-femoral bypass. Mechanical balloon thrombectomy
2430 is less likely to be successful for treatment of an endograft limb thrombosis due to difficulty
2431 advancing the catheter beyond the occluded segment, concerns related to dislodging or
2432 disrupting the sealing zones, and the presence of stents, which may interfere with balloon
2433 thrombectomy. The underlying cause of the thrombosis must be identified and treated and if a
2434 mechanical cause for thrombosis cannot be determined, femoral-femoral bypass should be
2435 considered. Simple thrombectomy or thrombolysis will often lead to recurrent early thrombosis.
2436 Five year patency for a femoral-femoral bypass graft, when placed in the treatment of
2437 aneurysmal disease exceeds 80%.666, 667
2438 2439 2440 We recommend that follow-up of patients after aneurysm repair include a thorough lower 2441 extremity pulse exam or ABI. 2442 2443 Level of recommendation Strong 2444 Quality of evidence Moderate 2445 2446 2447 We recommend a prompt evaluation for possible graft limb occlusion if patients develop new 2448 onset lower extremity claudication, ischemia, or a reduction in ABI after aneurysm repair. 2449 2450 Level of recommendation Strong 2451 Quality of evidence High 2452 2453
2454 Graft infection. All implanted aortic prostheses are at risk for infection either at
2455 implantation or later by hematogenous seeding. Although graft infection is rare with an
2456 incidence of 0.3%668, historically, it has been the indication for intervention in up to 25% of redo
2457 aortic surgery.658 Although controversial, the risk of graft infection after EVAR may be lower
2458 than after open repair, perhaps due to delivery of the endoprosthesis through a completely
2459 enclosed system.663, 669 However, the EVAR-1 trial had a comparable incidence of device
2460 infection between EVAR and open repair over a four year follow-up period.659 Similarly, in a
99
2461 recent analysis of more than 45,000 Medicare beneficiaries, graft infections or aortoenteric
2462 fistulae four years after EVAR or open repair was comparable for both groups (~0.3%).58
2463 Likewise, Vogel reported a nearly identical two-year incidence of graft infection (< 0.2%) for
2464 OSR or EVAR in a review of 14,000 patients undergoing aneurysm repair.670 Graft infection after
2465 EVAR or open repair may present in isolation or with an aortoenteric fistula.671, 672
2466 While aortic graft infection presents on average three years or later after open repair,
2467 endograft infection often manifests earlier for reasons that remain unclear.658 673, 674 Femoral
2468 artery extension of a prosthesis increases the incidence of graft infection from 1% to 3%.675
2469 Other predisposing factors for graft infection include the need for surgical revision and emergent
2470 indication for initial surgery. Generalized sepsis, groin drainage, pseudoaneurysm formation, or
2471 ill-defined pain may be presenting symptoms and staphylococcal organisms are the most
2472 frequent isolates.676 CT imaging may provide an initial estimate of the extent of infection,
2473 determine if a pseudoaneurysm exists at the proximal anastomosis, and assist in operative
2474 planning for effective revascularization of the lower extremities.
2475 Conventional treatment for graft infection includes staged excision of all infected graft
2476 material with extra-anatomic reconstruction, particularly in the presence of extensive
2477 contamination and gross purulence.658, 677-681 In situ reconstruction using femoral vein, a silver
2478 or antibiotic impregnated graft, or cryopreserved allograft represent additional surgical options,
2479 and particularly appropriate in the presence of minimal contamination. Placement of a silver or
2480 antibiotic prosthetic or PTFE graft in a grossly contaminated field is reserved for the unstable
2481 patient.677, 682-686
2482 Treatment of an endograft infection poses unique challenges. A dense inflammatory
2483 reaction can completely obliterate natural tissue planes and endograft hooks or suprarenal
2484 fixation may dictate the need for supraceliac cross clamping to explant the device. Further,
2485 hooks and the suprarenal segment may be embedded into the aortic wall or covered with a
2486 pseudo-intima requiring careful removal to avoid injury to the operator, aortic wall, as well as
100
2487 preservation of the aortic neck for closure or in situ reconstruction. Despite the introduction of
2488 endograft re-sheathing techniques, attendant renal ischemia is an established risk.
2489 Percutaneous drainage and antibiotic therapy has been suggested for patients unfit to undergo
2490 open repair.673, 687-689
2491 An aortoenteric fistula can complicate a graft infection in 1% to 2% of patients.671, 676
2492 Although the duodenum is most frequently affected, all viscera, including small and large bowel,
2493 have been implicated.672, 676 A common presentation is upper gastrointestinal bleeding, as a
2494 herald bleed, which may progress to exsanguinating hemorrhage.690 Any upper gastrointestinal
2495 bleeding in a patient with an aortic graft should raise the suspicion of an aortoenteric fistula.
2496 The diagnosis may occasionally be confirmed by endoscopy or CT imaging.691-693 Bleeding is
2497 more common when the anastomosis erodes into the gastrointestinal tract, while sepsis and
2498 abscess formation are more common with para-prosthetic fistula involving the body of the graft.
2499 Treatment strategies are similar to primary graft infections but must include closure of the
2500 visceral defect.694 While endovascular repair of an aortoenteric fistula is uniformly unsuccessful,
2501 severe hemorrhage may necessitate the use of an endograft to temporarily control bleeding, as
2502 a “bridge” to definitive surgical repair.695, 696
2503 Prevention of an aortic graft infection. Recommendations for antibiotic prophylaxis
2504 after placement of an aortic prosthesis following open surgical repair or EVAR have historically
2505 followed guidelines for the prevention of infective endocarditis after a prosthetic heart valve.
2506 Recent guidelines have sought to reduce the indications of antibiotic prophylaxis, particularly
2507 with the publication of the National Institute for Health and Clinical Excellence (NICE) guidance
2508 in 2008, which recommended against antibiotic prophylaxis for infective endocarditis, regardless
2509 of the dental, genitourinary, or gastrointestinal procedure, or predisposing cardiac condition,
2510 including the presence of a prosthetic valve.697 A recent report has observed a small but
2511 statistically significant increase in infective endocarditis cases in the UK since the
2512 implementation of the NICE recommendations.698 Although limitations exist in this study and
101
2513 causation has not been established, concerns have been raised.699 Several investigations note
2514 a relationship between dental procedures and infective endocarditis in high risk patients.423
2515 Current European Society of Cardiology, American College of Cardiology, and American Heart
2516 Association guidelines recommend ongoing use of antibiotic prophylaxis for patients with a
2517 prosthetic valve undergoing high risk procedures.700, 701 High risk procedures, as defined in both
2518 guidelines, included dental procedures involving the manipulation of the gingival or periapical
2519 region of teeth or perforation of the oral mucosa, including scaling and root canal procedures.701
2520 Both guidelines noted that there was no compelling evidence that bacteremia resulted from
2521 respiratory tract procedures, gastrointestinal or genitorurinary procedures, dermatological or
2522 musculoskeletal procedures and prophylaxis was not recommended for patients undergoing
2523 these procedures unless the procedures were performed in the presence of an infection.701 It
2524 was also strongly recommended that any potential sources of dental sepsis be eliminated at
2525 least 2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular
2526 foreign material, unless the procedure was deemed urgent. Others have raised concerns that
2527 patients undergoing colonoscopy or urological procedures, especially the elderly and those with
2528 cancer or who are immunocompromised require antibiotic prophylaxis.702, 703 Both the European
2529 and AHA/ACC guidelines noted that their recommendations were not based on strong evidence
2530 and further prospective evaluation was recommended.
2531 For those patients with an aortic prosthesis, whether placed by open surgical repair or
2532 EVAR, we suggest antibiotic prophylaxis to prevent graft infection prior to any dental procedure
2533 involving the manipulation of the gingival or periapical region of teeth or perforation of the oral
2534 mucosa, including scaling and root canal procedures. We also suggest antibiotic prophylaxis
2535 prior to respiratory tract procedures, gastrointestinal or genitorurinary procedures,
2536 dermatological or musculoskeletal procedures, if the potential for infection exists or the patient is
2537 immunocompromised.
2538
102
2539 2540 2541 We recommend antibiotic prophylaxis to prevent graft infection prior to any dental procedure 2542 involving the manipulation of the gingival or periapical region of teeth or perforation of the oral 2543 mucosa, including scaling and root canal procedures, for any patient with an aortic prosthesis, 2544 whether placed by open surgical repair or EVAR. 2545 2546 Level of recommendation Strong 2547 Quality of evidence Moderate 2548 2549 We suggest antibiotic prophylaxis prior to respiratory tract procedures, gastrointestinal or 2550 genitorurinary procedures, dermatological or musculoskeletal procedures, for any patient with 2551 an aortic prosthesis, if the potential for infection exists or the patient is immunocompromised. 2552 2553 Level of recommendation Good practice statement 2554 Quality of evidence Ungraded 2555 2556 2557 After aneurysm repair, we recommend prompt evaluation for possible graft infection if a patient 2558 presents with generalized sepsis, groin drainage, pseudoaneurysm formation, or ill-defined pain. 2559 2560 Level of recommendation Strong 2561 Quality of evidence High 2562 2563 2564 We recommend prompt evaluation for possible aortoenteric fistula in a patient presenting with 2565 gastrointestinal bleeding after aneurysm repair. 2566 2567 Level of recommendation Strong 2568 Quality of evidence High 2569 2570 In patients presenting with an infected graft in the presence of extensive contamination with 2571 gross purulence, we recommend extra-anatomic reconstruction followed by excision of all graft 2572 material along with aortic stump closure covered by an omental flap. 2573 2574 Level of recommendation Strong 2575 Quality of evidence Moderate 2576 2577 2578 In patients presenting with an infected graft with minimal contamination, we suggest in situ 2579 reconstruction with cryopresevered allograft. 2580 2581 Level of recommendation Weak 2582 Quality of evidence Moderate 2583 2584 2585 In a stable patient presenting with an infected graft, we suggest in situ reconstruction with 2586 femoral vein after graft excision and debridement. 2587 2588 Level of recommendation Weak 2589 Quality of evidence Moderate
103
2590 2591 In unstable patients with infected graft, we recommend in situ reconstruction with a silver or 2592 antibiotic impregnated graft, cryopreserved allograft, or a PTFE graft. 2593 2594 Level of recommendation Strong 2595 Quality of evidence Moderate 2596 2597 2598 2599 Incisional hernia. Retroperitoneal incisions for aortic aneurysm repair may lead to
2600 denervation of the 11th intercostal nerve, which has been associated with numbness in the
2601 region of the incision in up to one-third of patients, as well as bulging of the lateral abdominal
2602 wall with musculature atrophy in 7 to 15%.381, 704 Transperitoneal repair is associated with a
2603 higher incidence of late small bowel obstruction and approximately 10% of patients may develop
2604 a ventral hernia within the first 6 years after repair, particularly among those who are obese.705,
2605 706 Should a midline incision be used, continuous suturing technique and avoidance of rapidly
2606 absorbable sutures is recommended.707 Wound infections of the abdominal incisions are rare
2607 (0.4%).706
2608 Para-anastomotic aneurysm. Para-anastomotic aneurysms after aortic aneurysm
2609 repair include both false aneurysms resulting from a disruption of the anastomosis and true
2610 aneurysms that develop adjacent to the anastomosis. True metachronous aneurysms occur at
2611 a greater frequency than anastomotic pseudoaneurysms. However, the incidence of para-
2612 anastomotic aneurysms is not well defined. Predisposing factors include hypertension, COPD,
2613 and tobacco use.708-712 In the era prior to CT imaging, Szilagyi analyzed a 15-year experience in
2614 which anastomoses at the femoral artery were at highest risk (3%), followed by the iliac artery
2615 (1.2%) and infrarenal aorta (0.2%).711 Subsequent studies have reported an incidence after
2616 open repair of between 4% and 10% at 10-year follow-up.709 In one study of 511 patients,
2617 Kaplan-Meier analysis revealed a probability of para-anastomotic aneurysm of 0.8% at five
2618 years, 6.2% at 10 years, and 35.8% at 15 years.710 This observation has been confirmed by
2619 others, particularly the risk of femoral pseudoaneurysm formation among patients treated with
104
2620 an aortobifemoral graft.709, 712 Indolent graft infection should be suspected in all
2621 pseudoaneurysms.
2622 Given the inability to precisely differentiate anastomotic disruption from degenerative
2623 aneurysmal dilatation, indications for repairing para-anastomotic aneurysms are not well
2624 defined. Clearly large size and rapid enlargement are indications for intervention. Redo open
2625 repair carries a significant risk of major morbidity and mortality and endovascular repair, where
2626 anatomically feasible, provides a minimally invasive option.713, 714 Infrarenal and fenestrated
2627 endografts have been used with chimney, as well as snorkeling techniques.715-718 715, 717-719
2628
2629 Recommendation for postoperative surveillance
2630 Systematic reviews by the SVS showed a significant incidence of postoperative
2631 endoleaks up to 5 years after EVAR, which provides rationale for surveillance. The evidence
2632 was insufficient to recommend an optimal frequency of surveillance. MRI was more sensitive
2633 than CTA and contrast CT although the difference was small. Duplex ultrasound was inferior to
2634 CT and contrast enhanced ultrasound in terms of detection rate, although leaks missed on
2635 ultrasound did not require intervention or were not considered to be clinically significant.
2636 The goal of postoperative surveillance is to prevent late rupture and aneurysm-related
2637 death. After open surgical repair, an anastomotic aneurysm or aneurysmal dilatation in the
2638 adjacent visceral aorta or iliac arteries may occur in 1%, 5%, and 20% of patients at 5, 10 and
2639 15 years.709, 712 Thus, abdominal and pelvic CT imaging is recommend every 5 years after open
2640 surgical repair.
2641 Surveillance after EVAR is performed to identify sac growth, endoleak, device migration,
2642 or device failure. A comprehensive analysis of contemporary Medicare patients revealed that
2643 the incidence of late rupture 8 years after EVAR is over 5%.340 Most ruptures developed from
2644 type I or type III endoleaks with sac enlargement, predisposed by unfavorable anatomy for
2645 endovascular repair.720-722
105
2646 Surveillance imaging modality. Initially recommended surveillance protocols were
2647 consistent with those used by FDA-sponsored pivotal trials with CT imaging at 1, 6 and 12
2648 months and yearly thereafter. The 6-month CT scan can be eliminated from routine surveillance
2649 if the one-month scan shows no concerning endoleak or sac enlargement.723, 724
2650 Color duplex ultrasonography, contrast-enhanced color duplex ultrasonography, and
2651 three-dimensional contrast-enhanced ultrasonography have all shown to be accurate in
2652 detecting type I and type III endoleaks, as well as sac enlargement.725-729 Ultrasonography
2653 eliminates radiation exposure, reduces cost, and avoids use of a nephrotoxic contrast agent.
2654 Further surveillance with ultrasound is safe if CT imaging one year after EVAR demonstrates no
2655 endoleak and stable sac size724 729 or for those patients with a type II endoleak and a stable
2656 aneurysm size.728 A new endoleak, graft migration or aneurysm sac growth greater than 5 mm -
2657 10 mm should prompt further evaluation with a CT scan.
2658 Surveillance outcomes. Surveillance non-compliance rates approach 60%730, 731 with
2659 gaps observed 3 to 4 years after EVAR, particularly among patients of advanced age, Medicaid
2660 eligibility, or after treatment at a low volume center.730, 732 Although the risk of late device related
2661 complications and aneurysm rupture are well documented, population studies have not
2662 demonstrated that annual EVAR surveillance confers a survival benefit or decreases aneurysm-
2663 related mortality.731, 733 Not all late ruptures are preceded by endoleak or sac enlargement, which
2664 suggests that not all late ruptures can be prevented by vigilant surveillance.734, 735
2665 Summary. Current recommendations for surveillance after EVAR include a CT scan at
2666 one month. Concerning findings should prompt surveillance at 6 months. In the absence of a
2667 type I or type III endoleak and sac enlargement surveillance can be performed with CT or color
2668 duplex ultrasound. Annual duplex is most likely sufficient for routine surveillance in the absence
2669 of new endoleak or sac enlargement. New findings should prompt CT imaging to evaluate for I
2670 or type III endoleaks. Abdominal and pelvic CT imaging should be performed every 5 years
2671 after open surgical repair or EVAR.
106
2672 2673 2674 We recommend surveillance during the first year after EVAR using contrast enhanced CT at 2675 one month and in the absence of an endoleak or sac enlargement, contrast enhanced CT or 2676 color duplex sonographic imaging at 12 months. 2677 2678 Level of recommendation Strong 2679 Quality of evidence Moderate 2680 2681 2682 If a Type II endoleak is observed one month after EVAR, we suggest postoperative surveillance 2683 with contrast enhanced CT and color duplex sonographic imaging at six months. 2684 2685 Level of recommendation Weak 2686 Quality of evidence Moderate 2687 2688 2689 If neither endoleak nor AAA enlargement is observed one year after EVAR, we suggest color 2690 Duplex ultrasonography when feasible, or CT imaging if ultrasound is not possible, for annual 2691 surveillance. 2692 2693 Level of recommendation Weak 2694 Quality of evidence Low 2695 2696 2697 If a Type II endoleak is associated with an aneurysm sac that is shrinking or stable in size, we 2698 suggest color Duplex ultrasonography for continued surveillance at 6 month intervals for 24 2699 months and then annually thereafter. 2700 2701 Level of recommendation Weak 2702 Quality of evidence Low 2703 2704 2705 If a new endoleak is detected, we suggest evaluation for a Type I or Type III endoleak. 2706 2707 Level of recommendation Weak 2708 Quality of evidence Low 2709 2710 We suggest non-contrast CT imaging of the entire aorta at five-year intervals after open 2711 repair or EVAR. 2712 2713 Level of recommendation Weak 2714 Quality of evidence Low 2715 2716
2717
2718
107
2719 COST AND ECONOMIC CONSIDERATIONS IN ANEURYSM REPAIR
2720 The complexity and intensity associated with aortic aneurysm treatment results in
2721 significant costs and resource utilization. These initial costs include imaging, preoperative risk
2722 management, the operating room, personnel, implants, and recovery. Long-term follow-up and
2723 imaging has costs, as well as the treatment of any complications from the initial procedure or
2724 failure of the graft itself. Besides these provider costs, patients and their families also bear cost
2725 from lost work productivity and out-of-pocket expenditures.
2726 Contemporary estimates show that in-hospital costs of treatment for open repair or
2727 EVAR are approximately $40,000 in the US, with lower cost estimates in Canada ($16,000
2728 USD) and other countries.736, 737 Implants are a significant portion of EVAR costs (34-52%) but
2729 these costs are offset by the higher costs after open repair from longer hospitalization.738, 739
2730 While open repair is slightly more expensive during the initial hospitalization, there are no
2731 significant differences seen in long-term follow-up due to need for surveillance imaging and re-
2732 interventions after EVAR.
2733 Calculating cost of care does not shed light on the benefit of care. The major benefit of
2734 treatment for patients with an aortic aneurysm is increased survival. However, patients endure
2735 a decreased quality of life after surgery, which may be prolonged should a complication occur.
2736 Because EVAR confers a lower complication rate and smaller incisions compared to open
2737 repair, patients undergoing EVAR generally have better health-related quality of life within the
2738 first 12 months, though there is no significant difference beyond the first year.740
2739 When cost and effectiveness are combined, cost-effectiveness analysis can reveal the
2740 value of different treatment options, and also allow comparison to other treatments in other
2741 fields. Early Markov decision analysis models show that EVAR was cost-effective compared to
2742 open repair, with an incremental cost effectiveness ratio of $22,826.741 However, contemporary
2743 Markov models using data from the DREAM,742 EVAR-1,659 OVER,743 and ACE338 randomized
2744 trials showed EVAR to be cost-effective based on the OVER trial data, but no difference in
108
2745 lifetime cost-effectiveness was derived from data generated by the European trials, suggesting
2746 that results may not be generalizable among different countries.744 EVAR also does not appear
2747 to be cost-effective for treatment of complicated aneurysms. Cost comparisons for fenestrated
2748 or branched EVAR graft demonstrated higher costs in comparison to open repair (€38,212 vs.
2749 €16,497) without significant differences in 30-day mortality.745
2750 Most of the data for cost-effectiveness pertains to elective cases, where expected
2751 morbidity and mortality can be managed through patient selection and preparation. In the
2752 urgent and emergent situation, morbidity and mortality risk is higher, leading to higher costs and
2753 lower quality of life. Nevertheless, evidence suggests that EVAR in the acute setting is
2754 favorable.746
2755 A single screening ultrasound for abdominal aortic aneurysm in asymptomatic men over
2756 65 has shown to be cost-effective in the UK234 and through Markov modeling.747 In the UK, the
2757 cost per life year saved with screening was $1,173, which is less costly than screening
2758 programs for breast, cervical, and colorectal cancer.748 The cost-effectiveness of screening for
2759 younger cohorts, women, and reimaging intervals for small aneurysms remains uncertain. Early
2760 treatment of a small aneurysm, less than 5 cm in diameter, is not cost-effective in comparison to
2761 serial imaging.749
2762 Because of the lower peri-operative complication rates with EVAR, patients who could
2763 not undergo open repair are being offered EVAR or hybrid procedures. In the setting of
2764 constrained costs and capitated care, expensive procedures for asymptomatic elderly patients
2765 with significant comorbidities who will not derive a meaningful survival benefit are not cost-
2766 effective.
2767 EVAR implants are a major component of costs of treatment. As additional devices
2768 have been introduced to the market, it had been speculated that competition would lower price
2769 and incentivize further innovation. However, a decrease in device cost has not been observed.
2770 Several institutions have reported that EVAR confers a negative operating margin in Medicare
109
2771 beneficiaries.750, 751 While cost-effectiveness results can vary among different patient
2772 populations, healthcare systems, and over time, the factors that influence cost and outcomes
2773 remain consistent. In a future of rising costs and constrained resources, cost-effectiveness
2774 analysis will provide a basis to guide healthcare policy that sustains healthcare coverage for all.
2775 2776 2777 CARE OF THE PATIENT WITH AN AAA: AREAS IN NEED OF FURTHER RESEARCH 2778 2779 Advances in biotechnology, drug discovery, and in the engineering sciences holds
2780 significant promise for the development of new diagnostic tests, bioactive compounds, as well
2781 as intraoperative tools and devices that will enhance the care of the patient with an aortic
2782 aneurysm. Research is needed to: (1) ascertain genetic or other biological factors that
2783 accurately measure the life-long risk of developing an aortic aneurysm; (2) discover
2784 pharmacological agents to limit aneurysm enlargement; (3) characterize biomarkers or imaging
2785 derived determinants of rupture risk; (4) design prostheses that resist infection and thrombosis;
2786 (5) develop tools, intraoperative imaging or robotic systems, as well as improved endovascular
2787 grafts that facilitate repair in the presence of challenging anatomy and improve the safety and
2788 accuracy of device deployment; and (6) identify approaches that reliably treat type I and II
2789 endoleaks. All within the framework of enhancing cost effective care.
2790 A number of areas of uncertainty also exist in the care of patients with an abdominal
2791 aortic aneurysm in the application of existing technology that would benefit from further
2792 investigation. Further, given the role of sex differences in the pathophysiology and outcomes of
2793 AAA, investigations in cells, animals, and humans should be designed to assess for gender and
2794 should clearly state related study population details so that results can be interpreted
2795 appropriately. While the following list is not meant to be comprehensive, future research efforts
2796 should consider addressing the following topics:
2797 • What is the most cost effective and clinically effective surveillance protocol for the patient
2798 with a small aneurysm?
110
2799 • Should the aortic size index replace aortic diameter as a determinant for recommending
2800 aneurysm repair?
2801 • Do female patients benefit from a refined metric, such as the aortic size index, or size
2802 threshold for recommending repair?
2803 • Which quality and volume metrics best identify centers that should engage in either EVAR or
2804 the open surgical repair of an aortic aneurysm?
2805 • Does use of a perioperative mortality risk scoring scheme provide benefit in patient and
2806 family communication and mutual decision making?
2807 • Does a perioperative mortality risk scoring scheme provide utility to surgeons, patients, and
2808 families in guiding recommendations for repair in the high risk patient?
2809 • Can perioperative mortality risk scoring schemes be further refined to enhance their
2810 predictive ability?
2811 • Does a frailty assessment enhance our ability to identify those patients who will not benefit
2812 from aneurysm repair?
2813 • Can a single risk-benefit scoring scheme be developed, which incorporate risk of repair, risk
2814 of aneurysm rupture, and anticipated life expectancy?
2815 • Would a risk-benefit scoring scheme that incorporate risk of repair, risk of aneurysm rupture,
2816 and anticipated life expectancy assist mutual decision making between the surgeon, patient,
2817 and their family?
2818 • Will a defined system of care and associated time benchmark from first medical contact to
2819 intervention improve outcomes for the patient with a ruptured aneurysm?
2820 • Which factors are most important in optimizing patient outcomes within a system of care for
2821 the treatment of a ruptured aneurysm?
2822 • Is prophylaxis for deep vein thrombosis needed for the patient undergoing EVAR?
111
2823 • Does the patient undergoing open surgical repair and at low or moderate risk for deep vein
2824 thrombosis benefit from heparin prophylaxis?
2825 • What is the optimal hemoglobin level that necessitates transfusion in the stable
2826 postoperative patient without ongoing blood loss?
2827 • What is the optimal interval, imaging modality, and duration for postoperative surveillance
2828 after aneurysm repair?
2829 • What is the most cost effective and clinically effective surveillance protocol for the patient
2830 after EVAR?
2831
2832
112
2833 REFERENCES 2834 1. Brewster DC, Cronenwett JL, Hallett JW, Jr., Johnston KW, Krupski WC, 2835 Matsumura JS, et al. Guidelines for the treatment of abdominal aortic aneurysms. 2836 Report of a subcommittee of the Joint Council of the American Association for 2837 Vascular Surgery and Society for Vascular Surgery. J Vasc Surg. 2838 2003;37(5):1106-17. 2839 2. Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. 2840 The care of patients with an abdominal aortic aneurysm: the Society for Vascular 2841 Surgery practice guidelines. J Vasc Surg. 2009;50(4 Suppl):S2-49. 2842 3. Murad MH, Montori VM, Sidawy AN, Ascher E, Meissner MH, Chaikof EL, et al. 2843 Guideline methodology of the Society for Vascular Surgery including the 2844 experience with the GRADE framework. J Vasc Surg. 2011;53(5):1375-80. 2845 4. Kent KC, Zwolak RM, Egorova NN, Riles TS, Manganaro A, Moskowitz AJ, et al. 2846 Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 2847 million individuals. J Vasc Surg. 2010;52(3):539-48. 2848 5. Huber TS, Wang JG, Derrow AE, Dame DA, Ozaki CK, Zelenock GB, et al. 2849 Experience in the United States with intact abdominal aortic aneurysm repair. J 2850 Vasc Surg. 2001;33(2):304-10. 2851 6. Johnston KW. Influence of sex on the results of abdominal aortic aneurysm 2852 repair. Canadian Society for Vascular Surgery Aneurysm Study Group. J Vasc 2853 Surg. 1994;20(6):914-23. 2854 7. Vardulaki KA, Walker NM, Day NE, Duffy SW, Ashton HA, Scott RA. Quantifying 2855 the risks of hypertension, age, sex and smoking in patients with abdominal aortic 2856 aneurysm. Br J Surg. 2000;87(2):195-200. 2857 8. Dubey R, Levin MD, Szabo LZ, Laszlo CF, Kushal S, Singh JB, et al. 2858 Suppression of tumor growth by designed dimeric epidithiodiketopiperazine 2859 targeting hypoxia-inducible transcription factor complex. J Am Chem Soc. 2860 2013;135(11):4537-49. 2861 9. Zhang X, Thatcher S, Wu C, Daugherty A, Cassis LA. Castration of male mice 2862 prevents the progression of established angiotensin II-induced abdominal aortic 2863 aneurysms. J Vasc Surg. 2015;61(3):767-76. 2864 10. Stackelberg O, Bjorck M, Larsson SC, Orsini N, Wolk A. Alcohol consumption, 2865 specific alcoholic beverages, and abdominal aortic aneurysm. Circulation. 2866 2014;130(8):646-52. 2867 11. Stackelberg O, Bjorck M, Larsson SC, Orsini N, Wolk A. Fruit and vegetable 2868 consumption with risk of abdominal aortic aneurysm. Circulation. 2869 2013;128(8):795-802. 2870 12. Myers J, McElrath M, Jaffe A, Smith K, Fonda H, Vu A, et al. A randomized trial 2871 of exercise training in abdominal aortic aneurysm disease. Med Sci Sports Exerc. 2872 2014;46(1):2-9. 2873 13. Golledge J, Hankey GJ, Yeap BB, Almeida OP, Flicker L, Norman PE. Reported 2874 high salt intake is associated with increased prevalence of abdominal aortic 2875 aneurysm and larger aortic diameter in older men. PLoS One. 2876 2014;9(7):e102578. 2877 14. Lederle FA, Johnson GR, Wilson SE, Chute EP, Littooy FN, Bandyk D, et al. 2878 Prevalence and associations of abdominal aortic aneurysm detected through
113
2879 screening. Aneurysm Detection and Management (ADAM) Veterans Affairs 2880 Cooperative Study Group. Ann Intern Med. 1997;126(6):441-9. 2881 15. van de Luijtgaarden KM, Bastos Goncalves F, Hoeks SE, Valentijn TM, Stolker 2882 RJ, Majoor-Krakauer D, et al. Lower atherosclerotic burden in familial abdominal 2883 aortic aneurysm. J Vasc Surg. 2014;59(3):589-93. 2884 16. van Vlijmen-van Keulen CJ, Pals G, Rauwerda JA. Familial abdominal aortic 2885 aneurysm: a systematic review of a genetic background. Eur J Vasc Endovasc 2886 Surg. 2002;24(2):105-16. 2887 17. Norman PE, Curci JA. Understanding the effects of tobacco smoke on the 2888 pathogenesis of aortic aneurysm. Arterioscler Thromb Vasc Biol. 2889 2013;33(7):1473-7. 2890 18. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal 2891 aortic aneurysms. Circulation. 2008;117(14):1883-9. 2892 19. Sweeting MJ, Thompson SG, Brown LC, Powell JT. Meta-analysis of individual 2893 patient data to examine factors affecting growth and rupture of small abdominal 2894 aortic aneurysms. Br J Surg. 2012;99(5):655-65. 2895 20. Wilmink TB, Quick CR, Day NE. The association between cigarette smoking and 2896 abdominal aortic aneurysms. J Vasc Surg. 1999;30(6):1099-105. 2897 21. Lederle FA. The rise and fall of abdominal aortic aneurysm. Circulation. 2898 2011;124(10):1097-9. 2899 22. Stather PW, Sidloff DA, Rhema IA, Choke E, Bown MJ, Sayers RD. A review of 2900 current reporting of abdominal aortic aneurysm mortality and prevalence in the 2901 literature. Eur J Vasc Endovasc Surg. 2014;47(3):240-2. 2902 23. Schermerhorn ML, Bensley RP, Giles KA, Hurks R, O'Malley A J, Cotterill P, et 2903 al. Changes in abdominal aortic aneurysm rupture and short-term mortality, 2904 1995-2008: a retrospective observational study. Ann Surg. 2012;256(4):651-8. 2905 24. Nelissen BG, Herwaarden JA, Pasterkamp G, Moll FL, Vaartjes I. Shifting 2906 abdominal aortic aneurysm mortality trends in The Netherlands. J Vasc Surg. 2907 2015;61(3):642-7.e2. 2908 25. Sidloff D, Stather P, Dattani N, Bown M, Thompson J, Sayers R, et al. Aneurysm 2909 global epidemiology study: public health measures can further reduce abdominal 2910 aortic aneurysm mortality. Circulation. 2014;129(7):747-53. 2911 26. Wang S, Zhang C, Zhang M, Liang B, Zhu H, Lee J, et al. Activation of AMP- 2912 activated protein kinase alpha2 by nicotine instigates formation of abdominal 2913 aortic aneurysms in mice in vivo. Nat Med. 2012;18(6):902-10. 2914 27. Li ZZ, Dai QY. Pathogenesis of abdominal aortic aneurysms: role of nicotine and 2915 nicotinic acetylcholine receptors. Mediators Inflamm. 2012;2012:103120. 2916 28. Maegdefessel L, Azuma J, Toh R, Deng A, Merk DR, Raiesdana A, et al. 2917 MicroRNA-21 blocks abdominal aortic aneurysm development and nicotine- 2918 augmented expansion. Sci Transl Med. 2012;4(122):122ra22. 2919 29. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under 2920 ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 2921 1999;230(3):289-96. 2922 30. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the 2923 impact of size, gender, and expansion rate. J Vasc Surg. 2003;37(2):280-4.
114
2924 31. Cronenwett JL, Murphy TF, Zelenock GB, Whitehouse WM, Jr., Lindenauer SM, 2925 Graham LM, et al. Actuarial analysis of variables associated with rupture of small 2926 abdominal aortic aneurysms. Surgery. 1985;98(3):472-83. 2927 32. Norman PE, Powell JT. Abdominal aortic aneurysm: the prognosis in women is 2928 worse than in men. Circulation. 2007;115(22):2865-9. 2929 33. Cron DC, Coleman DM, Sheetz KH, Englesbe MJ, Waits SA. Aneurysms in 2930 abdominal organ transplant recipients. J Vasc Surg. 2014;59(3):594-8. 2931 34. Englesbe MJ, Wu AH, Clowes AW, Zierler RE. The prevalence and natural 2932 history of aortic aneurysms in heart and abdominal organ transplant patients. J 2933 Vasc Surg. 2003;37(1):27-31. 2934 35. Lindeman JH, Rabelink TJ, van Bockel JH. Immunosuppression and the 2935 abdominal aortic aneurysm: Doctor Jekyll or Mister Hyde? Circulation. 2936 2011;124(18):e463-5. 2937 36. Stackelberg O, Bjorck M, Larsson SC, Orsini N, Wolk A. Sex differences in the 2938 association between smoking and abdominal aortic aneurysm. Br J Surg. 2939 2014;101(10):1230-7. 2940 37. Buijs RV, Willems TP, Tio RA, Boersma HH, Tielliu IF, Slart RH, et al. 2941 Calcification as a risk factor for rupture of abdominal aortic aneurysm. Eur J Vasc 2942 Endovasc Surg. 2013;46(5):542-8. 2943 38. Lederle FA, Johnson GR, Wilson SE, Ballard DJ, Jordan WD, Jr., Blebea J, et al. 2944 Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for 2945 elective repair. Jama. 2002;287(22):2968-72. 2946 39. Parkinson F, Ferguson S, Lewis P, Williams IM, Twine CP. Rupture rates of 2947 untreated large abdominal aortic aneurysms in patients unfit for elective repair. J 2948 Vasc Surg. 2015;61(6):1606-12. 2949 40. Hallett JW, Jr., Marshall DM, Petterson TM, Gray DT, Bower TC, Cherry KJ, Jr., 2950 et al. Graft-related complications after abdominal aortic aneurysm repair: 2951 reassurance from a 36-year population-based experience. J Vasc Surg. 2952 1997;25(2):277-84. 2953 41. Brunkwall J, Hauksson H, Bengtsson H, Bergqvist D, Takolander R, Bergentz 2954 SE. Solitary aneurysms of the iliac arterial system: an estimate of their frequency 2955 of occurrence. J Vasc Surg. 1989;10(4):381-4. 2956 42. Chaer RA, Vasoncelos R, Marone LK, Al-Khoury G, Rhee RY, Cho JS, et al. 2957 Synchronous and metachronous thoracic aneurysms in patients with abdominal 2958 aortic aneurysms. J Vasc Surg. 2012;56(5):1261-5. 2959 43. Bernhard VM, Mitchell RS, Matsumura JS, Brewster DC, Decker M, Lamparello 2960 P, et al. Ruptured abdominal aortic aneurysm after endovascular repair. J Vasc 2961 Surg. 2002;35(6):1155-62. 2962 44. Faries PL, Cadot H, Agarwal G, Kent KC, Hollier LH, Marin ML. Management of 2963 endoleak after endovascular aneurysm repair: cuffs, coils, and conversion. J 2964 Vasc Surg. 2003;37(6):1155-61. 2965 45. Jones JE, Atkins MD, Brewster DC, Chung TK, Kwolek CJ, LaMuraglia GM, et al. 2966 Persistent type 2 endoleak after endovascular repair of abdominal aortic 2967 aneurysm is associated with adverse late outcomes. J Vasc Surg. 2007;46(1):1- 2968 8.
115
2969 46. Fink HA, Lederle FA, Roth CS, Bowles CA, Nelson DB, Haas MA. The accuracy 2970 of physical examination to detect abdominal aortic aneurysm. Arch Intern Med. 2971 2000;160(6):833-6. 2972 47. Norman PE, Powell JT. Site specificity of aneurysmal disease. Circulation. 2973 2010;121(4):560-8. 2974 48. Szilagyi DE, Schwartz RL, Reddy DJ. Popliteal arterial aneurysms. Their natural 2975 history and management. Arch Surg. 1981;116(5):724-8. 2976 49. Ramesh S, Michaels JA, Galland RB. Popliteal aneurysm: morphology and 2977 management. Br J Surg. 1993;80(12):1531-3. 2978 50. Dawson I, Sie RB, van Bockel JH. Atherosclerotic popliteal aneurysm. Br J Surg. 2979 1997;84(3):293-9. 2980 51. Graham LM, Zelenock GB, Whitehouse WM, Jr., Erlandson EE, Dent TL, 2981 Lindenauer SM, et al. Clinical significance of arteriosclerotic femoral artery 2982 aneurysms. Arch Surg. 1980;115(4):502-7. 2983 52. Whitehouse WM, Jr., Wakefield TW, Graham LM, Kazmers A, Zelenock GB, 2984 Cronenwett JL, et al. Limb-threatening potential of arteriosclerotic popliteal artery 2985 aneurysms. Surgery. 1983;93(5):694-9. 2986 53. Diwan A, Sarkar R, Stanley JC, Zelenock GB, Wakefield TW. Incidence of 2987 femoral and popliteal artery aneurysms in patients with abdominal aortic 2988 aneurysms. J Vasc Surg. 2000;31(5):863-9. 2989 54. Karthikesalingam A, Bahia SS, Patterson BO, Peach G, Vidal-Diez A, Ray KK, et 2990 al. The shortfall in long-term survival of patients with repaired thoracic or 2991 abdominal aortic aneurysms: retrospective case-control analysis of hospital 2992 episode statistics. Eur J Vasc Endovasc Surg. 2013;46(5):533-41. 2993 55. Roger VL, Ballard DJ, Hallett JW, Jr., Osmundson PJ, Puetz PA, Gersh BJ. 2994 Influence of coronary artery disease on morbidity and mortality after abdominal 2995 aortic aneurysmectomy: a population-based study, 1971-1987. J Am Coll Cardiol. 2996 1989;14(5):1245-52. 2997 56. Bahia SS, Holt PJ, Jackson D, Patterson BO, Hinchliffe RJ, Thompson MM, et al. 2998 Systematic Review and Meta-analysis of Long-term survival After Elective 2999 Infrarenal Abdominal Aortic Aneurysm Repair 1969-2011: 5 Year Survival 3000 Remains Poor Despite Advances in Medical Care and Treatment Strategies. Eur 3001 J Vasc Endovasc Surg. 2015;50(3):320-30. 3002 57. Goodney PP, Tavris D, Lucas FL, Gross T, Fisher ES, Finlayson SR. Causes of 3003 late mortality after endovascular and open surgical repair of infrarenal abdominal 3004 aortic aneurysms. J Vasc Surg. 2010;51(6):1340-7.e1. 3005 58. Schermerhorn ML, O'Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. 3006 Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare 3007 population. N Engl J Med. 2008;358(5):464-74. 3008 59. Siracuse JJ, Gill HL, Graham AR, Schneider DB, Connolly PH, Sedrakyan A, et 3009 al. Comparative safety of endovascular and open surgical repair of abdominal 3010 aortic aneurysms in low-risk male patients. J Vasc Surg. 2014;60(5):1154-8. 3011 60. Hicks CW, Wick EC, Canner JK, Black JH, 3rd, Arhuidese I, Qazi U, et al. 3012 Hospital-Level Factors Associated With Mortality After Endovascular and Open 3013 Abdominal Aortic Aneurysm Repair. JAMA Surg. 2015;150(7):632-6.
116
3014 61. Nguyen BN, Neville RF, Rahbar R, Amdur R, Sidawy AN. Comparison of 3015 outcomes for open abdominal aortic aneurysm repair and endovascular repair in 3016 patients with chronic renal insufficiency. Ann Surg. 2013;258(3):394-9. 3017 62. Stone DH, Goodney PP, Kalish J, Schanzer A, Indes J, Walsh DB, et al. Severity 3018 of chronic obstructive pulmonary disease is associated with adverse outcomes in 3019 patients undergoing elective abdominal aortic aneurysm repair. J Vasc Surg. 3020 2013;57(6):1531-6. 3021 63. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt 3022 B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and 3023 management of patients undergoing noncardiac surgery: executive summary: a 3024 report of the American College of Cardiology/American Heart Association Task 3025 Force on Practice Guidelines. Circulation. 2014;130(24):2215-45. 3026 64. Thompson AR, Peters N, Lovegrove RE, Ledwidge S, Kitching A, Magee TR, et 3027 al. Cardiopulmonary exercise testing provides a predictive tool for early and late 3028 outcomes in abdominal aortic aneurysm patients. Ann R Coll Surg Engl. 3029 2011;93(6):474-81. 3030 65. Prentis JM, Trenell MI, Jones DJ, Lees T, Clarke M, Snowden CP. Submaximal 3031 exercise testing predicts perioperative hospitalization after aortic aneurysm 3032 repair. J Vasc Surg. 2012;56(6):1564-70. 3033 66. Grant SW, Hickey GL, Wisely NA, Carlson ED, Hartley RA, Pichel AC, et al. 3034 Cardiopulmonary exercise testing and survival after elective abdominal aortic 3035 aneurysm repairdagger. Br J Anaesth. 2015;114(3):430-6. 3036 67. Elkalioubie A, Haulon S, Duhamel A, Rosa M, Rauch A, Staels B, et al. Meta- 3037 Analysis of Abdominal Aortic Aneurysm in Patients With Coronary Artery 3038 Disease. Am J Cardiol. 2015;116(9):1451-6. 3039 68. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, et al. 3040 Coronary-artery revascularization before elective major vascular surgery. N Engl 3041 J Med. 2004;351(27):2795-804. 3042 69. McFalls EO, Ward HB, Moritz TE, Littooy F, Santilli S, Rapp J, et al. Clinical 3043 factors associated with long-term mortality following vascular surgery: outcomes 3044 from the Coronary Artery Revascularization Prophylaxis (CARP) Trial. J Vasc 3045 Surg. 2007;46(4):694-700. 3046 70. Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 3047 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in 3048 Patients With Coronary Artery Disease: A Report of the American College of 3049 Cardiology/American Heart Association Task Force on Clinical Practice 3050 Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous 3051 Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass 3052 Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the 3053 Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 3054 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial 3055 Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non- 3056 ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on 3057 Perioperative Cardiovascular Evaluation and Management of Patients 3058 Undergoing Noncardiac Surgery. Circulation. 2016.
117
3059 71. Paty PS, Darling RC, 3rd, Chang BB, Lloyd WE, Kreienberg PB, Shah DM. 3060 Repair of large abdominal aortic aneurysm should be performed early after 3061 coronary artery bypass surgery. J Vasc Surg. 2000;31(2):253-9. 3062 72. Ohuchi H, Gojo S, Sato H, Kyo S. Simultaneous abdominal aortic aneurysm 3063 repair during the on-pump coronary artery bypass grafting. Ann Thorac 3064 Cardiovasc Surg. 2003;9(6):409-11. 3065 73. Morimoto K, Taniguchi I, Miyasaka S, Aoki T, Kato I, Yamaga T. Usefulness of 3066 one-stage coronary artery bypass grafting on the beating heart and abdominal 3067 aortic aneurysm repair. Ann Thorac Cardiovasc Surg. 2004;10(1):29-33. 3068 74. Kordowicz A, Ghosh J, Baguneid M. A single centre experience of simultaneous 3069 open abdominal aortic aneurysm and cardiac surgery. Interact Cardiovasc 3070 Thorac Surg. 2010;10(1):63-6. 3071 75. Devereaux PJ, Yang H, Guyatt GH, Leslie K, Villar JC, Monteri VM, et al. 3072 Rationale, design, and organization of the PeriOperative ISchemic Evaluation 3073 (POISE) trial: a randomized controlled trial of metoprolol versus placebo in 3074 patients undergoing noncardiac surgery. Am Heart J. 2006;152(2):223-30. 3075 76. Bouri S, Shun-Shin MJ, Cole GD, Mayet J, Francis DP. Meta-analysis of secure 3076 randomised controlled trials of beta-blockade to prevent perioperative death in 3077 non-cardiac surgery. Heart. 2014;100(6):456-64. 3078 77. Wijeysundera DN, Duncan D, Nkonde-Price C, Virani SS, Washam JB, 3079 Fleischmann KE, et al. Perioperative beta blockade in noncardiac surgery: a 3080 systematic review for the 2014 ACC/AHA guideline on perioperative 3081 cardiovascular evaluation and management of patients undergoing noncardiac 3082 surgery: a report of the American College of Cardiology/American Heart 3083 Association Task Force on practice guidelines. J Am Coll Cardiol. 3084 2014;64(22):2406-25. 3085 78. Smout J, Stansby G. Current practice in the use of antiplatelet agents in the peri- 3086 operative period by UK vascular surgeons. Ann R Coll Surg Engl. 2003;85(2):97- 3087 101. 3088 79. Lip GYH, Douketis JD. Perioperative management of patients receiving 3089 anticoagulants. In: Leung LLK, editor. UpToDate. UpToDate, Waltham, MA. 3090 (Accessed on January 1, 2016.). 3091 80. Meijer CA, Kokje VB, van Tongeren RB, Hamming JF, van Bockel JH, Moller 3092 GM, et al. An association between chronic obstructive pulmonary disease and 3093 abdominal aortic aneurysm beyond smoking: results from a case-control study. 3094 Eur J Vasc Endovasc Surg. 2012;44(2):153-7. 3095 81. Hertzer NR, Mascha EJ, Karafa MT, O'Hara PJ, Krajewski LP, Beven EG. Open 3096 infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience 3097 from 1989 to 1998. J Vasc Surg. 2002;35(6):1145-54. 3098 82. Upchurch GR, Jr., Proctor MC, Henke PK, Zajkowski P, Riles EM, Ascher MS, et 3099 al. Predictors of severe morbidity and death after elective abdominal aortic 3100 aneurysmectomy in patients with chronic obstructive pulmonary disease. J Vasc 3101 Surg. 2003;37(3):594-9. 3102 83. Compton CN, Dillavou ED, Sheehan MK, Rhee RY, Makaroun MS. Is abdominal 3103 aortic aneurysm repair appropriate in oxygen-dependent chronic obstructive 3104 pulmonary disease patients? J Vasc Surg. 2005;42(4):650-3.
118
3105 84. Qureshi MA, Greenberg RK, Mastracci TM, Eagleton MJ, Hernandez AV. 3106 Patients with chronic obstructive pulmonary disease have shorter survival but 3107 superior endovascular outcomes after endovascular aneurysm repair. J Vasc 3108 Surg. 2012;56(4):911-9.e2. 3109 85. Rigotti NA, Munafo MR, Stead LF. Interventions for smoking cessation in 3110 hospitalised patients. Cochrane Database Syst Rev. 2007(3):Cd001837. 3111 86. Thomsen T, Villebro N, Moller AM. Interventions for preoperative smoking 3112 cessation. Cochrane Database Syst Rev. 2014;3:Cd002294. 3113 87. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy 3114 for smoking cessation. Cochrane Database Syst Rev. 2004(3):Cd000146. 3115 88. Hughes JR, Stead LF, Hartmann-Boyce J, Cahill K, Lancaster T. Antidepressants 3116 for smoking cessation. Cochrane Database Syst Rev. 2014;1:Cd000031. 3117 89. Yuo TH, Sidaoui J, Marone LK, Avgerinos ED, Makaroun MS, Chaer RA. Limited 3118 survival in dialysis patients undergoing intact abdominal aortic aneurysm repair. J 3119 Vasc Surg. 2014;60(4):908-13.e1. 3120 90. Martin-Gonzalez T, Pincon C, Hertault A, Maurel B, Labbe D, Spear R, et al. 3121 Renal outcomes analysis after endovascular and open aortic aneurysm repair. J 3122 Vasc Surg. 2015;62(3):569-77. 3123 91. Lee JT, Varu VN, Tran K, Dalman RL. Renal function changes after 3124 snorkel/chimney repair of juxtarenal aneurysms. J Vasc Surg. 2014;60(3):563-70. 3125 92. Bown MJ, Norwood MG, Sayers RD. The management of abdominal aortic 3126 aneurysms in patients with concurrent renal impairment. Eur J Vasc Endovasc 3127 Surg. 2005;30(1):1-11. 3128 93. Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney 3129 injury: a KDIGO summary (Part 1). Crit Care. 2013;17(1):204. 3130 94. Comfere T, Sprung J, Kumar MM, Draper M, Wilson DP, Williams BA, et al. 3131 Angiotensin system inhibitors in a general surgical population. Anesth Analg. 3132 2005;100(3):636-44. 3133 95. Bertrand M, Godet G, Meersschaert K, Brun L, Salcedo E, Coriat P. Should the 3134 angiotensin II antagonists be discontinued before surgery? Anesth Analg. 3135 2001;92(1):26-30. 3136 96. Hersey P, Poullis M. Does the administration of mannitol prevent renal failure in 3137 open abdominal aortic aneurysm surgery? Interact Cardiovasc Thorac Surg. 3138 2008;7(5):906-9. 3139 97. Winkelmayer WC, Finkel KW. Prevention of acute kidney injury using vasoactive 3140 or antiplatelet treatment: three strikes and out? Jama. 2014;312(21):2221-2. 3141 98. Menting TP, Wever KE, Ozdemir-van Brunschot DM, Van der Vliet DJ, Rovers 3142 MM, Warle MC. Ischaemic preconditioning for the reduction of renal ischaemia 3143 reperfusion injury. Cochrane Database Syst Rev. 2017;3:CD010777. 3144 99. Desai M, Gurusamy KS, Ghanbari H, Hamilton G, Seifalian AM. Remote 3145 ischaemic preconditioning versus no remote ischaemic preconditioning for 3146 vascular and endovascular surgical procedures. Cochrane Database Syst Rev. 3147 2011(12):CD008472. 3148 100. Brevoord D, Kranke P, Kuijpers M, Weber N, Hollmann M, Preckel B. Remote 3149 ischemic conditioning to protect against ischemia-reperfusion injury: a systematic 3150 review and meta-analysis. PLoS One. 2012;7(7):e42179.
119
3151 101. Li L, Li G, Yu C, Li Y. The role of remote ischemic preconditioning on 3152 postoperative kidney injury in patients undergoing cardiac and vascular 3153 interventions: a meta-analysis. J Cardiothorac Surg. 2013;8:43. 3154 102. Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, et al. A simple 3155 risk score for prediction of contrast-induced nephropathy after percutaneous 3156 coronary intervention: development and initial validation. J Am Coll Cardiol. 3157 2004;44(7):1393-9. 3158 103. Rihal CS, Textor SC, Grill DE, Berger PB, Ting HH, Best PJ, et al. Incidence and 3159 prognostic importance of acute renal failure after percutaneous coronary 3160 intervention. Circulation. 2002;105(19):2259-64. 3161 104. Lameire N, Kellum JA. Contrast-induced acute kidney injury and renal support for 3162 acute kidney injury: a KDIGO summary (Part 2). Crit Care. 2013;17(1):205. 3163 105. Moore NN, Lapsley M, Norden AG, Firth JD, Gaunt ME, Varty K, et al. Does N- 3164 acetylcysteine prevent contrast-induced nephropathy during endovascular AAA 3165 repair? A randomized controlled pilot study. J Endovasc Ther. 2006;13(5):660-6. 3166 106. Patti G, Ricottini E, Nusca A, Colonna G, Pasceri V, D'Ambrosio A, et al. Short- 3167 term, high-dose Atorvastatin pretreatment to prevent contrast-induced 3168 nephropathy in patients with acute coronary syndromes undergoing 3169 percutaneous coronary intervention (from the ARMYDA-CIN [atorvastatin for 3170 reduction of myocardial damage during angioplasty--contrast-induced 3171 nephropathy] trial. Am J Cardiol. 2011;108(1):1-7. 3172 107. Leoncini M, Toso A, Maioli M, Tropeano F, Badia T, Villani S, et al. Early high- 3173 dose rosuvastatin and cardioprotection in the protective effect of rosuvastatin and 3174 antiplatelet therapy on contrast-induced acute kidney injury and myocardial 3175 damage in patients with acute coronary syndrome (PRATO-ACS) study. Am 3176 Heart J. 2014;168(5):792-7. 3177 108. Subramaniam RM, Suarez-Cuervo C, Wilson RF, Turban S, Zhang A, Sherrod C, 3178 et al. Effectiveness of Prevention Strategies for Contrast-Induced Nephropathy: A 3179 Systematic Review and Meta-analysis. Ann Intern Med. 2016;164(6):406-16. 3180 109. Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ. 3181 Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med. 3182 2003;348(6):491-9. 3183 110. Pannu N, Wiebe N, Tonelli M. Prophylaxis strategies for contrast-induced 3184 nephropathy. Jama. 2006;295(23):2765-79. 3185 111. Pannu N, Tonelli M. Strategies to reduce the risk of contrast nephropathy: an 3186 evidence-based approach. Curr Opin Nephrol Hypertens. 2006;15(3):285-90. 3187 112. Criado E, Kabbani L, Cho K. Catheter-less angiography for endovascular aortic 3188 aneurysm repair: a new application of carbon dioxide as a contrast agent. J Vasc 3189 Surg. 2008;48(3):527-34. 3190 113. Krasznai AG, Sigterman TA, Bouwman LH. Contrast Free Duplex-Assisted 3191 EVAR in Patients with Chronic Renal Insufficiency. Ann Vasc Dis. 2014;7(4):426- 3192 9. 3193 114. Kaladji A, Dumenil A, Mahe G, Castro M, Cardon A, Lucas A, et al. Safety and 3194 accuracy of endovascular aneurysm repair without pre-operative and intra- 3195 operative contrast agent. Eur J Vasc Endovasc Surg. 2015;49(3):255-61.
120
3196 115. De Rango P, Farchioni L, Fiorucci B, Lenti M. Diabetes and abdominal aortic 3197 aneurysms. Eur J Vasc Endovasc Surg. 2014;47(3):243-61. 3198 116. Berry AJ, Smith RB, 3rd, Weintraub WS, Chaikof EL, Dodson TF, Lumsden AB, 3199 et al. Age versus comorbidities as risk factors for complications after elective 3200 abdominal aortic reconstructive surgery. J Vasc Surg. 2001;33(2):345-52. 3201 117. Dardik A, Lin JW, Gordon TA, Williams GM, Perler BA. Results of elective 3202 abdominal aortic aneurysm repair in the 1990s: A population-based analysis of 3203 2335 cases. J Vasc Surg. 1999;30(6):985-95. 3204 118. Treiman GS, Treiman RL, Foran RF, Cossman DV, Cohen JL, Levin PM, et al. 3205 The influence of diabetes mellitus on the risk of abdominal aortic surgery. Am 3206 Surg. 1994;60(6):436-40. 3207 119. Axelrod DA, Upchurch GR, Jr., DeMonner S, Stanley JC, Khuri S, Daley J, et al. 3208 Perioperative cardiovascular risk stratification of patients with diabetes who 3209 undergo elective major vascular surgery. J Vasc Surg. 2002;35(5):894-901. 3210 120. Leurs LJ, Laheij RJ, Buth J. Influence of diabetes mellitus on the endovascular 3211 treatment of abdominal aortic aneurysms. J Endovasc Ther. 2005;12(3):288-96. 3212 121. FDA Drug Safety Communication: FDA revises warnings regarding use of the 3213 diabetes medicine metformin in certain patients with reduced kidney function. 3214 2016. 3215 122. Baerlocher MO, Asch M, Myers A. Five things to know about...metformin and 3216 intravenous contrast. CMAJ. 2013;185(1):E78. 3217 123. Milne AA, Adam DJ, Murphy WG, Ruckley CV. Effects of asymptomatic 3218 abdominal aortic aneurysm on the soluble coagulation system, platelet count and 3219 platelet activation. Eur J Vasc Endovasc Surg. 1999;17(5):434-7. 3220 124. Ho P, Ting AC, Cheng SW. Blood loss and transfusion in elective abdominal 3221 aortic aneurysm surgery. ANZ J Surg. 2004;74(8):631-4. 3222 125. Bradbury A, Adam D, Garrioch M, Brittenden J, Gillies T, Ruckley CV. Changes 3223 in platelet count, coagulation and fibrinogen associated with elective repair of 3224 asymptomatic abdominal aortic aneurysm and aortic reconstruction for occlusive 3225 disease. Eur J Vasc Endovasc Surg. 1997;13(4):375-80. 3226 126. Matsumura JS, Katzen BT, Sullivan TM, Dake MD, Naftel DC. Predictors of 3227 survival following open and endovascular repair of abdominal aortic aneurysms. 3228 Ann Vasc Surg. 2009;23(2):153-8. 3229 127. Wong YY, Golledge J, Flicker L, McCaul KA, Hankey GJ, van Bockxmeer FM, et 3230 al. Plasma total homocysteine is associated with abdominal aortic aneurysm and 3231 aortic diameter in older men. J Vasc Surg. 2013;58(2):364-70. 3232 128. Takagi H, Umemoto T. A meta-analysis of circulating homocysteine levels in 3233 subjects with versus without abdominal aortic aneurysm. Int Angiol. 3234 2015;34(3):229-37. 3235 129. Cao H, Hu X, Zhang Q, Li J, Wang J, Shao Y, et al. Homocysteine level and risk 3236 of abdominal aortic aneurysm: a meta-analysis. PLoS One. 2014;9(1):e85831. 3237 130. Golledge J, Tsao PS, Dalman RL, Norman PE. Circulating markers of abdominal 3238 aortic aneurysm presence and progression. Circulation. 2008;118(23):2382-92. 3239 131. Sidloff DA, Stather PW, Choke E, Bown MJ, Sayers RD. A systematic review and 3240 meta-analysis of the association between markers of hemostasis and abdominal 3241 aortic aneurysm presence and size. J Vasc Surg. 2014;59(2):528-35.e4.
121
3242 132. Stather PW, Sidloff DA, Dattani N, Gokani VJ, Choke E, Sayers RD, et al. Meta- 3243 analysis and meta-regression analysis of biomarkers for abdominal aortic 3244 aneurysm. Br J Surg. 2014;101(11):1358-72. 3245 133. Norman P, Spencer CA, Lawrence-Brown MM, Jamrozik K. C-reactive protein 3246 levels and the expansion of screen-detected abdominal aortic aneurysms in men. 3247 Circulation. 2004;110(7):862-6. 3248 134. Maegdefessel L, Azuma J, Toh R, Merk DR, Deng A, Chin JT, et al. Inhibition of 3249 microRNA-29b reduces murine abdominal aortic aneurysm development. J Clin 3250 Invest. 2012;122(2):497-506. 3251 135. Maegdefessel L, Dalman RL, Tsao PS. Pathogenesis of abdominal aortic 3252 aneurysms: microRNAs, proteases, genetic associations. Annu Rev Med. 3253 2014;65:49-62. 3254 136. Zhang W, Shang T, Huang C, Yu T, Liu C, Qiao T, et al. Plasma microRNAs 3255 serve as potential biomarkers for abdominal aortic aneurysm. Clin Biochem. 3256 2015;48(15):988-92. 3257 137. Cheuk BL, Cheng SW. Identification and characterization of microRNAs in 3258 vascular smooth muscle cells from patients with abdominal aortic aneurysms. J 3259 Vasc Surg. 2014;59(1):202-9. 3260 138. Htun NM, Peter K. Biomarkers for AAA: Encouraging steps but clinical relevance 3261 still to be delivered. Proteomics Clin Appl. 2014;8(9-10):732-4. 3262 139. Moris DN, Georgopoulos SE. Circulating biomarkers for abdominal aortic 3263 aneurysm: what did we learn in the last decade? Int Angiol. 2013;32(3):266-80. 3264 140. Clifton MA. Familial abdominal aortic aneurysms. Br J Surg. 1977;64(11):765-6. 3265 141. Wahlgren CM, Larsson E, Magnusson PK, Hultgren R, Swedenborg J. Genetic 3266 and environmental contributions to abdominal aortic aneurysm development in a 3267 twin population. J Vasc Surg. 2010;51(1):3-7. 3268 142. Hinterseher I, Tromp G, Kuivaniemi H. Genes and abdominal aortic aneurysm. 3269 Ann Vasc Surg. 2011;25(3):388-412. 3270 143. Duellman T, Warren CL, Matsumura J, Yang J. Analysis of multiple genetic 3271 polymorphisms in aggressive-growing and slow-growing abdominal aortic 3272 aneurysms. J Vasc Surg. 2014;60(3):613-21.e3. 3273 144. Golledge J, Kuivaniemi H. Genetics of abdominal aortic aneurysm. Curr Opin 3274 Cardiol. 2013;28(3):290-6. 3275 145. Young RP, Whittington CF, Hopkins RJ, Hay BA, Epton MJ, Black PN, et al. 3276 Chromosome 4q31 locus in COPD is also associated with lung cancer. Eur 3277 Respir J. 2010;36(6):1375-82. 3278 146. Yasuno K, Bakircioglu M, Low SK, Bilguvar K, Gaal E, Ruigrok YM, et al. 3279 Common variant near the endothelin receptor type A (EDNRA) gene is 3280 associated with intracranial aneurysm risk. Proc Natl Acad Sci U S A. 3281 2011;108(49):19707-12. 3282 147. Leeper NJ, Raiesdana A, Kojima Y, Kundu RK, Cheng H, Maegdefessel L, et al. 3283 Loss of CDKN2B promotes p53-dependent smooth muscle cell apoptosis and 3284 aneurysm formation. Arterioscler Thromb Vasc Biol. 2013;33(1):e1-e10. 3285 148. Bown MJ. Genomic insights into abdominal aortic aneurysms. Ann R Coll Surg 3286 Engl. 2014;96(6):405-14.
122
3287 149. Kojima Y, Downing K, Kundu R, Miller C, Dewey F, Lancero H, et al. Cyclin- 3288 dependent kinase inhibitor 2B regulates efferocytosis and atherosclerosis. J Clin 3289 Invest. 2014;124(3):1083-97. 3290 150. Maegdefessel L, Rayner KJ, Leeper NJ. MicroRNA regulation of vascular smooth 3291 muscle function and phenotype: early career committee contribution. Arterioscler 3292 Thromb Vasc Biol. 2015;35(1):2-6. 3293 151. Toghill BJ, Saratzis A, Harrison SC, Verissimo AR, Mallon EB, Bown MJ. The 3294 potential role of DNA methylation in the pathogenesis of abdominal aortic 3295 aneurysm. Atherosclerosis. 2015;241(1):121-9. 3296 152. Kontusaari S, Tromp G, Kuivaniemi H, Romanic AM, Prockop DJ. A mutation in 3297 the gene for type III procollagen (COL3A1) in a family with aortic aneurysms. J 3298 Clin Invest. 1990;86(5):1465-73. 3299 153. Kontusaari S, Tromp G, Kuivaniemi H, Ladda RL, Prockop DJ. Inheritance of an 3300 RNA splicing mutation (G+ 1 IVS20) in the type III procollagen gene (COL3A1) in 3301 a family having aortic aneurysms and easy bruisability: phenotypic overlap 3302 between familial arterial aneurysms and Ehlers-Danlos syndrome type IV. Am J 3303 Hum Genet. 1990;47(1):112-20. 3304 154. Dietz HC, Cutting GR, Pyeritz RE, Maslen CL, Sakai LY, Corson GM, et al. 3305 Marfan syndrome caused by a recurrent de novo missense mutation in the 3306 fibrillin gene. Nature. 1991;352(6333):337-9. 3307 155. Quill DS, Colgan MP, Sumner DS. Ultrasonic screening for the detection of 3308 abdominal aortic aneurysms. Surg Clin North Am. 1989;69(4):713-20. 3309 156. Graeve AH, Carpenter CM, Wicks JD, Edwards WS. Discordance in the sizing of 3310 abdominal aortic aneurysm and its significance. Am J Surg. 1982;144(6):627-34. 3311 157. Wilmink AB, Forshaw M, Quick CR, Hubbard CS, Day NE. Accuracy of serial 3312 screening for abdominal aortic aneurysms by ultrasound. J Med Screen. 3313 2002;9(3):125-7. 3314 158. Jaakkola P, Hippelainen M, Farin P, Rytkonen H, Kainulainen S, Partanen K. 3315 Interobserver variability in measuring the dimensions of the abdominal aorta: 3316 comparison of ultrasound and computed tomography. Eur J Vasc Endovasc 3317 Surg. 1996;12(2):230-7. 3318 159. Singh K, Jacobsen BK, Solberg S, Bonaa KH, Kumar S, Bajic R, et al. Intra- and 3319 interobserver variability in the measurements of abdominal aortic and common 3320 iliac artery diameter with computed tomography. The Tromso study. Eur J Vasc 3321 Endovasc Surg. 2003;25(5):399-407. 3322 160. Wanhainen A, Bergqvist D, Bjorck M. Measuring the abdominal aorta with 3323 ultrasonography and computed tomography - difference and variability. Eur J 3324 Vasc Endovasc Surg. 2002;24(5):428-34. 3325 161. Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, Acher CW, et al. 3326 Variability in measurement of abdominal aortic aneurysms. Abdominal Aortic 3327 Aneurysm Detection and Management Veterans Administration Cooperative 3328 Study Group. J Vasc Surg. 1995;21(6):945-52. 3329 162. Hendy K, Gunnarson R, Golledge J. Growth rates of small abdominal aortic 3330 aneurysms assessed by computerised tomography--a systematic literature 3331 review. Atherosclerosis. 2014;235(1):182-8.
123
3332 163. Wang XL, Thompson MM, Dole WP, Dalman RL, Zalewski A. Standardization of 3333 outcome measures in clinical trials of pharmacological treatment for abdominal 3334 aortic aneurysm. Expert Rev Cardiovasc Ther. 2012;10(10):1251-60. 3335 164. Ihara T, Komori K, Yamamoto K, Kobayashi M, Banno H, Kodama A. Three- 3336 dimensional workstation is useful for measuring the correct size of abdominal 3337 aortic aneurysm diameters. Ann Vasc Surg. 2013;27(2):154-61. 3338 165. Lederle FA, Johnson GR, Wilson SE, Gordon IL, Chute EP, Littooy FN, et al. 3339 Relationship of age, gender, race, and body size to infrarenal aortic diameter. 3340 The Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative 3341 Study Investigators. J Vasc Surg. 1997;26(4):595-601. 3342 166. Lindholt JS, Vammen S, Juul S, Henneberg EW, Fasting H. The validity of 3343 ultrasonographic scanning as screening method for abdominal aortic aneurysm. 3344 Eur J Vasc Endovasc Surg. 1999;17(6):472-5. 3345 167. Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of 3346 emergency ultrasound for abdominal aortic aneurysm over two years. Acad 3347 Emerg Med. 2003;10(8):867-71. 3348 168. Costantino TG, Bruno EC, Handly N, Dean AJ. Accuracy of emergency medicine 3349 ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med. 3350 2005;29(4):455-60. 3351 169. Reed MJ, Cheung LT. Emergency department led emergency ultrasound may 3352 improve the time to diagnosis in patients presenting with a ruptured abdominal 3353 aortic aneurysm. Eur J Emerg Med. 2014;21(4):272-5. 3354 170. Bonnafy T, Lacroix P, Desormais I, Labrunie A, Marin B, Leclerc A, et al. 3355 Reliability of the measurement of the abdominal aortic diameter by novice 3356 operators using a pocket-sized ultrasound system. Arch Cardiovasc Dis. 3357 2013;106(12):644-50. 3358 171. Blaivas M, Theodoro D. Frequency of incomplete abdominal aorta visualization 3359 by emergency department bedside ultrasound. Acad Emerg Med. 3360 2004;11(1):103-5. 3361 172. Adam DJ, Bradbury AW, Stuart WP, Woodburn KR, Murie JA, Jenkins AM, et al. 3362 The value of computed tomography in the assessment of suspected ruptured 3363 abdominal aortic aneurysm. J Vasc Surg. 1998;27(3):431-7. 3364 173. Biancari F, Paone R, Venermo M, D'Andrea V, Perala J. Diagnostic accuracy of 3365 computed tomography in patients with suspected abdominal aortic aneurysm 3366 rupture. Eur J Vasc Endovasc Surg. 2013;45(3):227-30. 3367 174. Taheri MS, Haghighatkhah H, Pourghorban R, Hosseini A. Multidetector 3368 computed tomography findings of abdominal aortic aneurysm and its 3369 complications: a pictorial review. Emerg Radiol. 2013;20(5):443-51. 3370 175. Darling RC, Messina CR, Brewster DC, Ottinger LW. Autopsy study of 3371 unoperated abdominal aortic aneurysms. The case for early resection. 3372 Circulation. 1977;56(3 Suppl):II161-4. 3373 176. Limet R, Sakalihassan N, Albert A. Determination of the expansion rate and 3374 incidence of rupture of abdominal aortic aneurysms. J Vasc Surg. 3375 1991;14(4):540-8.
124
3376 177. Hatakeyama T, Shigematsu H, Muto T. Risk factors for rupture of abdominal 3377 aortic aneurysm based on three-dimensional study. J Vasc Surg. 3378 2001;33(3):453-61. 3379 178. Sonesson B, Sandgren T, Lanne T. Abdominal aortic aneurysm wall mechanics 3380 and their relation to risk of rupture. Eur J Vasc Endovasc Surg. 1999;18(6):487- 3381 93. 3382 179. Roccabianca S, Figueroa CA, Tellides G, Humphrey JD. Quantification of 3383 regional differences in aortic stiffness in the aging human. J Mech Behav Biomed 3384 Mater. 2014;29:618-34. 3385 180. Raaz U, Zollner AM, Schellinger IN, Toh R, Nakagami F, Brandt M, et al. 3386 Segmental aortic stiffening contributes to experimental abdominal aortic 3387 aneurysm development. Circulation. 2015;131(20):1783-95. 3388 181. Hall AJ, Busse EF, McCarville DJ, Burgess JJ. Aortic wall tension as a predictive 3389 factor for abdominal aortic aneurysm rupture: improving the selection of patients 3390 for abdominal aortic aneurysm repair. Ann Vasc Surg. 2000;14(2):152-7. 3391 182. Fillinger MF, Raghavan ML, Marra SP, Cronenwett JL, Kennedy FE. In vivo 3392 analysis of mechanical wall stress and abdominal aortic aneurysm rupture risk. J 3393 Vasc Surg. 2002;36(3):589-97. 3394 183. Fillinger MF, Marra SP, Raghavan ML, Kennedy FE. Prediction of rupture risk in 3395 abdominal aortic aneurysm during observation: wall stress versus diameter. J 3396 Vasc Surg. 2003;37(4):724-32. 3397 184. Venkatasubramaniam AK, Fagan MJ, Mehta T, Mylankal KJ, Ray B, Kuhan G, et 3398 al. A comparative study of aortic wall stress using finite element analysis for 3399 ruptured and non-ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc 3400 Surg. 2004;28(2):168-76. 3401 185. Wassef M, Baxter BT, Chisholm RL, Dalman RL, Fillinger MF, Heinecke J, et al. 3402 Pathogenesis of abdominal aortic aneurysms: a multidisciplinary research 3403 program supported by the National Heart, Lung, and Blood Institute. J Vasc Surg. 3404 2001;34(4):730-8. 3405 186. Raghavan ML, Vorp DA, Federle MP, Makaroun MS, Webster MW. Wall stress 3406 distribution on three-dimensionally reconstructed models of human abdominal 3407 aortic aneurysm. J Vasc Surg. 2000;31(4):760-9. 3408 187. Vande Geest JP, Wang DH, Wisniewski SR, Makaroun MS, Vorp DA. Towards a 3409 noninvasive method for determination of patient-specific wall strength distribution 3410 in abdominal aortic aneurysms. Ann Biomed Eng. 2006;34(7):1098-106. 3411 188. Malkawi AH, Hinchliffe RJ, Xu Y, Holt PJ, Loftus IM, Thompson MM. Patient- 3412 specific biomechanical profiling in abdominal aortic aneurysm development and 3413 rupture. J Vasc Surg. 2010;52(2):480-8. 3414 189. Kok AM, Nguyen VL, Speelman L, Brands PJ, Schurink GW, van de Vosse FN, 3415 et al. Feasibility of wall stress analysis of abdominal aortic aneurysms using 3416 three-dimensional ultrasound. J Vasc Surg. 2015;61(5):1175-84. 3417 190. Goergen CJ, Azuma J, Barr KN, Magdefessel L, Kallop DY, Gogineni A, et al. 3418 Influences of aortic motion and curvature on vessel expansion in murine 3419 experimental aneurysms. Arterioscler Thromb Vasc Biol. 2011;31(2):270-9. 3420 191. Les AS, Shadden SC, Figueroa CA, Park JM, Tedesco MM, Herfkens RJ, et al. 3421 Quantification of hemodynamics in abdominal aortic aneurysms during rest and
125
3422 exercise using magnetic resonance imaging and computational fluid dynamics. 3423 Ann Biomed Eng. 2010;38(4):1288-313. 3424 192. Les AS, Yeung JJ, Schultz GM, Herfkens RJ, Dalman RL, Taylor CA. 3425 Supraceliac and Infrarenal Aortic Flow in Patients with Abdominal Aortic 3426 Aneurysms: Mean Flows, Waveforms, and Allometric Scaling Relationships. 3427 Cardiovasc Eng Technol. 2010;1(1). 3428 193. Suh GY, Les AS, Tenforde AS, Shadden SC, Spilker RL, Yeung JJ, et al. 3429 Quantification of particle residence time in abdominal aortic aneurysms using 3430 magnetic resonance imaging and computational fluid dynamics. Ann Biomed 3431 Eng. 2011;39(2):864-83. 3432 194. Yeung JJ, Kim HJ, Abbruzzese TA, Vignon-Clementel IE, Draney-Blomme MT, 3433 Yeung KK, et al. Aortoiliac hemodynamic and morphologic adaptation to chronic 3434 spinal cord injury. J Vasc Surg. 2006;44(6):1254-65. 3435 195. Erhart P, Grond-Ginsbach C, Hakimi M, Lasitschka F, Dihlmann S, Bockler D, et 3436 al. Finite element analysis of abdominal aortic aneurysms: predicted rupture risk 3437 correlates with aortic wall histology in individual patients. J Endovasc Ther. 3438 2014;21(4):556-64. 3439 196. Erhart P, Hyhlik-Durr A, Geisbusch P, Kotelis D, Muller-Eschner M, Gasser TC, 3440 et al. Finite element analysis in asymptomatic, symptomatic, and ruptured 3441 abdominal aortic aneurysms: in search of new rupture risk predictors. Eur J Vasc 3442 Endovasc Surg. 2015;49(3):239-45. 3443 197. McGloughlin TM, Doyle BJ. New approaches to abdominal aortic aneurysm 3444 rupture risk assessment: engineering insights with clinical gain. Arterioscler 3445 Thromb Vasc Biol. 2010;30(9):1687-94. 3446 198. Xenos M, Labropoulos N, Rambhia S, Alemu Y, Einav S, Tassiopoulos A, et al. 3447 Progression of abdominal aortic aneurysm towards rupture: refining clinical risk 3448 assessment using a fully coupled fluid-structure interaction method. Ann Biomed 3449 Eng. 2015;43(1):139-53. 3450 199. Figueroa CA, Baek S, Taylor CA, Humphrey JD. A Computational Framework for 3451 Fluid-Solid-Growth Modeling in Cardiovascular Simulations. Comput Methods 3452 Appl Mech Eng. 2009;198(45-46):3583-602. 3453 200. Stenbaek J, Kalin B, Swedenborg J. Growth of thrombus may be a better 3454 predictor of rupture than diameter in patients with abdominal aortic aneurysms. 3455 Eur J Vasc Endovasc Surg. 2000;20(5):466-9. 3456 201. Golledge J, Iyer V, Jenkins J, Bradshaw B, Cronin O, Walker PJ. Thrombus 3457 volume is similar in patients with ruptured and intact abdominal aortic aneurysms. 3458 J Vasc Surg. 2014;59(2):315-20. 3459 202. Courtois A, Nusgens BV, Hustinx R, Namur G, Gomez P, Somja J, et al. 18F- 3460 FDG uptake assessed by PET/CT in abdominal aortic aneurysms is associated 3461 with cellular and molecular alterations prefacing wall deterioration and rupture. J 3462 Nucl Med. 2013;54(10):1740-7. 3463 203. Barwick TD, Lyons OT, Mikhaeel NG, Waltham M, O'Doherty MJ. 18F-FDG PET- 3464 CT uptake is a feature of both normal diameter and aneurysmal aortic wall and is 3465 not related to aneurysm size. Eur J Nucl Med Mol Imaging. 2014;41(12):2310-8.
126
3466 204. Shi S, Orbay H, Yang Y, Graves SA, Nayak TR, Hong H, et al. PET Imaging of 3467 Abdominal Aortic Aneurysm with 64Cu-Labeled Anti-CD105 Antibody Fab 3468 Fragment. J Nucl Med. 2015;56(6):927-32. 3469 205. Thompson AR, Cooper JA, Ashton HA, Hafez H. Growth rates of small 3470 abdominal aortic aneurysms correlate with clinical events. Br J Surg. 3471 2010;97(1):37-44. 3472 206. Tedesco MM, Terashima M, Blankenberg FG, Levashova Z, Spin JM, Backer 3473 MV, et al. Analysis of in situ and ex vivo vascular endothelial growth factor 3474 receptor expression during experimental aortic aneurysm progression. 3475 Arterioscler Thromb Vasc Biol. 2009;29(10):1452-7. 3476 207. Kitagawa T, Kosuge H, Chang E, James ML, Yamamoto T, Shen B, et al. 3477 Integrin-targeted molecular imaging of experimental abdominal aortic aneurysms 3478 by (18)F-labeled Arg-Gly-Asp positron-emission tomography. Circ Cardiovasc 3479 Imaging. 2013;6(6):950-6. 3480 208. Kitagawa T, Kosuge H, Uchida M, Dua MM, Iida Y, Dalman RL, et al. RGD- 3481 conjugated human ferritin nanoparticles for imaging vascular inflammation and 3482 angiogenesis in experimental carotid and aortic disease. Mol Imaging Biol. 3483 2012;14(3):315-24. 3484 209. Golestani R, Razavian M, Nie L, Zhang J, Jung JJ, Ye Y, et al. Imaging vessel 3485 wall biology to predict outcome in abdominal aortic aneurysm. Circ Cardiovasc 3486 Imaging. 2015;8(1):e002471. 3487 210. Nguyen VL, Backes WH, Kooi ME, Wishaupt MC, Hellenthal FA, Bosboom EM, 3488 et al. Quantification of abdominal aortic aneurysm wall enhancement with 3489 dynamic contrast-enhanced MRI: feasibility, reproducibility, and initial 3490 experience. J Magn Reson Imaging. 2014;39(6):1449-56. 3491 211. Feringa HH, Bax JJ, Boersma E, Kertai MD, Meij SH, Galal W, et al. High-dose 3492 beta-blockers and tight heart rate control reduce myocardial ischemia and 3493 troponin T release in vascular surgery patients. Circulation. 2006;114(1 3494 Suppl):I344-9. 3495 212. Buijs RV, Willems TP, Tio RA, Boersma HH, Tielliu IF, Slart RH, et al. Current 3496 state of experimental imaging modalities for risk assessment of abdominal aortic 3497 aneurysm. J Vasc Surg. 2013;57(3):851-9. 3498 213. McBride OM, Berry C, Burns P, Chalmers RT, Doyle B, Forsythe R, et al. MRI 3499 using ultrasmall superparamagnetic particles of iron oxide in patients under 3500 surveillance for abdominal aortic aneurysms to predict rupture or surgical repair: 3501 MRI for abdominal aortic aneurysms to predict rupture or surgery-the MA(3)RS 3502 study. Open Heart. 2015;2(1):e000190. 3503 214. Larsson E, Labruto F, Gasser TC, Swedenborg J, Hultgren R. Analysis of aortic 3504 wall stress and rupture risk in patients with abdominal aortic aneurysm with a 3505 gender perspective. J Vasc Surg. 2011;54(2):295-9. 3506 215. Lo RC, Lu B, Fokkema MT, Conrad M, Patel VI, Fillinger M, et al. Relative 3507 importance of aneurysm diameter and body size for predicting abdominal aortic 3508 aneurysm rupture in men and women. J Vasc Surg. 2014;59(5):1209-16. 3509 216. Scott RA, Bridgewater SG, Ashton HA. Randomized clinical trial of screening for 3510 abdominal aortic aneurysm in women. Br J Surg. 2002;89(3):283-5.
127
3511 217. Lindholt JS, Juul S, Fasting H, Henneberg EW. Hospital costs and benefits of 3512 screening for abdominal aortic aneurysms. Results from a randomised population 3513 screening trial. Eur J Vasc Endovasc Surg. 2002;23(1):55-60. 3514 218. Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA, et al. The 3515 Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal 3516 aortic aneurysm screening on mortality in men: a randomised controlled trial. 3517 Lancet. 2002;360(9345):1531-9. 3518 219. Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screening on the 3519 incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized 3520 controlled study. Br J Surg. 1995;82(8):1066-70. 3521 220. Scott RA, Vardulaki KA, Walker NM, Day NE, Duffy SW, Ashton HA. The long- 3522 term benefits of a single scan for abdominal aortic aneurysm (AAA) at age 65. 3523 Eur J Vasc Endovasc Surg. 2001;21(6):535-40. 3524 221. Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer CA, Tuohy RJ, 3525 et al. Population based randomised controlled trial on impact of screening on 3526 mortality from abdominal aortic aneurysm. Bmj. 2004;329(7477):1259. 3527 222. Guirguis-Blake JM, Beil TL, Sun X, Senger CA, Whitlock EP. Primary Care 3528 Screening for Abdominal Aortic Aneurysm: A Systematic Evidence Review for 3529 the U.S. Preventive Services Task Force [Internet]. Agency for Healthcare 3530 Research and Quality (US). 2014;14-05202-EF-1. 3531 223. Thompson SG, Ashton HA, Gao L, Buxton MJ, Scott RA. Final follow-up of the 3532 Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal 3533 aortic aneurysm screening. Br J Surg. 2012;99(12):1649-56. 3534 224. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane 3535 Database Syst Rev. 2007(2):Cd002945. 3536 225. Wanhainen A, Lundkvist J, Bergqvist D, Bjorck M. Cost-effectiveness of 3537 screening women for abdominal aortic aneurysm. J Vasc Surg. 2006;43(5):908- 3538 14. 3539 226. Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for abdominal aortic 3540 aneurysm: a best-evidence systematic review for the U.S. Preventive Services 3541 Task Force. Ann Intern Med. 2005;142(3):203-11. 3542 227. LeFevre ML. Screening for abdominal aortic aneurysm: U.S. Preventive Services 3543 Task Force recommendation statement. Ann Intern Med. 2014;161(4):281-90. 3544 228. Shreibati JB, Baker LC, Hlatky MA, Mell MW. Impact of the Screening Abdominal 3545 Aortic Aneurysms Very Efficiently (SAAAVE) Act on abdominal ultrasonography 3546 use among Medicare beneficiaries. Arch Intern Med. 2012;172(19):1456-62. 3547 229. Mell MW, Hlatky MA, Shreibati JB, Dalman RL, Baker LC. Late diagnosis of 3548 abdominal aortic aneurysms substantiates underutilization of abdominal aortic 3549 aneurysm screening for Medicare beneficiaries. J Vasc Surg. 2013;57(6):1519- 3550 23, 23.e1. 3551 230. Hye RJ, Smith AE, Wong GH, Vansomphone SS, Scott RD, Kanter MH. 3552 Leveraging the electronic medical record to implement an abdominal aortic 3553 aneurysm screening program. J Vasc Surg. 2014;59(6):1535-42. 3554 231. Hager J, Lanne T, Carlsson P, Lundgren F. Lower prevalence than expected 3555 when screening 70-year-old men for abdominal aortic aneurysm. Eur J Vasc 3556 Endovasc Surg. 2013;46(4):453-9.
128
3557 232. Davis M, Harris M, Earnshaw JJ. Implementation of the National Health Service 3558 Abdominal Aortic Aneurysm Screening Program in England. J Vasc Surg. 3559 2013;57(5):1440-5. 3560 233. Spronk S, van Kempen BJ, Boll AP, Jorgensen JJ, Hunink MG, Kristiansen IS. 3561 Cost-effectiveness of screening for abdominal aortic aneurysm in the 3562 Netherlands and Norway. Br J Surg. 2011;98(11):1546-55. 3563 234. Glover MJ, Kim LG, Sweeting MJ, Thompson SG, Buxton MJ. Cost-effectiveness 3564 of the National Health Service Abdominal Aortic Aneurysm Screening 3565 Programme in England. Br J Surg. 2014;101(8):976-82. 3566 235. Svensjo S, Mani K, Bjorck M, Lundkvist J, Wanhainen A. Screening for 3567 abdominal aortic aneurysm in 65-year-old men remains cost-effective with 3568 contemporary epidemiology and management. Eur J Vasc Endovasc Surg. 3569 2014;47(4):357-65. 3570 236. Svensjo S, Bjorck M, Wanhainen A. Editor's choice: five-year outcomes in men 3571 screened for abdominal aortic aneurysm at 65 years of age: a population-based 3572 cohort study. Eur J Vasc Endovasc Surg. 2014;47(1):37-44. 3573 237. Svensjo S, Bjorck M, Wanhainen A. Update on screening for abdominal aortic 3574 aneurysm: a topical review. Eur J Vasc Endovasc Surg. 2014;48(6):659-67. 3575 238. Aboyans V, Bataille V, Bliscaux P, Ederhy S, Filliol D, Honton B, et al. 3576 Effectiveness of screening for abdominal aortic aneurysm during 3577 echocardiography. Am J Cardiol. 2014;114(7):1100-4. 3578 239. Grondal N, Sogaard R, Lindholt JS. Baseline prevalence of abdominal aortic 3579 aneurysm, peripheral arterial disease and hypertension in men aged 65-74 years 3580 from a population screening study (VIVA trial). Br J Surg. 2015;102(8):902-6. 3581 240. Zarrouk M, Gottsater A, Malina M, Holst J. Academic vascular unit collaboration 3582 with advertising agency yields higher compliance in screening for abdominal 3583 aortic aneurysm. J Med Screen. 2014;21(4):216-8. 3584 241. Zarrouk M, Holst J, Malina M, Lindblad B, Wann-Hansson C, Rosvall M, et al. 3585 The importance of socioeconomic factors for compliance and outcome at 3586 screening for abdominal aortic aneurysm in 65-year-old men. J Vasc Surg. 3587 2013;58(1):50-5. 3588 242. Couto E, Duffy SW, Ashton HA, Walker NM, Myles JP, Scott RA, et al. 3589 Probabilities of progression of aortic aneurysms: estimates and implications for 3590 screening policy. J Med Screen. 2002;9(1):40-2. 3591 243. Powell JT, Brown LC, Forbes JF, Fowkes FG, Greenhalgh RM, Ruckley CV, et 3592 al. Final 12-year follow-up of surgery versus surveillance in the UK Small 3593 Aneurysm Trial. Br J Surg. 2007;94(6):702-8. 3594 244. Lederle FA, Johnson GR, Wilson SE, Chute EP, Hye RJ, Makaroun MS, et al. 3595 The aneurysm detection and management study screening program: validation 3596 cohort and final results. Aneurysm Detection and Management Veterans Affairs 3597 Cooperative Study Investigators. Arch Intern Med. 2000;160(10):1425-30. 3598 245. Brady AR, Thompson SG, Fowkes FG, Greenhalgh RM, Powell JT. Abdominal 3599 aortic aneurysm expansion: risk factors and time intervals for surveillance. 3600 Circulation. 2004;110(1):16-21. 3601 246. Thompson SG, Brown LC, Sweeting MJ, Bown MJ, Kim LG, Glover MJ, et al. 3602 Systematic review and meta-analysis of the growth and rupture rates of small
129
3603 abdominal aortic aneurysms: implications for surveillance intervals and their cost- 3604 effectiveness. Health Technol Assess. 2013;17(41):1-118. 3605 247. United Kingdom Small Aneurysm Trial P. Long-term outcomes of immediate 3606 repair compared with surveillance of small abdominal aortic aneurysms. N Engl J 3607 Med. 2002;346(19):1445-52. 3608 248. Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, Acher CW, et al. 3609 Immediate repair compared with surveillance of small abdominal aortic 3610 aneurysms. N Engl J Med. 2002;346(19):1437-44. 3611 249. Dua A, Kuy S, Lee CJ, Upchurch GR, Jr., Desai SS. Epidemiology of aortic 3612 aneurysm repair in the United States from 2000 to 2010. J Vasc Surg. 3613 2014;59(6):1512-7. 3614 250. Buck DB, van Herwaarden JA, Schermerhorn ML, Moll FL. Endovascular 3615 treatment of abdominal aortic aneurysms. Nat Rev Cardiol. 2014;11(2):112-23. 3616 251. Cao P, De Rango P, Verzini F, Parlani G, Romano L, Cieri E, et al. Comparison 3617 of surveillance versus aortic endografting for small aneurysm repair (CAESAR): 3618 results from a randomised trial. Eur J Vasc Endovasc Surg. 2011;41(1):13-25. 3619 252. Ouriel K, Clair DG, Kent KC, Zarins CK, Positive Impact of Endovascular Options 3620 for treating Aneurysms Early I. Endovascular repair compared with surveillance 3621 for patients with small abdominal aortic aneurysms. J Vasc Surg. 3622 2010;51(5):1081-7. 3623 253. Filardo G PJ, Martinez MA, Ballard DJ. Surgery for small asymptomatic 3624 abdominal aortic aneurysms. Cochrane Database Syst Rev. 2015;2:CD001835. 3625 254. Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson 3626 SG. Systematic review and meta-analysis of growth rates of small abdominal 3627 aortic aneurysms. Br J Surg. 2011;98(5):609-18. 3628 255. Sweeting MJ, Thompson SG, Brown LC, Powell JT, collaborators R. Meta- 3629 analysis of individual patient data to examine factors affecting growth and rupture 3630 of small abdominal aortic aneurysms. Br J Surg. 2012;99(5):655-65. 3631 256. Bhak RH, Wininger M, Johnson GR, Lederle FA, Messina LM, Ballard DJ, et al. 3632 Factors associated with small abdominal aortic aneurysm expansion rate. JAMA 3633 Surg. 2015;150(1):44-50. 3634 257. Chang JB, Stein TA, Liu JP, Dunn ME. Risk factors associated with rapid growth 3635 of small abdominal aortic aneurysms. Surgery. 1997;121(2):117-22. 3636 258. MacSweeney ST, O'Meara M, Alexander C, O'Malley MK, Powell JT, Greenhalgh 3637 RM. High prevalence of unsuspected abdominal aortic aneurysm in patients with 3638 confirmed symptomatic peripheral or cerebral arterial disease. Br J Surg. 3639 1993;80(5):582-4. 3640 259. Brady AR, Thompson SG, Fowkes FG, Greenhalgh RM, Powell JT, Participants 3641 UKSAT. Abdominal aortic aneurysm expansion: risk factors and time intervals for 3642 surveillance. Circulation. 2004;110(1):16-21. 3643 260. Propanolol Aneurysm Trial I. Propranolol for small abdominal aortic aneurysms: 3644 results of a randomized trial. J Vasc Surg. 2002;35(1):72-9. 3645 261. Lindholt JS, Henneberg EW, Juul S, Fasting H. Impaired results of a randomised 3646 double blinded clinical trial of propranolol versus placebo on the expansion rate 3647 of small abdominal aortic aneurysms. Int Angiol. 1999;18(1):52-7.
130
3648 262. Ferguson CD, Clancy P, Bourke B, Walker PJ, Dear A, Buckenham T, et al. 3649 Association of statin prescription with small abdominal aortic aneurysm 3650 progression. Am Heart J. 2010;159(2):307-13. 3651 263. Takagi H, Yamamoto H, Iwata K, Goto S, Umemoto T, Group A. Effects of statin 3652 therapy on abdominal aortic aneurysm growth: a meta-analysis and meta- 3653 regression of observational comparative studies. Eur J Vasc Endovasc Surg. 3654 2012;44(3):287-92. 3655 264. Wemmelund H, Hogh A, Hundborg HH, Thomsen RW, Johnsen SP, Lindholt JS. 3656 Statin use and rupture of abdominal aortic aneurysm. Br J Surg. 3657 2014;101(8):966-75. 3658 265. Periard D, Guessous I, Mazzolai L, Haesler E, Monney P, Hayoz D. Reduction of 3659 small infrarenal abdominal aortic aneurysm expansion rate by statins. Vasa. 3660 2012;41(1):35-42. 3661 266. Sweeting MJ, Thompson SG, Brown LC, Greenhalgh RM, Powell JT. Use of 3662 angiotensin converting enzyme inhibitors is associated with increased growth 3663 rate of abdominal aortic aneurysms. J Vasc Surg. 2010;52(1):1-4. 3664 267. Kristensen KE, Torp-Pedersen C, Gislason GH, Egfjord M, Rasmussen HB, 3665 Hansen PR. Angiotensin-converting enzyme inhibitors and angiotensin II 3666 receptor blockers in patients with abdominal aortic aneurysms: nation-wide 3667 cohort study. Arterioscler Thromb Vasc Biol. 2015;35(3):733-40. 3668 268. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J 3669 Vasc Surg. 2002;35(1):72-9. 3670 269. Lederle FA, Taylor BC. ACE inhibitors and aortic rupture. Lancet. 3671 2006;368(9547):1571. 3672 270. Lindholt JS, Ashton HA, Scott RA. Indicators of infection with Chlamydia 3673 pneumoniae are associated with expansion of abdominal aortic aneurysms. J 3674 Vasc Surg. 2001;34(2):212-5. 3675 271. Karlsson L, Gnarpe J, Bergqvist D, Lindback J, Parsson H. The effect of 3676 azithromycin and Chlamydophilia pneumonia infection on expansion of small 3677 abdominal aortic aneurysms--a prospective randomized double-blind trial. J Vasc 3678 Surg. 2009;50(1):23-9. 3679 272. Curci JA, Mao D, Bohner DG, Allen BT, Rubin BG, Reilly JM, et al. Preoperative 3680 treatment with doxycycline reduces aortic wall expression and activation of matrix 3681 metalloproteinases in patients with abdominal aortic aneurysms. J Vasc Surg. 3682 2000;31(2):325-42. 3683 273. Baxter BT, Pearce WH, Waltke EA, Littooy FN, Hallett JW, Jr., Kent KC, et al. 3684 Prolonged administration of doxycycline in patients with small asymptomatic 3685 abdominal aortic aneurysms: report of a prospective (Phase II) multicenter study. 3686 J Vasc Surg. 2002;36(1):1-12. 3687 274. Meijer CA, Stijnen T, Wasser MN, Hamming JF, van Bockel JH, Lindeman JH, et 3688 al. Doxycycline for stabilization of abdominal aortic aneurysms: a randomized 3689 trial. Ann Intern Med. 2013;159(12):815-23. 3690 275. Dalman RL, Tedesco MM, Myers J, Taylor CA. AAA disease: mechanism, 3691 stratification, and treatment. Ann N Y Acad Sci. 2006;1085:92-109.
131
3692 276. Swanson RJ, Littooy FN, Hunt TK, Stoney RJ. Laparotomy as a precipitating 3693 factor in the rupture of intra-abdominal aneurysms. Arch Surg. 1980;115(3):299- 3694 304. 3695 277. Cohen JR, Perry MO, Hariri R, Holt J, Alvarez O. Aortic collagenase activity as 3696 affected by laparotomy, cecal resection, aortic mobilization, and aortotomy in 3697 rats. J Vasc Surg. 1984;1(4):562-5. 3698 278. Durham SJ, Steed DL, Moosa HH, Makaroun MS, Webster MW. Probability of 3699 rupture of an abdominal aortic aneurysm after an unrelated operative procedure: 3700 a prospective study. J Vasc Surg. 1991;13(2):248-51. 3701 279. Patterson BO, Holt PJ, Hinchliffe R, Loftus IM, Thompson MM. Predicting risk in 3702 elective abdominal aortic aneurysm repair: a systematic review of current 3703 evidence. Eur J Vasc Endovasc Surg. 2008;36(6):637-45. 3704 280. Samy AK, Murray G, MacBain G. Glasgow aneurysm score. Cardiovasc Surg. 3705 1994;2(1):41-4. 3706 281. Biancari F, Hobo R, Juvonen T. Glasgow Aneurysm Score predicts survival after 3707 endovascular stenting of abdominal aortic aneurysm in patients from the 3708 EUROSTAR registry. Br J Surg. 2006;93(2):191-4. 3709 282. Egorova N, Giacovelli JK, Gelijns A, Greco G, Moskowitz A, McKinsey J, et al. 3710 Defining high-risk patients for endovascular aneurysm repair. J Vasc Surg. 3711 2009;50(6):1271-9.e1. 3712 283. Giles KA, Schermerhorn ML, O'Malley AJ, Cotterill P, Jhaveri A, Pomposelli FB, 3713 et al. Risk prediction for perioperative mortality of endovascular vs open repair of 3714 abdominal aortic aneurysms using the Medicare population. J Vasc Surg. 3715 2009;50(2):256-62. 3716 284. Eslami MH, Rybin D, Doros G, Kalish JA, Farber A, Vascular Study Group of 3717 New E. Comparison of a Vascular Study Group of New England risk prediction 3718 model with established risk prediction models of in-hospital mortality after 3719 elective abdominal aortic aneurysm repair. J Vasc Surg. 2015;62(5):1125-33.e2. 3720 285. Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D. Endovascular 3721 repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J 3722 Med. 2010;362(20):1872-80. 3723 286. De Martino RR, Brooke BS, Robinson W, Schanzer A, Indes JE, Wallaert JB, et 3724 al. Designation as "unfit for open repair" is associated with poor outcomes after 3725 endovascular aortic aneurysm repair. Circ Cardiovasc Qual Outcomes. 3726 2013;6(5):575-81. 3727 287. Karthikesalingam A, Nicoli TK, Holt PJ, Hinchliffe RJ, Pasha N, Loftus IM, et al. 3728 The fate of patients referred to a specialist vascular unit with large infra-renal 3729 abdominal aortic aneurysms over a two-year period. Eur J Vasc Endovasc Surg. 3730 2011;42(3):295-301. 3731 288. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation 3732 for abdominal aortic aneurysms. Ann Vasc Surg. 1991;5(6):491-9. 3733 289. Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et 3734 al. Reporting standards for endovascular aortic aneurysm repair. J Vasc Surg. 3735 2002;35(5):1048-60. 3736 290. Nelson PR, Kracjer Z, Kansal N, Rao V, Bianchi C, Hashemi H, et al. A 3737 multicenter, randomized, controlled trial of totally percutaneous access versus
132
3738 open femoral exposure for endovascular aortic aneurysm repair (the PEVAR 3739 trial). J Vasc Surg. 2014;59(5):1181-93. 3740 291. Lobato AC, Quick RC, Vaughn PL, Rodriguez-Lopez J, Douglas M, Diethrich EB. 3741 Transrenal fixation of aortic endografts: intermediate follow-up of a single-center 3742 experience. J Endovasc Ther. 2000;7(4):273-8. 3743 292. Malina M, Brunkwall J, Ivancev K, Lindh M, Lindblad B, Risberg B. Renal arteries 3744 covered by aortic stents: clinical experience from endovascular grafting of aortic 3745 aneurysms. Eur J Vasc Endovasc Surg. 1997;14(2):109-13. 3746 293. Marin ML, Parsons RE, Hollier LH, Mitty HA, Ahn J, Parsons RE, et al. Impact of 3747 transrenal aortic endograft placement on endovascular graft repair of abdominal 3748 aortic aneurysms. J Vasc Surg. 1998;28(4):638-46. 3749 294. Cayne NS, Rhee SJ, Veith FJ, Lipsitz EC, Ohki T, Gargiulo NJ, 3rd, et al. Does 3750 transrenal fixation of aortic endografts impair renal function? J Vasc Surg. 3751 2003;38(4):639-44. 3752 295. O'Donnell ME, Sun Z, Winder RJ, Ellis PK, Lau LL, Blair PH. Suprarenal fixation 3753 of endovascular aortic stent grafts: assessment of medium-term to long-term 3754 renal function by analysis of juxtarenal stent morphology. J Vasc Surg. 3755 2007;45(4):694-700. 3756 296. Greenberg RK, Chuter TA, Lawrence-Brown M, Haulon S, Nolte L, Zenith I. 3757 Analysis of renal function after aneurysm repair with a device using suprarenal 3758 fixation (Zenith AAA Endovascular Graft) in contrast to open surgical repair. J 3759 Vasc Surg. 2004;39(6):1219-28. 3760 297. Kramer SC, Seifarth H, Pamler R, Fleiter T, Buhring J, Sunder-Plassmann L, et 3761 al. Renal infarction following endovascular aortic aneurysm repair: incidence and 3762 clinical consequences. J Endovasc Ther. 2002;9(1):98-102. 3763 298. Lau LL, Hakaim AG, Oldenburg WA, Neuhauser B, McKinney JM, Paz-Fumagalli 3764 R, et al. Effect of suprarenal versus infrarenal aortic endograft fixation on renal 3765 function and renal artery patency: a comparative study with intermediate follow- 3766 up. J Vasc Surg. 2003;37(6):1162-8. 3767 299. Burks JA, Jr., Faries PL, Gravereaux EC, Hollier LH, Marin ML. Endovascular 3768 repair of abdominal aortic aneurysms: stent-graft fixation across the visceral 3769 arteries. J Vasc Surg. 2002;35(1):109-13. 3770 300. Choke E, Munneke G, Morgan R, Belli AM, Dawson J, Loftus IM, et al. Visceral 3771 and renal artery complications of suprarenal fixation during endovascular 3772 aneurysm repair. Cardiovasc Intervent Radiol. 2007;30(4):619-27. 3773 301. Antonello M, Menegolo M, Piazza M, Bonfante L, Grego F, Frigatti P. Outcomes 3774 of endovascular aneurysm repair on renal function compared with open repair. J 3775 Vasc Surg. 2013;58(4):886-93. 3776 302. Saratzis A, Sarafidis P, Melas N, Hunter JP, Saratzis N, Kiskinis D, et al. 3777 Suprarenal graft fixation in endovascular abdominal aortic aneurysm repair is 3778 associated with a decrease in renal function. J Vasc Surg. 2012;56(3):594-600. 3779 303. Miller LE, Razavi MK, Lal BK. Suprarenal versus infrarenal stent graft fixation on 3780 renal complications after endovascular aneurysm repair. J Vasc Surg. 3781 2015;61(5):1340-9.e1.
133
3782 304. Lee WA, O'Dorisio J, Wolf YG, Hill BB, Fogarty TJ, Zarins CK. Outcome after 3783 unilateral hypogastric artery occlusion during endovascular aneurysm repair. J 3784 Vasc Surg. 2001;33(5):921-6. 3785 305. Schoder M, Zaunbauer L, Holzenbein T, Fleischmann D, Cejna M, Kretschmer 3786 G, et al. Internal iliac artery embolization before endovascular repair of 3787 abdominal aortic aneurysms: frequency, efficacy, and clinical results. AJR Am J 3788 Roentgenol. 2001;177(3):599-605. 3789 306. Cynamon J, Lerer D, Veith FJ, Taragin BH, Wahl SI, Lautin JL, et al. Hypogastric 3790 artery coil embolization prior to endoluminal repair of aneurysms and fistulas: 3791 buttock claudication, a recognized but possibly preventable complication. J Vasc 3792 Interv Radiol. 2000;11(5):573-7. 3793 307. Lee C, Dougherty M, Calligaro K. Concomitant unilateral internal iliac artery 3794 embolization and endovascular infrarenal aortic aneurysm repair. J Vasc Surg. 3795 2006;43(5):903-7. 3796 308. Rhee RY, Muluk SC, Tzeng E, Missig-Carroll N, Makaroun MS. Can the internal 3797 iliac artery be safely covered during endovascular repair of abdominal aortic and 3798 iliac artery aneurysms? Ann Vasc Surg. 2002;16(1):29-36. 3799 309. Farahmand P, Becquemin JP, Desgranges P, Allaire E, Marzelle J, Roudot- 3800 Thoraval F. Is hypogastric artery embolization during endovascular aortoiliac 3801 aneurysm repair (EVAR) innocuous and useful? Eur J Vasc Endovasc Surg. 3802 2008;35(4):429-35. 3803 310. Dadian N, Ohki T, Veith FJ, Edelman M, Mehta M, Lipsitz EC, et al. Overt colon 3804 ischemia after endovascular aneurysm repair: the importance of 3805 microembolization as an etiology. J Vasc Surg. 2001;34(6):986-96. 3806 311. Resnick SA, Eskandari MK. Outcomes of Amplatzer vascular plugs for occlusion 3807 of internal iliacs during aortoiliac aneurysm stent grafting. Ann Vasc Surg. 3808 2008;22(5):613-7. 3809 312. Ryer EJ, Garvin RP, Webb TP, Franklin DP, Elmore JR. Comparison of 3810 outcomes with coils versus vascular plug embolization of the internal iliac artery 3811 for endovascular aortoiliac aneurysm repair. J Vasc Surg. 2012;56(5):1239-45. 3812 313. Lee WA, Nelson PR, Berceli SA, Seeger JM, Huber TS. Outcome after 3813 hypogastric artery bypass and embolization during endovascular aneurysm 3814 repair. J Vasc Surg. 2006;44(6):1162-8. 3815 314. Mehta M, Veith FJ, Darling RC, Roddy SP, Ohki T, Lipsitz EC, et al. Effects of 3816 bilateral hypogastric artery interruption during endovascular and open aortoiliac 3817 aneurysm repair. J Vasc Surg. 2004;40(4):698-702. 3818 315. Lin PH, Bush RL, Lumsden AB. Sloughing of the scrotal skin and impotence 3819 subsequent to bilateral hypogastric artery embolization for endovascular 3820 aortoiliac aneurysm repair. J Vasc Surg. 2001;34(4):748-50. 3821 316. Wolpert LM, Dittrich KP, Hallisey MJ, Allmendinger PP, Gallagher JJ, Heydt K, et 3822 al. Hypogastric artery embolization in endovascular abdominal aortic aneurysm 3823 repair. J Vasc Surg. 2001;33(6):1193-8. 3824 317. Jean-Baptiste E, Brizzi S, Bartoli MA, Sadaghianloo N, Baque J, Magnan PE, et 3825 al. Pelvic ischemia and quality of life scores after interventional occlusion of the 3826 hypogastric artery in patients undergoing endovascular aortic aneurysm repair. J 3827 Vasc Surg. 2014;60(1):40-9,9.e1.
134
3828 318. Bergamini TM, Rachel ES, Kinney EV, Jung MT, Kaebnick HW, Mitchell RA. 3829 External iliac artery-to-internal iliac artery endograft: a novel approach to 3830 preserve pelvic inflow in aortoiliac stent grafting. J Vasc Surg. 2002;35(1):120-4. 3831 319. Faries PL, Morrissey N, Burks JA, Gravereaux E, Kerstein MD, Teodorescu VJ, 3832 et al. Internal iliac artery revascularization as an adjunct to endovascular repair of 3833 aortoiliac aneurysms. J Vasc Surg. 2001;34(5):892-9. 3834 320. Malina M, Dirven M, Sonesson B, Resch T, Dias N, Ivancev K. Feasibility of a 3835 branched stent-graft in common iliac artery aneurysms. J Endovasc Ther. 3836 2006;13(4):496-500. 3837 321. Serracino-Inglott F, Bray AE, Myers P. Endovascular abdominal aortic aneurysm 3838 repair in patients with common iliac artery aneurysms--Initial experience with the 3839 Zenith bifurcated iliac side branch device. J Vasc Surg. 2007;46(2):211-7. 3840 322. Ziegler P, Avgerinos ED, Umscheid T, Perdikides T, Erz K, Stelter WJ. Branched 3841 iliac bifurcation: 6 years experience with endovascular preservation of internal 3842 iliac artery flow. J Vasc Surg. 2007;46(2):204-10. 3843 323. Rayt HS, Bown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London NJ, et al. 3844 Buttock claudication and erectile dysfunction after internal iliac artery 3845 embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc 3846 Intervent Radiol. 2008;31(4):728-34. 3847 324. Arko FR, Lee WA, Hill BB, Fogarty TJ, Zarins CK. Hypogastric artery bypass to 3848 preserve pelvic circulation: improved outcome after endovascular abdominal 3849 aortic aneurysm repair. J Vasc Surg. 2004;39(2):404-8. 3850 325. Parodi JC, Ferreira M. Relocation of the iliac artery bifurcation to facilitate 3851 endoluminal treatment of abdominal aortic aneurysms. J Endovasc Surg. 3852 1999;6(4):342-7. 3853 326. Lobato AC, Camacho-Lobato L. The sandwich technique to treat complex 3854 aortoiliac or isolated iliac aneurysms: results of midterm follow-up. J Vasc Surg. 3855 2013;57(2 Suppl):26S-34S. 3856 327. Oderich GS, Greenberg RK. Endovascular iliac branch devices for iliac 3857 aneurysms. Perspect Vasc Surg Endovasc Ther. 2011;23(3):166-72. 3858 328. Brewster DC, Retana A, Waltman AC, Darling RC. Angiography in the 3859 management of aneurysms of the abdominal aorta. Its value and safety. N Engl J 3860 Med. 1975;292(16):822-5. 3861 329. Olin JW, Melia M, Young JR, Graor RA, Risius B. Prevalence of atherosclerotic 3862 renal artery stenosis in patients with atherosclerosis elsewhere. Am J Med. 3863 1990;88(1N):46N-51N. 3864 330. Williamson WK, Abou-Zamzam AM, Jr., Moneta GL, Yeager RA, Edwards JM, 3865 Taylor LM, Jr., et al. Prophylactic repair of renal artery stenosis is not justified in 3866 patients who require infrarenal aortic reconstruction. J Vasc Surg. 1998;28(1):14- 3867 20. 3868 331. Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM, et al. 3869 Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J 3870 Med. 2014;370(1):13-22. 3871 332. Greenberg JI, Dorsey C, Dalman RL, Lee JT, Harris EJ, Hernandez-Boussard T, 3872 et al. Long-term results after accessory renal artery coverage during 3873 endovascular aortic aneurysm repair. J Vasc Surg. 2012;56(2):291-6.
135
3874 333. Aquino RV, Rhee RY, Muluk SC, Tzeng EY, Carrol NM, Makaroun MS. Exclusion 3875 of accessory renal arteries during endovascular repair of abdominal aortic 3876 aneurysms. J Vasc Surg. 2001;34(5):878-84. 3877 334. Karmacharya J, Parmer SS, Antezana JN, Fairman RM, Woo EY, Velazquez 3878 OC, et al. Outcomes of accessory renal artery occlusion during endovascular 3879 aneurysm repair. J Vasc Surg. 2006;43(1):8-13. 3880 335. United Kingdom ETI, Greenhalgh RM, Brown LC, Powell JT, Thompson SG, 3881 Epstein D, et al. Endovascular versus open repair of abdominal aortic aneurysm. 3882 N Engl J Med. 2010;362(20):1863-71. 3883 336. De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW, et al. 3884 Long-term outcome of open or endovascular repair of abdominal aortic 3885 aneurysm. N Engl J Med. 2010;362(20):1881-9. 3886 337. Lederle FA, Freischlag JA, Kyriakides TC, Matsumura JS, Padberg FT, Jr., 3887 Kohler TR, et al. Long-term comparison of endovascular and open repair of 3888 abdominal aortic aneurysm. N Engl J Med. 2012;367(21):1988-97. 3889 338. Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P, et al. 3890 A randomized controlled trial of endovascular aneurysm repair versus open 3891 surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc 3892 Surg. 2011;53(5):1167-73.e1. 3893 339. Paravastu SC, Jayarajasingam R, Cottam R, Palfreyman SJ, Michaels JA, 3894 Thomas SM. Endovascular repair of abdominal aortic aneurysm. Cochrane 3895 Database Syst Rev. 2014;1:CD004178. 3896 340. Schermerhorn ML, Buck DB, O'Malley AJ, Curran T, McCallum JC, Darling J, et 3897 al. Long-Term Outcomes of Abdominal Aortic Aneurysm in the Medicare 3898 Population. N Engl J Med. 2015;373(4):328-38. 3899 341. Landon BE, O'Malley AJ, Giles K, Cotterill P, Schermerhorn ML. Volume- 3900 outcome relationships and abdominal aortic aneurysm repair. Circulation. 3901 2010;122(13):1290-7. 3902 342. Dua A, Furlough CL, Ray H, Sharma S, Upchurch GR, Desai SS. The effect of 3903 hospital factors on mortality rates after abdominal aortic aneurysm repair. J Vasc 3904 Surg. 2014;60(6):1446-51. 3905 343. Zettervall SL, Schermerhorn ML, Soden PA, McCallum JC, Shean KE, Deery SE, 3906 et al. The Effect of Surgeon and Hospital Volume on Mortality following Open and 3907 Endovascular Repair of Abdominal Aortic Aneurysms. J Vasc Surg. 2016;In 3908 press. 3909 344. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et 3910 al. A randomized trial comparing conventional and endovascular repair of 3911 abdominal aortic aneurysms. N Engl J Med. 2004;351(16):1607-18. 3912 345. Rajani RR, Arthurs ZM, Srivastava SD, Lyden SP, Clair DG, Eagleton MJ. 3913 Repairing immediate proximal endoleaks during abdominal aortic aneurysm 3914 repair. J Vasc Surg. 2011;53(5):1174-7. 3915 346. Mehta M, Sternbach Y, Taggert JB, Kreienberg PB, Roddy SP, Paty PS, et al. 3916 Long-term outcomes of secondary procedures after endovascular aneurysm 3917 repair. J Vasc Surg. 2010;52(6):1442-9.
136
3918 347. Veith FJ, Baum RA, Ohki T, Amor M, Adiseshiah M, Blankensteijn JD, et al. 3919 Nature and significance of endoleaks and endotension: summary of opinions 3920 expressed at an international conference. J Vasc Surg. 2002;35(5):1029-35. 3921 348. Jordan WD, Jr., Mehta M, Varnagy D, Moore WM, Jr., Arko FR, Joye J, et al. 3922 Results of the ANCHOR prospective, multicenter registry of EndoAnchors for 3923 type Ia endoleaks and endograft migration in patients with challenging anatomy. 3924 J Vasc Surg. 2014;60(4):885-92.e2. 3925 349. Bastos Goncalves F, Verhagen HJ, Vasanthananthan K, Zandvoort HJ, Moll FL, 3926 van Herwaarden JA. Spontaneous delayed sealing in selected patients with a 3927 primary type-Ia endoleak after endovascular aneurysm repair. Eur J Vasc 3928 Endovasc Surg. 2014;48(1):53-9. 3929 350. Katsargyris A, Yazar O, Oikonomou K, Bekkema F, Tielliu I, Verhoeven EL. 3930 Fenestrated stent-grafts for salvage of prior endovascular abdominal aortic 3931 aneurysm repair. Eur J Vasc Endovasc Surg. 2013;46(1):49-56. 3932 351. Martin Z, Greenberg RK, Mastracci TM, Eagleton MJ, O'Callaghan A, Bena J. 3933 Late rescue of proximal endograft failure using fenestrated and branched 3934 devices. J Vasc Surg. 2014;59(6):1479-87. 3935 352. Donas KP, Telve D, Torsello G, Pitoulias G, Schwindt A, Austermann M. Use of 3936 parallel grafts to save failed prior endovascular aortic aneurysm repair and type 3937 Ia endoleaks. J Vasc Surg. 2015;62(3):578-84. 3938 353. Montelione N, Pecoraro F, Puippe G, Chaykovska L, Rancic Z, Pfammatter T, et 3939 al. A 12-Year Experience With Chimney and Periscope Grafts for Treatment of 3940 Type I Endoleaks. J Endovasc Ther. 2015;22(4):568-74. 3941 354. van Marrewijk C, Buth J, Harris PL, Norgren L, Nevelsteen A, Wyatt MG. 3942 Significance of endoleaks after endovascular repair of abdominal aortic 3943 aneurysms: The EUROSTAR experience. J Vasc Surg. 2002;35(3):461-73. 3944 355. Chuter TA, Faruqi RM, Sawhney R, Reilly LM, Kerlan RB, Canto CJ, et al. 3945 Endoleak after endovascular repair of abdominal aortic aneurysm. J Vasc Surg. 3946 2001;34(1):98-105. 3947 356. White GH, May J, Waugh RC, Chaufour X, Yu W. Type III and type IV endoleak: 3948 toward a complete definition of blood flow in the sac after endoluminal AAA 3949 repair. J Endovasc Surg. 1998;5(4):305-9. 3950 357. Cuypers P, Buth J, Harris PL, Gevers E, Lahey R. Realistic expectations for 3951 patients with stent-graft treatment of abdominal aortic aneurysms. Results of a 3952 European multicentre registry. Eur J Vasc Endovasc Surg. 1999;17(6):507-16. 3953 358. Buck DB, Karthaus EG, Soden PA, Ultee KH, van Herwaarden JA, Moll FL, et al. 3954 Percutaneous versus femoral cutdown access for endovascular aneurysm repair. 3955 J Vasc Surg. 2015;62(1):16-21. 3956 359. Malkawi AH, Hinchliffe RJ, Holt PJ, Loftus IM, Thompson MM. Percutaneous 3957 access for endovascular aneurysm repair: a systematic review. Eur J Vasc 3958 Endovasc Surg. 2010;39(6):676-82. 3959 360. Lee WA, Brown MP, Nelson PR, Huber TS, Seeger JM. Midterm outcomes of 3960 femoral arteries after percutaneous endovascular aortic repair using the Preclose 3961 technique. J Vasc Surg. 2008;47(5):919-23.
137
3962 361. Starnes BW, Andersen CA, Ronsivalle JA, Stockmaster NR, Mullenix PS, Statler 3963 JD. Totally percutaneous aortic aneurysm repair: experience and prudence. J 3964 Vasc Surg. 2006;43(2):270-6. 3965 362. Bensley RP, Hurks R, Huang Z, Pomposelli F, Hamdan A, Wyers M, et al. 3966 Ultrasound-guided percutaneous endovascular aneurysm repair success is 3967 predicted by access vessel diameter. J Vasc Surg. 2012;55(6):1554-61. 3968 363. Eisenack M, Umscheid T, Tessarek J, Torsello GF, Torsello GB. Percutaneous 3969 endovascular aortic aneurysm repair: a prospective evaluation of safety, 3970 efficiency, and risk factors. J Endovasc Ther. 2009;16(6):708-13. 3971 364. Mousa AY, Campbell JE, Broce M, Abu-Halimah S, Stone PA, Hass SM, et al. 3972 Predictors of percutaneous access failure requiring open femoral surgical 3973 conversion during endovascular aortic aneurysm repair. J Vasc Surg. 3974 2013;58(5):1213-9. 3975 365. Teh LG, Sieunarine K, van Schie G, Goodman MA, Lawrence-Brown M, 3976 Prendergast FJ, et al. Use of the percutaneous vascular surgery device for 3977 closure of femoral access sites during endovascular aneurysm repair: lessons 3978 from our experience. Eur J Vasc Endovasc Surg. 2001;22(5):418-23. 3979 366. Manunga JM, Gloviczki P, Oderich GS, Kalra M, Duncan AA, Fleming MD, et al. 3980 Femoral artery calcification as a determinant of success for percutaneous access 3981 for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 3982 2013;58(5):1208-12. 3983 367. Arthurs ZM, Starnes BW, Sohn VY, Singh N, Andersen CA. Ultrasound-guided 3984 access improves rate of access-related complications for totally percutaneous 3985 aortic aneurysm repair. Ann Vasc Surg. 2008;22(6):736-41. 3986 368. Sarmiento JM, Wisniewski PJ, Do NT, Slezak JM, Tayyarah M, Aka PK, et al. 3987 The Kaiser Permanente experience with ultrasound-guided percutaneous 3988 endovascular abdominal aortic aneurysm repair. Ann Vasc Surg. 2012;26(7):906- 3989 12. 3990 369. Bechara CF, Barshes NR, Pisimisis G, Chen H, Pak T, Lin PH, et al. Predicting 3991 the learning curve and failures of total percutaneous endovascular aortic 3992 aneurysm repair. J Vasc Surg. 2013;57(1):72-6. 3993 370. van Zeggeren L, Bastos Goncalves F, van Herwaarden JA, Zandvoort HJ, 3994 Werson DA, Vos JA, et al. Incidence and treatment results of Endurant endograft 3995 occlusion. J Vasc Surg. 2013;57(5):1246-54. 3996 371. Cochennec F, Becquemin JP, Desgranges P, Allaire E, Kobeiter H, Roudot- 3997 Thoraval F. Limb graft occlusion following EVAR: clinical pattern, outcomes and 3998 predictive factors of occurrence. Eur J Vasc Endovasc Surg. 2007;34(1):59-65. 3999 372. Maldonado TS, Rockman CB, Riles E, Douglas D, Adelman MA, Jacobowitz GR, 4000 et al. Ischemic complications after endovascular abdominal aortic aneurysm 4001 repair. J Vasc Surg. 2004;40(4):703-9. 4002 373. Moulakakis KG, Alepaki M, Sfyroeras GS, Antonopoulos CN, Giannakopoulos 4003 TG, Kakisis J, et al. The impact of endograft type on inflammatory response after 4004 endovascular treatment of abdominal aortic aneurysm. J Vasc Surg. 4005 2013;57(3):668-77. 4006 374. de la Motte L, Kehlet H, Vogt K, Nielsen CH, Groenvall JB, Nielsen HB, et al. 4007 Preoperative methylprednisolone enhances recovery after endovascular aortic
138
4008 repair: a randomized, double-blind, placebo-controlled clinical trial. Ann Surg. 4009 2014;260(3):540-8. 4010 375. Kakisis JD, Moulakakis KG, Antonopoulos CN, Mylonas SN, Giannakopoulos 4011 TG, Sfyroeras GS, et al. Volume of new-onset thrombus is associated with the 4012 development of postimplantation syndrome after endovascular aneurysm repair. 4013 J Vasc Surg. 2014;60(5):1140-5. 4014 376. Voute MT, Bastos Goncalves FM, van de Luijtgaarden KM, Klein Nulent CG, 4015 Hoeks SE, Stolker RJ, et al. Stent graft composition plays a material role in the 4016 postimplantation syndrome. J Vasc Surg. 2012;56(6):1503-9. 4017 377. Blum U, Voshage G, Lammer J, Beyersdorf F, Tollner D, Kretschmer G, et al. 4018 Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms. N Engl J 4019 Med. 1997;336(1):13-20. 4020 378. Miller A, Marotta M, Scordi-Bello I, Tammaro Y, Marin M, Divino C. Ischemic 4021 colitis after endovascular aortoiliac aneurysm repair: a 10-year retrospective 4022 study. Arch Surg. 2009;144(10):900-3. 4023 379. Becquemin JP, Majewski M, Fermani N, Marzelle J, Desgrandes P, Allaire E, et 4024 al. Colon ischemia following abdominal aortic aneurysm repair in the era of 4025 endovascular abdominal aortic repair. J Vasc Surg. 2008;47(2):258-63. 4026 380. Cambria RP, Brewster DC, Abbott WM, Freehan M, Megerman J, LaMuraglia G, 4027 et al. Transperitoneal versus retroperitoneal approach for aortic reconstruction: a 4028 randomized prospective study. J Vasc Surg. 1990;11(2):314-24. 4029 381. Sicard GA, Reilly JM, Rubin BG, Thompson RW, Allen BT, Flye MW, et al. 4030 Transabdominal versus retroperitoneal incision for abdominal aortic surgery: 4031 report of a prospective randomized trial. J Vasc Surg. 1995;21(2):174-81. 4032 382. Sieunarine K, Lawrence-Brown MM, Goodman MA. Comparison of 4033 transperitoneal and retroperitoneal approaches for infrarenal aortic surgery: early 4034 and late results. Cardiovasc Surg. 1997;5(1):71-6. 4035 383. West CA, Noel AA, Bower TC, Cherry KJ, Jr., Gloviczki P, Sullivan TM, et al. 4036 Factors affecting outcomes of open surgical repair of pararenal aortic aneurysms: 4037 a 10-year experience. J Vasc Surg. 2006;43(5):921-7. 4038 384. Knott AW, Kalra M, Duncan AA, Reed NR, Bower TC, Hoskin TL, et al. Open 4039 repair of juxtarenal aortic aneurysms (JAA) remains a safe option in the era of 4040 fenestrated endografts. J Vasc Surg. 2008;47(4):695-701. 4041 385. O'Hara PJ, Hakaim AG, Hertzer NR, Krajewski LP, Cox GS, Beven EG. Surgical 4042 management of aortic aneurysm and coexistent horseshoe kidney: review of a 4043 31-year experience. J Vasc Surg. 1993;17(5):940-7. 4044 386. Todd GJ, DeRose JJ, Jr. Retroperitoneal approach for repair of inflammatory 4045 aortic aneurysms. Ann Vasc Surg. 1995;9(6):525-34. 4046 387. Green RM, Ricotta JJ, Ouriel K, DeWeese JA. Results of supraceliac aortic 4047 clamping in the difficult elective resection of infrarenal abdominal aortic 4048 aneurysm. J Vasc Surg. 1989;9(1):124-34. 4049 388. Nypaver TJ, Shepard AD, Reddy DJ, Elliott JP, Jr., Ernst CB. Supraceliac aortic 4050 cross-clamping: determinants of outcome in elective abdominal aortic 4051 reconstruction. J Vasc Surg. 1993;17(5):868-75.
139
4052 389. Chong T, Nguyen L, Owens CD, Conte MS, Belkin M. Suprarenal aortic cross- 4053 clamp position: a reappraisal of its effects on outcomes for open abdominal aortic 4054 aneurysm repair. J Vasc Surg. 2009;49(4):873-80. 4055 390. Braithwaite BD, Davies B, Heather BP, Earnshaw JJ. Early results of a 4056 randomized trial of rifampicin-bonded Dacron grafts for extra-anatomic vascular 4057 reconstruction. Joint Vascular Research Group. Br J Surg. 1998;85(10):1378-81. 4058 391. Earnshaw JJ, Whitman B, Heather BP. Two-year results of a randomized 4059 controlled trial of rifampicin-bonded extra-anatomic dacron grafts. Br J Surg. 4060 2000;87(6):758-9. 4061 392. D'Addato M, Curti T, Freyrie A. Prophylaxis of graft infection with rifampicin- 4062 bonded Gelseal graft: 2-year follow-up of a prospective clinical trial. Italian 4063 Investigators Group. Cardiovasc Surg. 1996;4(2):200-4. 4064 393. Ricco JB, InterGard Silver Study G. InterGard silver bifurcated graft: features and 4065 results of a multicenter clinical study. J Vasc Surg. 2006;44(2):339-46. 4066 394. Hassen-Khodja R, Feugier P, Favre JP, Nevelsteen A, Ferreira J, University 4067 Association for Research in Vascular S. Outcome of common iliac arteries after 4068 straight aortic tube-graft placement during elective repair of infrarenal abdominal 4069 aortic aneurysms. J Vasc Surg. 2006;44(5):943-8. 4070 395. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic 4071 aneurysm. Part II. Variables predicting morbidity and mortality. J Vasc Surg. 4072 1989;9(3):437-47. 4073 396. Johnston KW, Scobie TK. Multicenter prospective study of nonruptured 4074 abdominal aortic aneurysms. I. Population and operative management. J Vasc 4075 Surg. 1988;7(1):69-81. 4076 397. Calcagno D, Hallett JW, Jr., Ballard DJ, Naessens JM, Cherry KJ, Jr., Gloviczki 4077 P, et al. Late iliac artery aneurysms and occlusive disease after aortic tube grafts 4078 for abdominal aortic aneurysm repair. A 35-year experience. Ann Surg. 4079 1991;214(6):733-6. 4080 398. Brewster DC, Franklin DP, Cambria RP, Darling RC, Moncure AC, Lamuraglia 4081 GM, et al. Intestinal ischemia complicating abdominal aortic surgery. Surgery. 4082 1991;109(4):447-54. 4083 399. Mitchell KM, Valentine RJ. Inferior mesenteric artery reimplantation does not 4084 guarantee colon viability in aortic surgery. J Am Coll Surg. 2002;194(2):151-5. 4085 400. Senekowitsch C, Assadian A, Assadian O, Hartleb H, Ptakovsky H, Hagmuller 4086 GW. Replanting the inferior mesentery artery during infrarenal aortic aneurysm 4087 repair: influence on postoperative colon ischemia. J Vasc Surg. 2006;43(4):689- 4088 94. 4089 401. Pearce JD, Edwards MS, Stafford JM, Deonanan JK, Davis RP, Corriere MA, et 4090 al. Open repair of aortic aneurysms involving the renal vessels. Ann Vasc Surg. 4091 2007;21(6):676-86. 4092 402. Oderich GS, Bower TC, Sullivan TM, Bjarnason H, Cha S, Gloviczki P. Open 4093 versus endovascular revascularization for chronic mesenteric ischemia: risk- 4094 stratified outcomes. J Vasc Surg. 2009;49(6):1472-9.e3. 4095 403. Ouriel K, Ricotta JJ, Adams JT, Deweese JA. Management of cholelithiasis in 4096 patients with abdominal aortic aneurysm. Ann Surg. 1983;198(6):717-9.
140
4097 404. Nora JD, Pairolero PC, Nivatvongs S, Cherry KJ, Hallett JW, Gloviczki P. 4098 Concomitant abdominal aortic aneurysm and colorectal carcinoma: priority of 4099 resection. J Vasc Surg. 1989;9(5):630-5. 4100 405. Blankensteijn JD, Lindenburg FP, Van der Graaf Y, Eikelboom BC. Influence of 4101 study design on reported mortality and morbidity rates after abdominal aortic 4102 aneurysm repair. Br J Surg. 1998;85(12):1624-30. 4103 406. Conrad MF, Crawford RS, Pedraza JD, Brewster DC, Lamuraglia GM, Corey M, 4104 et al. Long-term durability of open abdominal aortic aneurysm repair. J Vasc 4105 Surg. 2007;46(4):669-75. 4106 407. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-72. 4107 408. Galland RB. Mortality following elective infrarenal aortic reconstruction: a Joint 4108 Vascular Research Group study. Br J Surg. 1998;85(5):633-6. 4109 409. Hua HT, Cambria RP, Chuang SK, Stoner MC, Kwolek CJ, Rowell KS, et al. 4110 Early outcomes of endovascular versus open abdominal aortic aneurysm repair 4111 in the National Surgical Quality Improvement Program-Private Sector (NSQIP- 4112 PS). J Vasc Surg. 2005;41(3):382-9. 4113 410. Kazmers A, Jacobs L, Perkins A, Lindenauer SM, Bates E. Abdominal aortic 4114 aneurysm repair in Veterans Affairs medical centers. J Vasc Surg. 4115 1996;23(2):191-200. 4116 411. Lawrence PF, Gazak C, Bhirangi L, Jones B, Bhirangi K, Oderich G, et al. The 4117 epidemiology of surgically repaired aneurysms in the United States. J Vasc Surg. 4118 1999;30(4):632-40. 4119 412. Lederle FA, Kane RL, MacDonald R, Wilt TJ. Systematic review: repair of 4120 unruptured abdominal aortic aneurysm. Ann Intern Med. 2007;146(10):735-41. 4121 413. Lee WA, Carter JW, Upchurch G, Seeger JM, Huber TS. Perioperative outcomes 4122 after open and endovascular repair of intact abdominal aortic aneurysms in the 4123 United States during 2001. J Vasc Surg. 2004;39(3):491-6. 4124 414. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG, participants 4125 Et. Comparison of endovascular aneurysm repair with open repair in patients 4126 with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality 4127 results: randomised controlled trial. Lancet. 2004;364(9437):843-8. 4128 415. Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT, Jr., Matsumura JS, 4129 Kohler TR, et al. Outcomes following endovascular vs open repair of abdominal 4130 aortic aneurysm: a randomized trial. JAMA. 2009;302(14):1535-42. 4131 416. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, et al. 4132 Hospital volume and surgical mortality in the United States. N Engl J Med. 4133 2002;346(15):1128-37. 4134 417. Shackley P, Slack R, Booth A, Michaels J. Is there a positive volume-outcome 4135 relationship in peripheral vascular surgery? Results of a systematic review. Eur J 4136 Vasc Endovasc Surg. 2000;20(4):326-35. 4137 418. Dimick JB, Cowan JA, Jr., Stanley JC, Henke PK, Pronovost PJ, Upchurch GR, 4138 Jr. Surgeon specialty and provider volumes are related to outcome of intact 4139 abdominal aortic aneurysm repair in the United States. J Vasc Surg. 4140 2003;38(4):739-44.
141
4141 419. Mehta M, Taggert J, Darling RC, 3rd, Chang BB, Kreienberg PB, Paty PS, et al. 4142 Establishing a protocol for endovascular treatment of ruptured abdominal aortic 4143 aneurysms: outcomes of a prospective analysis. J Vasc Surg. 2006;44(1):1-8. 4144 420. Moore R, Nutley M, Cina CS, Motamedi M, Faris P, Abuznadah W. Improved 4145 survival after introduction of an emergency endovascular therapy protocol for 4146 ruptured abdominal aortic aneurysms. J Vasc Surg. 2007;45(3):443-50. 4147 421. Larzon T, Lindgren R, Norgren L. Endovascular treatment of ruptured abdominal 4148 aortic aneurysms: a shift of the paradigm? J Endovasc Ther. 2005;12(5):548-55. 4149 422. Alsac JM, Desgranges P, Kobeiter H, Becquemin JP. Emergency endovascular 4150 repair for ruptured abdominal aortic aneurysms: feasibility and comparison of 4151 early results with conventional open repair. Eur J Vasc Endovasc Surg. 4152 2005;30(6):632-9. 4153 423. Chambers JB, Shanson D, Hall R, Pepper J, Venn G, McGurk M. Antibiotic 4154 prophylaxis of endocarditis: the rest of the world and NICE. J R Soc Med. 4155 2011;104(4):138-40. 4156 424. Lachat M, Enzler M. Innovations in the treatment of ruptured AAA may improve 4157 future outcome. Vasa. 2007;36(4):227-8. 4158 425. Veith FJ, Ohki T, Lipsitz EC, Suggs WD, Cynamon J. Endovascular grafts and 4159 other catheter-directed techniques in the management of ruptured abdominal 4160 aortic aneurysms. Semin Vasc Surg. 2003;16(4):326-31. 4161 426. Reimerink JJ, van der Laan MJ, Koelemay MJ, Balm R, Legemate DA. 4162 Systematic review and meta-analysis of population-based mortality from ruptured 4163 abdominal aortic aneurysm. Br J Surg. 2013;100(11):1405-13. 4164 427. Starnes BW, Quiroga E, Hutter C, Tran NT, Hatsukami T, Meissner M, et al. 4165 Management of ruptured abdominal aortic aneurysm in the endovascular era. J 4166 Vasc Surg. 2010;51(1):9-17. 4167 428. Holt PJ, Poloniecki JD, Gerrard D, Loftus IM, Thompson MM. Meta-analysis and 4168 systematic review of the relationship between volume and outcome in abdominal 4169 aortic aneurysm surgery. Br J Surg. 2007;94(4):395-403. 4170 429. Hafez H, Owen LW, Lorimer CF, Bajwa A. Advantage of a one-stop referral and 4171 management service for ruptured abdominal aortic aneurysms. Br J Surg. 4172 2009;96(12):1416-21. 4173 430. Starnes BW, Garland BT, Desikan S, Tran NT, Quiroga E, Singh N. VESS26. 4174 EVAR Candidacy Impacts 30-day Mortality for REVAR but Not for Open Repair 4175 of Ruptured Abdominal Aortic Aneurysms. Journal of Vascular Surgery;59(6):15- 4176 6S. 4177 431. Tran NT, Quiroga E, Singh N, Caps MT, Starnes BW, Garland BT, et al. PC36. 4178 Preoperative Risk Score for the Prediction of Mortality Following Repair of 4179 Ruptured Abdominal Aortic Aneurysms. Journal of Vascular Surgery;61(6):127S. 4180 432. Mell MW, Wang NE, Morrison DE, Hernandez-Boussard T. Interfacility transfer 4181 and mortality for patients with ruptured abdominal aortic aneurysm. J Vasc Surg. 4182 2014;60(3):553-7. 4183 433. Beekley AC. Damage control resuscitation: a sensible approach to the 4184 exsanguinating surgical patient. Crit Care Med. 2008;36(7 Suppl):S267-74. 4185 434. Haveman JW, Karliczek A, Verhoeven EL, Tielliu IF, de Vos R, Zwaveling JH, et 4186 al. Results of streamlined regional ambulance transport and subsequent
142
4187 treatment of acute abdominal aortic aneurysms. Emerg Med J. 2006;23(10):807- 4188 10. 4189 435. Salhab M, Farmer J, Osman I. Impact of delay on survival in patients with 4190 ruptured abdominal aortic aneurysm. Vascular. 2006;14(1):38-42. 4191 436. Nault P, Brisson-Tessier C, Hamel D, Lambert LJ, Blais C. A new metric for 4192 centralization of ruptured abdominal aortic aneurysm repair in large territories. J 4193 Vasc Surg. 2015;62(4):862-7. 4194 437. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. 4195 ACC/AHA guidelines for the management of patients with ST-elevation 4196 myocardial infarction--executive summary: a report of the American College of 4197 Cardiology/American Heart Association Task Force on Practice Guidelines 4198 (Writing Committee to Revise the 1999 Guidelines for the Management of 4199 Patients With Acute Myocardial Infarction). Circulation. 2004;110(5):588-636. 4200 438. Jacobs AK, Antman EM, Faxon DP, Gregory T, Solis P. Development of systems 4201 of care for ST-elevation myocardial infarction patients: executive summary. 4202 Circulation. 2007;116(2):217-30. 4203 439. Bagai A, Al-Khalidi HR, Sherwood MW, Munoz D, Roettig ML, Jollis JG, et al. 4204 Regional systems of care demonstration project: Mission: Lifeline STEMI 4205 Systems Accelerator: design and methodology. Am Heart J. 2014;167(1):15- 4206 21.e3. 4207 440. Chakrabarti A, Krumholz HM, Wang Y, Rumsfeld JS, Nallamothu BK, National 4208 Cardiovascular Data R. Time-to-reperfusion in patients undergoing interhospital 4209 transfer for primary percutaneous coronary intervention in the U.S: an analysis of 4210 2005 and 2006 data from the National Cardiovascular Data Registry. J Am Coll 4211 Cardiol. 2008;51(25):2442-3. 4212 441. Bagai A, Al-Khalidi HR, Sherwood MW, Munoz D, Roettig ML, Jollis JG, et al. 4213 Regional systems of care demonstration project: Mission: Lifeline STEMI 4214 Systems Accelerator: design and methodology. Am Heart J. 2014;167(1):15-21 4215 e3. 4216 442. Blankenship JC, Scott TD, Skelding KA, Haldis TA, Tompkins-Weber K, Sledgen 4217 MY, et al. Door-to-balloon times under 90 min can be routinely achieved for 4218 patients transferred for ST-segment elevation myocardial infarction percutaneous 4219 coronary intervention in a rural setting. J Am Coll Cardiol. 2011;57(3):272-9. 4220 443. Malina M, Veith F, Ivancev K, Sonesson B. Balloon occlusion of the aorta during 4221 endovascular repair of ruptured abdominal aortic aneurysm. J Endovasc Ther. 4222 2005;12(5):556-9. 4223 444. Mehta M, Byrne J, Taggert J. Endovascular aneurysm repair as a mean of 4224 treatment for ruptured abdominal aortic aneurysms. Chin Med J (Engl). 4225 2013;126(3):558-64. 4226 445. McMahon GS, Rayt HS, Galinanes M, Nasim A. Combined emergency 4227 abdominal aortic aneurysm repair and valve replacement in a patient with severe 4228 aortic stenosis. Ann Vasc Surg. 2012;26(4):571.e7-9. 4229 446. Mastracci TM, Garrido-Olivares L, Cina CS, Clase CM. Endovascular repair of 4230 ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. J 4231 Vasc Surg. 2008;47(1):214-21.
143
4232 447. Bockler D, Holden A, Thompson M, Hayes P, Krievins D, de Vries JP, et al. 4233 Multicenter Nellix EndoVascular Aneurysm Sealing system experience in 4234 aneurysm sac sealing. J Vasc Surg. 2015;62(2):290-8. 4235 448. de Bruin JL, Brownrigg JR, Karthikesalingam A, Patterson BO, Holt PJ, Hinchliffe 4236 RJ, et al. Endovascular aneurysm sealing for the treatment of ruptured 4237 abdominal aortic aneurysms. J Endovasc Ther. 2015;22(3):283-7. 4238 449. Hoornweg LL, Wisselink W, Vahl A, Balm R, Amsterdam Acute Aneurysm Trial 4239 C. The Amsterdam Acute Aneurysm Trial: suitability and application rate for 4240 endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc 4241 Endovasc Surg. 2007;33(6):679-83. 4242 450. Investigators IT, Powell JT, Sweeting MJ, Thompson MM, Ashleigh R, Bell R, et 4243 al. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 4244 30 day outcomes from IMPROVE randomised trial. BMJ. 2014;348:f7661. 4245 451. Lesperance K, Andersen C, Singh N, Starnes B, Martin MJ. Expanding use of 4246 emergency endovascular repair for ruptured abdominal aortic aneurysms: 4247 disparities in outcomes from a nationwide perspective. J Vasc Surg. 4248 2008;47(6):1165-70. 4249 452. Mureebe L, Egorova N, Giacovelli JK, Gelijns A, Kent KC, McKinsey JF. National 4250 trends in the repair of ruptured abdominal aortic aneurysms. J Vasc Surg. 4251 2008;48(5):1101-7. 4252 453. Ersryd S, Djavani-Gidlund K, Wanhainen A, Bjorck M. Editor's Choice - 4253 Abdominal Compartment Syndrome After Surgery for Abdominal Aortic 4254 Aneurysm: A Nationwide Population Based Study. Eur J Vasc Endovasc Surg. 4255 2016;52(2):158-65. 4256 454. Mehta M, Darling RC, 3rd, Roddy SP, Fecteau S, Ozsvath KJ, Kreienberg PB, et 4257 al. Factors associated with abdominal compartment syndrome complicating 4258 endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg. 4259 2005;42(6):1047-51. 4260 455. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain ML, De 4261 Keulenaer B, et al. Intra-abdominal hypertension and the abdominal 4262 compartment syndrome: updated consensus definitions and clinical practice 4263 guidelines from the World Society of the Abdominal Compartment Syndrome. 4264 Intensive Care Med. 2013;39(7):1190-206. 4265 456. Tottrup M, Fedder AM, Jensen RH, Tottrup A, Laustsen J. The value of routine 4266 flexible sigmoidoscopy within 48 hours after surgical repair of ruptured abdominal 4267 aortic aneurysms. Ann Vasc Surg. 2013;27(6):714-8. 4268 457. Perry RJ, Martin MJ, Eckert MJ, Sohn VY, Steele SR. Colonic ischemia 4269 complicating open vs endovascular abdominal aortic aneurysm repair. J Vasc 4270 Surg. 2008;48(2):272-7. 4271 458. Bjorck M, Bergqvist D, Troeng T. Incidence and clinical presentation of bowel 4272 ischaemia after aortoiliac surgery--2930 operations from a population-based 4273 registry in Sweden. Eur J Vasc Endovasc Surg. 1996;12(2):139-44. 4274 459. Sandison AJ, Panayiotopoulos Y, Edmondson RC, Tyrrell MR, Taylor PR. A 4- 4275 year prospective audit of the cause of death after infrarenal aortic aneurysm 4276 surgery. Br J Surg. 1996;83(10):1386-9.
144
4277 460. Champagne BJ, Lee EC, Valerian B, Mulhotra N, Mehta M. Incidence of colonic 4278 ischemia after repair of ruptured abdominal aortic aneurysm with endograft. J Am 4279 Coll Surg. 2007;204(4):597-602. 4280 461. Bown MJ, Nicholson ML, Bell PR, Sayers RD. Cytokines and inflammatory 4281 pathways in the pathogenesis of multiple organ failure following abdominal aortic 4282 aneurysm repair. Eur J Vasc Endovasc Surg. 2001;22(6):485-95. 4283 462. Mehta M, Byrne J, Darling RC, 3rd, Paty PS, Roddy SP, Kreienberg PB, et al. 4284 Endovascular repair of ruptured infrarenal abdominal aortic aneurysm is 4285 associated with lower 30-day mortality and better 5-year survival rates than open 4286 surgical repair. J Vasc Surg. 2013;57(2):368-75. 4287 463. Bown MJ, Nicholson ML, Bell PR, Sayers RD. The systemic inflammatory 4288 response syndrome, organ failure, and mortality after abdominal aortic aneurysm 4289 repair. J Vasc Surg. 2003;37(3):600-6. 4290 464. McPhee J, Eslami MH, Arous EJ, Messina LM, Schanzer A. Endovascular 4291 treatment of ruptured abdominal aortic aneurysms in the United States (2001- 4292 2006): a significant survival benefit over open repair is independently associated 4293 with increased institutional volume. J Vasc Surg. 2009;49(4):817-26. 4294 465. van Beek SC, Reimerink JJ, Vahl AC, Wisselink W, Reekers JA, van Geloven N, 4295 et al. Effect of regional cooperation on outcomes from ruptured abdominal aortic 4296 aneurysm. Br J Surg. 2014;101(7):794-801. 4297 466. Brake MA, Shalhoub J, Crane JS, Gibbs RG, Franklin IJ. Investigation and 4298 treatment of a complicated inflammatory aortoiliac aneurysm. Vasc Endovascular 4299 Surg. 2012;46(2):190-4. 4300 467. Fatima J, Gota C, Clair DG, Billings SD, Gornik HL. Inflammatory abdominal 4301 aortic aneurysm with retroperitoneal fibrosis. Circulation. 2014;130(15):1300-2. 4302 468. Mirault T, Lambert M, Puech P, Argatu D, Renaud A, Duhamel A, et al. Malignant 4303 retroperitoneal fibrosis: MRI characteristics in 50 patients. Medicine (Baltimore). 4304 2012;91(5):242-50. 4305 469. Ketha SS, Warrington KJ, McPhail IR. Inflammatory abdominal aortic aneurysm: 4306 a case report and review of literature. Vasc Endovascular Surg. 2014;48(1):65-9. 4307 470. Sterpetti AV. Etiology of inflammatory abdominal aortic aneurysms. Surgery. 4308 2013;153(5):741-2. 4309 471. Galosi AB, Grilli Cicilioni C, Sbrollini G, Angelini A, Maselli G, Carbonari L. 4310 Inflammatory abdominal aortic aneurysm presenting as bilateral 4311 hydroureteronephrosis: a case report and review of literature. Arch Ital Urol 4312 Androl. 2014;86(4):385-6. 4313 472. Paravastu SC, Ghosh J, Murray D, Farquharson FG, Serracino-Inglott F, Walker 4314 MG. A systematic review of open versus endovascular repair of inflammatory 4315 abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2009;38(3):291-7. 4316 473. Maeda H, Umezawa H, Hattori T, Nakamura T, Umeda T, Kobayashi H, et al. 4317 Early and late outcomes of inflammatory abdominal aortic aneurysms: 4318 comparison with the outcomes after open surgical and endovascular aneurysm 4319 repair in literature reviews. Int Angiol. 2013;32(1):67-73. 4320 474. Nagahama H, Nakamura K, Matsuyama M, Endou J, Nishimura M, Ishii H, et al. 4321 Inflammatory abdominal aortic aneurysm: report of seven cases. Ann Vasc Dis. 4322 2013;6(4):756-8.
145
4323 475. Nuellari E, Prifti E, Esposito G, Kapedani E. Surgical treatment of inflammatory 4324 abdominal aortic aneurysms: outcome and predictors analysis. Med Arch. 4325 2014;68(4):244-8. 4326 476. Stone WM, Fankhauser GT. Inflammatory aneurysms treated with EVAR. Semin 4327 Vasc Surg. 2012;25(4):227-31. 4328 477. Stone WM, Fankhauser GT, Bower TC, Oderich GS, Oldenburg WA, Kalra M, et 4329 al. Comparison of open and endovascular repair of inflammatory aortic 4330 aneurysms. J Vasc Surg. 2012;56(4):951-5. 4331 478. Chan YC, Qing KX, Ting AC, Cheng SW. Endovascular infrarenal aneurysm 4332 repair in patients with horseshoe kidneys: case series and literature review. 4333 Vascular. 2011;19(3):126-31. 4334 479. Ceulemans LJ, Duchateau J, Vanhoenacker FM, De Leersnyder J. The 4335 therapeutic implications of an abdominal aortic aneurysm with coincident 4336 horseshoe kidney. Acta Chir Belg. 2014;114(1):71-4. 4337 480. Frego M, Bianchera G, Angriman I, Pilon F, Fitta C, Miotto D. Abdominal aortic 4338 aneurysm with coexistent horseshoe kidney. Surg Today. 2007;37(7):626-30. 4339 481. Radermecker MA, Van Damme H, Kerzmann A, Creemers E, Limet R. 4340 Association of abdominal aortic aneurysm, horseshoe kidneys, and left-sided 4341 inferior vena cava: report of two cases. J Vasc Surg. 2008;47(3):645-8. 4342 482. Fakhro A, Shah N, Barnes TL. Endovascular repair of a common iliac 4343 pseudoaneurysm and aortic ectasia in a patient with horseshoe kidney and 4344 pancreatitis: a case report. Ann Med Surg (Lond). 2013;2(2):65-7. 4345 483. Tan TW, Farber A. Percutaneous endovascular repair of abdominal aortic 4346 aneurysm with coexisting horseshoe kidney: technical aspects and review of the 4347 literature. Int J Angiol. 2011;20(4):247-50. 4348 484. Brechtel K, Kalender G, Heller S, Schmehl J, Stock U, Scheule AM, et al. 4349 Endovascular repair of infrarenal abdominal aortic aneurysm associated with a 4350 horseshoe kidney and graft thrombosis in early follow-up. Acta Radiol. 4351 2009;50(6):624-8. 4352 485. Krivoshei L, Akin-Olugbade Y, McWilliams G, Halak M, Silverberg D. 4353 Endovascular repair of an abdominal aortic aneurysm in the presence of a 4354 hydronephrotic horseshoe kidney. Vascular. 2012;20(1):54-6. 4355 486. Brown K, Robinson D, Bray A. Customized fenestrated endovascular graft repair 4356 of abdominal aortic aneurysm with concomitant horseshoe kidney. Vascular. 4357 2014;22(3):193-7. 4358 487. Rey J, Golpanian S, Yang JK, Moreno E, Velazquez OC, Goldstein LJ, et al. 4359 Extra-anatomic endovascular repair of an abdominal aortic aneurysm with a 4360 horseshoe kidney supplied by the aneurysmal aorta. Ann Vasc Surg. 4361 2015;29(5):1021.e9-12. 4362 488. Makita S, Yoshizaki T, Tabuchi N. A case of abdominal aortic aneurysm with 4363 horseshoe kidney. Ann Thorac Cardiovasc Surg. 2009;15(2):129-32. 4364 489. Han A, Kim SM, Choi C, Min SI, Ha J, Min SK. Open Surgical Repair of 4365 Abdominal Aortic Aneurysm Coexisting with Horseshoe Kidney. Vasc Specialist 4366 Int. 2015;31(2):54-7.
146
4367 490. Chihara S, Fujino T, Matsuo H, Hidaka A. Surgical treatment of abdominal aortic 4368 aneurysm associated with horseshoe kidney: symphysiotomy using harmonic 4369 focus. Ann Thorac Cardiovasc Surg. 2014;20 Suppl:922-5. 4370 491. Davidovic L, Markovic M, Ilic N, Koncar I, Kostic D, Simic D, et al. Repair of 4371 abdominal aortic aneurysms in the presence of the horseshoe kidney. Int Angiol. 4372 2011;30(6):534-40. 4373 492. Ikeda A, Tsukada T, Konishi T, Matsuzaki K, Jikuya T, Hiramatsu Y. Open 4374 surgical repair for a ruptured abdominal aortic aneurysm with a horseshoe 4375 kidney. Ann Vasc Dis. 2015;8(1):52-5. 4376 493. Carnicelli AP, Doyle A, Singh M. Hybrid repair of an abdominal aortic aneurysm 4377 in a patient with a horseshoe kidney. J Vasc Surg. 2013;57(4):1113-5. 4378 494. Tadros RO, Malik RK, Ellozy SH, Marin ML, Faries PL, Vouyouka AG. A novel 4379 approach to the management of an inflammatory abdominal aortic aneurysm 4380 associated with crossed-fused renal ectopia. Ann Vasc Surg. 2011;25(7):984.e9- 4381 14. 4382 495. Chaudhuri A. Exclusion of an infrarenal AAA with coincident horseshoe kidney 4383 and renovascular anomalies is feasible using a standard stent-graft. Eur J Vasc 4384 Endovasc Surg. 2011;41(5):654-6. 4385 496. Spear R, Maurel B, Sobocinski J, Perini P, Guillou M, Midulla M, et al. Technical 4386 note and results in the management of anatomical variants of renal 4387 vascularisation during endovascular aneurysm repair. Eur J Vasc Endovasc 4388 Surg. 2012;43(4):398-403. 4389 497. Kotsikoris I, Papas TT, Papanas N, Maras D, Andrikopoulou M, Bessias N, et al. 4390 Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: a 12- 4391 year series. Vasc Endovascular Surg. 2012;46(1):26-9. 4392 498. Gedvilas D, Argatu D, Lukosevicius S, Basevicius A. Aorto-caval fistula clinically 4393 presenting as left renal colic. Findings of multislice computed tomography. 4394 Medicina (Kaunas). 2008;44(8):619-22. 4395 499. Myers PO, Kalangos A, Terraz S. Ruptured aortic aneurysm masquerading as 4396 phlegmasia cerulea. Am J Emerg Med. 2008;26(9):1067.e1-2. 4397 500. Pevec WC, Lee ES, Lamba R. Symptomatic, acute aortocaval fistula 4398 complicating an infrarenal aortic aneurysm. J Vasc Surg. 2010;51(2):475. 4399 501. Shah TR, Parikh P, Borkon M, Mocharla R, Lonier J, Rosenzweig BP, et al. 4400 Endovascular repair of contained abdominal aortic aneurysm rupture with 4401 aortocaval fistula presenting with high-output heart failure. Vasc Endovascular 4402 Surg. 2013;47(1):51-6. 4403 502. Laporte F, Olivier A, Groben L, Admant P, Aliot E. Aortocaval fistula: an 4404 uncommon cause of paradoxical embolism. J Cardiovasc Med (Hagerstown). 4405 2012;13(1):68-71. 4406 503. Lebon A, Agueznai M, Labombarda F. High-output heart failure resulting from 4407 chronic aortocaval fistula. Circulation. 2013;127(4):527-8. 4408 504. Loos MJ, Scheer M, van der Vliet JA, Warle MC. Ruptured iliac artery aneurysm 4409 presenting as acute right heart failure and cardiac arrest. Ann Vasc Surg. 4410 2015;29(2):363.e5-7. 4411 505. Lorenzati B, Perotto M, Bottone S, Tenconi G, Gazzina G, Cataldi W. Aortocaval 4412 fistula. Intern Emerg Med. 2014;9(8):895-6.
147
4413 506. Nakazawa S, Mohara J, Takahashi T, Koike N, Takeyoshi I. Aortocaval fistula 4414 associated with ruptured abdominal aortic aneurysm. Ann Vasc Surg. 4415 2014;28(7):1793.e5-9. 4416 507. Bhatia M, Platon A, Khabiri E, Becker C, Poletti PA. Contrast enhanced 4417 ultrasonography versus MR angiography in aortocaval fistula: case report. 4418 Abdom Imaging. 2010;35(3):376-80. 4419 508. Egan DJ, Saul T, Herbert-Cohen D, Lewiss RE. Bedside ultrasound diagnosis of 4420 an aortocaval fistula in the emergency department. J Emerg Med. 4421 2014;47(2):e55-7. 4422 509. Matsushita M, Ikezawa T, Sugimoto M, Idetsu A. Management of symptomatic 4423 abdominal aortic aneurysms following emergency computed tomography. Surg 4424 Today. 2014;44(4):620-5. 4425 510. Vigna C, Santoro T, Facciorusso A, Paroni G, Fanelli R. Aortocaval fistula 4426 mimicking an acute coronary syndrome. J Cardiovasc Med (Hagerstown). 4427 2008;9(11):1138-9. 4428 511. Akwei S, Altaf N, Tennant W, MacSweeney S, Braithwaite B. Emergency 4429 endovascular repair of aortocaval fistula--a single center experience. Vasc 4430 Endovascular Surg. 2011;45(5):442-6. 4431 512. Brightwell RE, Pegna V, Boyne N. Aortocaval fistula: current management 4432 strategies. ANZ J Surg. 2013;83(1-2):31-5. 4433 513. Fujisawa Y, Kurimoto Y, Morishita K, Fukada J, Saito T, Ohori S, et al. 4434 Aortocaval fistula after endovascular stent-grafting of abdominal aortic aneurysm. 4435 J Cardiovasc Surg (Torino). 2009;50(3):387-9. 4436 514. Guzzardi G, Fossaceca R, Divenuto I, Musiani A, Brustia P, Carriero A. 4437 Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval 4438 fistula. Cardiovasc Intervent Radiol. 2010;33(4):853-6. 4439 515. Janczak D, Chabowski M, Szydelko T, Garcarek J. Endovascular exclusion of a 4440 large spontaneous aortocaval fistula in a patient with a ruptured aortic aneurysm. 4441 Vascular. 2014;22(3):202-5. 4442 516. Juszkat R, Pukacki F, Zarzecka A, Kulesza J, Majewski W. Endovascular 4443 treatment of ruptured abdominal aneurysm into the inferior vena cava in patient 4444 after stent graft placement. Cardiovasc Intervent Radiol. 2009;32(4):776-80. 4445 517. Srisuwan T, Kanjanavanit R, Rerkasem K. Endovascular aortic stenting in 4446 patients with chronic traumatic aortocaval fistula. Ann Vasc Dis. 2013;6(4):741-4. 4447 518. Morikawa K, Setoguchi H, Yoshino J, Motoyama M, Makizono R, Yokoo T, et al. 4448 Anesthetic management of a patient with aortocaval fistula. J Anesth. 4449 2009;23(1):111-4. 4450 519. Porhomayon J, Hassan MA, Perala PR, Nader ND. Anesthetic management of 4451 aortocaval fistula repair associated with aortic valve replacement, severe aortic 4452 regurgitation, and bacterial endocarditis. J Anesth. 2011;25(2):263-6. 4453 520. Simsek E, Caliskan A, Tutun U, Sahin S. Cause of a rare acute renal 4454 insufficiency: rupture aortocaval fistula. Vascular. 2014;22(4):290-2. 4455 521. Takkar C, Choi L, Mastouri N, Kadambi PV. Aortocaval fistula: a rare cause of 4456 venous hypertension and acute renal failure. Case Rep Surg. 2012;2012:487079. 4457 522. Oda T, Yasunaga H, Hosokawa Y, Nomura Y, Shojima T, Zaima Y, et al. 4458 Preoperative computed tomographic diagnosis of an aortocaval fistula associated
148
4459 with aneurysm of the abdominal aorta. Ann Thorac Cardiovasc Surg. 4460 2011;17(5):531-3. 4461 523. Unosawa S, Kimura H, Niino T. Surgical repair of ruptured abdominal aortic 4462 aneurysm with non-bleeding aortocaval fistula. Ann Vasc Dis. 2013;6(2):209-11. 4463 524. Nakad G, AbiChedid G, Osman R. Endovascular treatment of major abdominal 4464 arteriovenous fistulas: a systematic review. Vasc Endovascular Surg. 2014;48(5- 4465 6):388-95. 4466 525. LaBarbera M, Nathanson D, Hui P. Percutaneous closure of aortocaval fistula 4467 using the amplatzer muscular VSD occluder. J Invasive Cardiol. 2011;23(8):343- 4468 4. 4469 526. Bernstein J, Jimenez JC. Inferior vena cava thrombosis following endovascular 4470 repair of acute aortocaval fistula: a word of caution. Vasc Endovascular Surg. 4471 2013;47(6):467-9. 4472 527. ElKassaby M, Alawy M, Zaki M, Hynes N, Tawfick W, Sultan S. Total 4473 endovascular management of ruptured aortocaval fistula: technical challenges 4474 and case report. Vascular. 2014;22(4):306-9. 4475 528. Melas N, Saratzis A, Saratzis N, Lazaridis I, Kiskinis D. Inferior vena cava stent- 4476 graft placement to treat endoleak associated with an aortocaval fistula. J 4477 Endovasc Ther. 2011;18(2):250-4. 4478 529. Silveira PG, Cunha JR, Lima GB, Franklin RN, Bortoluzzi CT, Galego Gdo N. 4479 Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval 4480 fistula based on aortic and inferior vena cava stent-graft placement. Ann Vasc 4481 Surg. 2014;28(8):1933.e1-5. 4482 530. Wozniak MF, LaMuraglia GM, Musch G. Anesthesia for open abdominal aortic 4483 surgery. Int Anesthesiol Clin. 2005;43(1):61-78. 4484 531. Norris EJ, Beattie C, Perler BA, Martinez EA, Meinert CL, Anderson GF, et al. 4485 Double-masked randomized trial comparing alternate combinations of 4486 intraoperative anesthesia and postoperative analgesia in abdominal aortic 4487 surgery. Anesthesiology. 2001;95(5):1054-67. 4488 532. Garnett RL, MacIntyre A, Lindsay P, Barber GG, Cole CW, Hajjar G, et al. 4489 Perioperative ischaemia in aortic surgery: combined epidural/general 4490 anaesthesia and epidural analgesia vs general anaesthesia and i.v. analgesia. 4491 Can J Anaesth. 1996;43(8):769-77. 4492 533. Veering BT. Are epidurals worthwhile in vascular surgery? Curr Opin 4493 Anaesthesiol. 2008;21(5):616-8. 4494 534. Brustia P, Renghi A, Fassiola A, Gramaglia L, Della Corte F, Cassatella R, et al. 4495 Fast-track approach in abdominal aortic surgery: left subcostal incision with 4496 blended anesthesia. Interact Cardiovasc Thorac Surg. 2007;6(1):60-4. 4497 535. Kalko Y, Ugurlucan M, Basaran M, Aydin U, Kafa U, Kosker T, et al. Epidural 4498 anaesthesia and mini-laparotomy for the treatment of abdominal aortic 4499 aneurysms in patients with severe chronic obstructive pulmonary disease. Acta 4500 Chir Belg. 2007;107(3):307-12. 4501 536. McGregor WE, Koler AJ, Labat GC, Perni V, Hirko MK, Rubin JR. Awake aortic 4502 aneurysm repair in patients with severe pulmonary disease. Am J Surg. 4503 1999;178(2):121-4.
149
4504 537. Ruppert V, Leurs LJ, Steckmeier B, Buth J, Umscheid T. Influence of anesthesia 4505 type on outcome after endovascular aortic aneurysm repair: an analysis based 4506 on EUROSTAR data. J Vasc Surg. 2006;44(1):16-21. 4507 538. Edwards MS, Andrews JS, Edwards AF, Ghanami RJ, Corriere MA, Goodney 4508 PP, et al. Results of endovascular aortic aneurysm repair with general, regional, 4509 and local/monitored anesthesia care in the American College of Surgeons 4510 National Surgical Quality Improvement Program database. J Vasc Surg. 4511 2011;54(5):1273-82. 4512 539. Karthikesalingam A, Thrumurthy SG, Young EL, Hinchliffe RJ, Holt PJ, 4513 Thompson MM. Locoregional anesthesia for endovascular aneurysm repair. J 4514 Vasc Surg. 2012;56(2):510-9. 4515 540. Roberts K, Revell M, Youssef H, Bradbury AW, Adam DJ. Hypotensive 4516 resuscitation in patients with ruptured abdominal aortic aneurysm. Eur J Vasc 4517 Endovasc Surg. 2006;31(4):339-44. 4518 541. Stewart A, Eyers PS, Earnshaw JJ. Prevention of infection in arterial 4519 reconstruction. Cochrane Database Syst Rev. 2006(3):CD003073. 4520 542. Fontaine MJ, Winters JL, Moore SB, McGregor CG, Santrach PJ. Frozen 4521 preoperative autologous blood donation for heart transplantation at the Mayo 4522 Clinic from 1988 to 1999. Transfusion. 2003;43(4):476-80. 4523 543. Freischlag JA. Intraoperative blood salvage in vascular surgery - worth the effort? 4524 Crit Care. 2004;8 Suppl 2:S53-6. 4525 544. Huber TS, Carlton LC, Irwin PB, Flug RR, Harward TR, Flynn TC, et al. 4526 Intraoperative autologous transfusion during elective infrarenal aortic 4527 reconstruction. J Surg Res. 1997;67(1):14-20. 4528 545. Huber TS, McGorray SP, Carlton LC, Irwin PB, Flug RR, Flynn TC, et al. 4529 Intraoperative autologous transfusion during elective infrarenal aortic 4530 reconstruction: a decision analysis model. J Vasc Surg. 1997;25(6):984-93. 4531 546. Klein AA, Nashef SA, Sharples L, Bottrill F, Dyer M, Armstrong J, et al. A 4532 randomized controlled trial of cell salvage in routine cardiac surgery. Anesth 4533 Analg. 2008;107(5):1487-95. 4534 547. Eichert I, Isgro F, Kiessling AH, Saggau W. Cell saver, ultrafiltration and direct 4535 transfusion: comparative study of three blood processing techniques. Thorac 4536 Cardiovasc Surg. 2001;49(3):149-52. 4537 548. Carless PA, Henry DA, Moxey AJ, O'Connell DL, Fergusson DA. Cell salvage for 4538 minimising perioperative allogeneic blood transfusion. Cochrane Database Syst 4539 Rev. 2003(4):CD001888. 4540 549. Takagi H, Sekino S, Kato T, Matsuno Y, Umemoto T. Intraoperative 4541 autotransfusion in abdominal aortic aneurysm surgery: meta-analysis of 4542 randomized controlled trials. Arch Surg. 2007;142(11):1098-101. 4543 550. Kauvar DS, Sarfati MR, Kraiss LW. Intraoperative blood product resuscitation 4544 and mortality in ruptured abdominal aortic aneurysm. J Vasc Surg. 4545 2012;55(3):688-92. 4546 551. Cina CS, Clase CM. Coagulation disorders and blood product use in patients 4547 undergoing thoracoabdominal aortic aneurysm repair. Transfus Med Rev. 4548 2005;19(2):143-54.
150
4549 552. Hess JR, Holcomb JB. Transfusion practice in military trauma. Transfus Med. 4550 2008;18(3):143-50. 4551 553. Spinella PC. Warm fresh whole blood transfusion for severe hemorrhage: U.S. 4552 military and potential civilian applications. Crit Care Med. 2008;36(7 Suppl):S340- 4553 5. 4554 554. Mell MW, O'Neil AS, Callcut RA, Acher CW, Hoch JR, Tefera G, et al. Effect of 4555 early plasma transfusion on mortality in patients with ruptured abdominal aortic 4556 aneurysm. Surgery. 2010;148(5):955-62. 4557 555. American Society of Anesthesiologists Task Force on Perioperative Blood M. 4558 Practice guidelines for perioperative blood management: an updated report by 4559 the American Society of Anesthesiologists Task Force on Perioperative Blood 4560 Management*. Anesthesiology. 2015;122(2):241-75. 4561 556. Koncar IB, Davidovic LB, Savic N, Sindelic RB, Ilic N, Dragas M, et al. Role of 4562 recombinant factor VIIa in the treatment of intractable bleeding in vascular 4563 surgery. J Vasc Surg. 2011;53(4):1032-7. 4564 557. Toomtong P, Suksompong S. Intravenous fluids for abdominal aortic surgery. 4565 Cochrane Database Syst Rev. 2010(1):CD000991. 4566 558. McArdle GT, McAuley DF, McKinley A, Blair P, Hoper M, Harkin DW. Preliminary 4567 results of a prospective randomized trial of restrictive versus standard fluid 4568 regime in elective open abdominal aortic aneurysm repair. Ann Surg. 4569 2009;250(1):28-34. 4570 559. Norris EJ. Perioperative Management of the Patient Undergoing Aortic Vascular 4571 Surgery. ASA Refresher Courses in Anesthesiology. 2005;33(1):187-202. 4572 560. Bender JS, Smith-Meek MA, Jones CE. Routine pulmonary artery catheterization 4573 does not reduce morbidity and mortality of elective vascular surgery: results of a 4574 prospective, randomized trial. Ann Surg. 1997;226(3):229-36. 4575 561. Isaacson IJ, Lowdon JD, Berry AJ, Smith RB, 3rd, Knos GB, Weitz FI, et al. The 4576 value of pulmonary artery and central venous monitoring in patients undergoing 4577 abdominal aortic reconstructive surgery: a comparative study of two selected, 4578 randomized groups. J Vasc Surg. 1990;12(6):754-60. 4579 562. Valentine RJ, Duke ML, Inman MH, Grayburn PA, Hagino RT, Kakish HB, et al. 4580 Effectiveness of pulmonary artery catheters in aortic surgery: a randomized trial. 4581 J Vasc Surg. 1998;27(2):203-11. 4582 563. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt 4583 B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and 4584 management of patients undergoing noncardiac surgery: executive summary: a 4585 report of the American College of Cardiology/American Heart Association Task 4586 Force on practice guidelines. Developed in collaboration with the American 4587 College of Surgeons, American Society of Anesthesiologists, American Society 4588 of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm 4589 Society, Society for Cardiovascular Angiography and Interventions, Society of 4590 Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by 4591 the Society of Hospital Medicine. J Nucl Cardiol. 2015;22(1):162-215. 4592 564. Porter TR, Shillcutt SK, Adams MS, Desjardins G, Glas KE, Olson JJ, et al. 4593 Guidelines for the use of echocardiography as a monitor for therapeutic
151
4594 intervention in adults: a report from the American Society of Echocardiography. J 4595 Am Soc Echocardiogr. 2015;28(1):40-56. 4596 565. Mahmood F, Christie A, Matyal R. Transesophageal echocardiography and 4597 noncardiac surgery. Semin Cardiothorac Vasc Anesth. 2008;12(4):265-89. 4598 566. Ali ZA, Callaghan CJ, Ali AA, Sheikh AY, Akhtar A, Pavlovic A, et al. 4599 Perioperative myocardial injury after elective open abdominal aortic aneurysm 4600 repair predicts outcome. Eur J Vasc Endovasc Surg. 2008;35(4):413-9. 4601 567. Le Manach Y, Perel A, Coriat P, Godet G, Bertrand M, Riou B. Early and delayed 4602 myocardial infarction after abdominal aortic surgery. Anesthesiology. 4603 2005;102(5):885-91. 4604 568. Kertai MD, Boersma E, Klein J, Van Urk H, Bax JJ, Poldermans D. Long-term 4605 prognostic value of asymptomatic cardiac troponin T elevations in patients after 4606 major vascular surgery. Eur J Vasc Endovasc Surg. 2004;28(1):59-66. 4607 569. Landesberg G, Shatz V, Akopnik I, Wolf YG, Mayer M, Berlatzky Y, et al. 4608 Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia 4609 with long-term survival after major vascular surgery. J Am Coll Cardiol. 4610 2003;42(9):1547-54. 4611 570. Landesberg G, Mosseri M, Wolf Y, Vesselov Y, Weissman C. Perioperative 4612 myocardial ischemia and infarction: identification by continuous 12-lead 4613 electrocardiogram with online ST-segment monitoring. Anesthesiology. 4614 2002;96(2):264-70. 4615 571. Garcia S, Marston N, Sandoval Y, Pierpont G, Adabag S, Brenes J, et al. 4616 Prognostic value of 12-lead electrocardiogram and peak troponin I level after 4617 vascular surgery. J Vasc Surg. 2013;57(1):166-72. 4618 572. Elmore JR, Franklin DP, Youkey JR, Oren JW, Frey CM. Normothermia is 4619 protective during infrarenal aortic surgery. J Vasc Surg. 1998;28(6):984-92. 4620 573. Gregorini P, Cangini D. Control of body temperature during abdominal aortic 4621 surgery. Acta Anaesthesiol Scand. 1996;40(2):187-90. 4622 574. Muth CM, Mainzer B, Peters J. The use of countercurrent heat exchangers 4623 diminishes accidental hypothermia during abdominal aortic aneurysm surgery. 4624 Acta Anaesthesiol Scand. 1996;40(10):1197-202. 4625 575. Teli M, Morris-Stiff G, Rees JR, Woodsford PV, Lewis MH. Vascular surgery, ICU 4626 and HDU: a 14-year observational study. Ann R Coll Surg Engl. 2008;90(4):291- 4627 6. 4628 576. Bertges DJ, Rhee RY, Muluk SC, Trachtenberg JD, Steed DL, Webster MW, et 4629 al. Is routine use of the intensive care unit after elective infrarenal abdominal 4630 aortic aneurysm repair necessary? J Vasc Surg. 2000;32(4):634-42. 4631 577. Lawlor DK, Lovell MB, DeRose G, Forbes TL, Harris KA. Is intensive care 4632 necessary after elective abdominal aortic aneurysm repair? Can J Surg. 4633 2004;47(5):359-63. 4634 578. Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal 4635 Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia. 4636 2008;63(1):44-51. 4637 579. Phan TD, Ismail H, Heriot AG, Ho KM. Improving perioperative outcomes: fluid 4638 optimization with the esophageal Doppler monitor, a metaanalysis and review. J 4639 Am Coll Surg. 2008;207(6):935-41.
152
4640 580. Legrand G, Ruscio L, Benhamou D, Pelletier-Fleury N. Goal-Directed Fluid 4641 Therapy Guided by Cardiac Monitoring During High-Risk Abdominal Surgery in 4642 Adult Patients: Cost-Effectiveness Analysis of Esophageal Doppler and Arterial 4643 Pulse Pressure Waveform Analysis. Value Health. 2015;18(5):605-13. 4644 581. Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early 4645 goal-directed therapy after major surgery reduces complications and duration of 4646 hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care. 4647 2005;9(6):R687-93. 4648 582. Mukherjee D. "Fast-track" abdominal aortic aneurysm repair. Vasc Endovascular 4649 Surg. 2003;37(5):329-34. 4650 583. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after 4651 abdominal surgery. Cochrane Database Syst Rev. 2007(3):CD004929. 4652 584. Chaar CI, Fitzgerald TN, Dewan M, Huddle M, Schlosser FJ, Perkal M, et al. 4653 Endovascular aneurysm repair is associated with less malnutrition than open 4654 abdominal aortic aneurysm repair. Am J Surg. 2009;198(5):623-7. 4655 585. Westvik TS, Krause LK, Pradhan S, Westvik HH, Maloney SP, Rutland R, et al. 4656 Malnutrition after vascular surgery: are patients with chronic renal failure at 4657 increased risk? Am J Surg. 2006;192(5):e22-7. 4658 586. Han-Geurts IJ, Hop WC, Kok NF, Lim A, Brouwer KJ, Jeekel J. Randomized 4659 clinical trial of the impact of early enteral feeding on postoperative ileus and 4660 recovery. Br J Surg. 2007;94(5):555-61. 4661 587. Ramanan B, Gupta PK, Sundaram A, Lynch TG, MacTaggart JN, Baxter BT, et 4662 al. In-hospital and postdischarge venous thromboembolism after vascular 4663 surgery. J Vasc Surg. 2013;57(6):1589-96. 4664 588. Davenport DL, Xenos ES. Deep venous thrombosis after repair of nonruptured 4665 abdominal aneurysm. J Vasc Surg. 2013;57(3):678-83.e1. 4666 589. Olin JW, Graor RA, O'Hara P, Young JR. The incidence of deep venous 4667 thrombosis in patients undergoing abdominal aortic aneurysm resection. J Vasc 4668 Surg. 1993;18(6):1037-41. 4669 590. Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. 4670 Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy 4671 and Prevention of Thrombosis, 9th ed: American College of Chest Physicians 4672 Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S- 4673 77S. 4674 591. Killewich LA, Aswad MA, Sandager GP, Lilly MP, Flinn WR. A randomized, 4675 prospective trial of deep venous thrombosis prophylaxis in aortic surgery. Arch 4676 Surg. 1997;132(5):499-504. 4677 592. Belch JJ, Lowe GD, Pollock JG, Forbes CD, Prentice CR. Low dose heparin in 4678 the prevention of deep-vein thrombosis after aortic bifurcation graft surgery. 4679 Thromb Haemost. 1980;42(5):1429-33. 4680 593. Harjola P, Meurala H, Frick MH. Prevention of deep venous thrombosis and 4681 thrombo-embolism by dipyridamole and acetylsalicylic acid after reconstructive 4682 arterial surgery. J Cardiovasc Surg (Torino). 1980;21(4):451-4. 4683 594. Spebar MJ, Collins GJ, Jr., Rich NM, Kang IY, Clagett GP, Salander JM. 4684 Perioperative heparin prophylaxis of deep venous thrombosis in patients with 4685 peripheral vascular disease. Am J Surg. 1981;142(6):649-50.
153
4686 595. Urbanyi B, Spillner G, Schleinzer P, Freidank H, Schlosser V. Prophylaxis 4687 Against Thromboembolism in Vascular Surgery: (A Randomised Clinical Trial). 4688 Vascular and Endovascular Surgery. 1982;16(4):253-9. 4689 596. Speziale F, Verardi S, Taurino M, Nicolini G, Rizzo L, Fiorani P, et al. Low 4690 molecular weight heparin prevention of post-operative deep vein thrombosis in 4691 vascular surgery. Pharmatherapeutica. 1988;5(4):261-8. 4692 597. Farkas JC, Chapuis C, Combe S, Silsiguen M, Marzelle J, Laurian C, et al. A 4693 randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to 4694 prevent deep-vein thrombosis in patients undergoing vascular surgery. Eur J 4695 Vasc Surg. 1993;7(5):554-60. 4696 598. Lastoria S, Rollo HA, Yoshida WB, Giannini M, Moura R, Maffei FH. Prophylaxis 4697 of deep-vein thrombosis after lower extremity amputation: comparison of low 4698 molecular weight heparin with unfractionated heparin. Acta Cir Bras. 4699 2006;21(3):184-6. 4700 599. Obi AT, Park YJ, Bove P, Cuff R, Kazmers A, Gurm HS, et al. The association of 4701 perioperative transfusion with 30-day morbidity and mortality in patients 4702 undergoing major vascular surgery. J Vasc Surg. 2015;61(4):1000-9.e1. 4703 600. Hebert PC, Carson JL. Transfusion threshold of 7 g per deciliter--the new normal. 4704 N Engl J Med. 2014;371(15):1459-61. 4705 601. Curley GF, Shehata N, Mazer CD, Hare GM, Friedrich JO. Transfusion triggers 4706 for guiding RBC transfusion for cardiovascular surgery: a systematic review and 4707 meta-analysis*. Crit Care Med. 2014;42(12):2611-24. 4708 602. Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies 4709 for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 4710 2012;4:Cd002042. 4711 603. American Society of Anesthesiologists Task Force on Acute Pain M. Practice 4712 guidelines for acute pain management in the perioperative setting: an updated 4713 report by the American Society of Anesthesiologists Task Force on Acute Pain 4714 Management. Anesthesiology. 2012;116(2):248-73. 4715 604. Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for 4716 abdominal aortic surgery. Cochrane Database Syst Rev. 2016(1):CD005059. 4717 605. Bardia A, Sood A, Mahmood F, Orhurhu V, Mueller A, Montealegre-Gallegos M, 4718 et al. Combined Epidural-General Anesthesia vs General Anesthesia Alone for 4719 Elective Abdominal Aortic Aneurysm Repair. JAMA Surg. 2016. 4720 606. Panaretou V, Toufektzian L, Siafaka I, Kouroukli I, Sigala F, Vlachopoulos C, et 4721 al. Postoperative pulmonary function after open abdominal aortic aneurysm 4722 repair in patients with chronic obstructive pulmonary disease: epidural versus 4723 intravenous analgesia. Ann Vasc Surg. 2012;26(2):149-55. 4724 607. Wallace D, Bright E, London NJ. The incidence of epidural abscess following 4725 epidural analgesia in open abdominal aortic aneurysm repair. Ann R Coll Surg 4726 Engl. 2010;92(1):31-3. 4727 608. Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the 4728 clinical effectiveness of transversus abdominis plane block. J Clin Anesth. 4729 2011;23(1):7-14. 4730 609. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: a 4731 systematic review. Reg Anesth Pain Med. 2012;37(2):193-209.
154
4732 610. Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus 4733 abdominis plane (TAP) blocks for analgesia after abdominal surgery. Cochrane 4734 Database Syst Rev. 2010(12):CD007705. 4735 611. Ouriel K, Clair DG, Greenberg RK, Lyden SP, O'Hara PJ, Sarac TP, et al. 4736 Endovascular repair of abdominal aortic aneurysms: device-specific outcome. J 4737 Vasc Surg. 2003;37(5):991-8. 4738 612. Peterson BG, Matsumura JS, Brewster DC, Makaroun MS, Excluder Bifurcated 4739 Endoprosthesis I. Five-year report of a multicenter controlled clinical trial of open 4740 versus endovascular treatment of abdominal aortic aneurysms. J Vasc Surg. 4741 2007;45(5):885-90. 4742 613. Sheehan MK, Ouriel K, Greenberg R, McCann R, Murphy M, Fillinger M, et al. 4743 Are type II endoleaks after endovascular aneurysm repair endograft dependent? 4744 J Vasc Surg. 2006;43(4):657-61. 4745 614. AbuRahma AF, Welch CA, Mullins BB, Dyer B. Computed tomography versus 4746 color duplex ultrasound for surveillance of abdominal aortic stent-grafts. J 4747 Endovasc Ther. 2005;12(5):568-73. 4748 615. Sato DT, Goff CD, Gregory RT, Robinson KD, Carter KA, Herts BR, et al. 4749 Endoleak after aortic stent graft repair: diagnosis by color duplex ultrasound scan 4750 versus computed tomography scan. J Vasc Surg. 1998;28(4):657-63. 4751 616. Baum RA, Carpenter JP, Cope C, Golden MA, Velazquez OC, Neschis DG, et al. 4752 Aneurysm sac pressure measurements after endovascular repair of abdominal 4753 aortic aneurysms. J Vasc Surg. 2001;33(1):32-41. 4754 617. Buth J, Laheij RJ. Early complications and endoleaks after endovascular 4755 abdominal aortic aneurysm repair: report of a multicenter study. J Vasc Surg. 4756 2000;31(1 Pt 1):134-46. 4757 618. Harris PL, Vallabhaneni SR, Desgranges P, Becquemin JP, van Marrewijk C, 4758 Laheij RJ. Incidence and risk factors of late rupture, conversion, and death after 4759 endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. 4760 European Collaborators on Stent/graft techniques for aortic aneurysm repair. J 4761 Vasc Surg. 2000;32(4):739-49. 4762 619. Schurink GW, Aarts NJ, Wilde J, van Baalen JM, Chuter TA, Schultze Kool LJ, et 4763 al. Endoleakage after stent-graft treatment of abdominal aneurysm: implications 4764 on pressure and imaging--an in vitro study. J Vasc Surg. 1998;28(2):234-41. 4765 620. Bail DH, Walker T, Giehl J. Vascular endostapling systems for vascular 4766 endografts (T)EVAR--systematic review--current state. Vasc Endovascular Surg. 4767 2013;47(4):261-6. 4768 621. de Vries JP, Ouriel K, Mehta M, Varnagy D, Moore WM, Jr., Arko FR, et al. 4769 Analysis of EndoAnchors for endovascular aneurysm repair by indications for 4770 use. J Vasc Surg. 2014;60(6):1460-7.e1. 4771 622. Maldonado TS, Rosen RJ, Rockman CB, Adelman MA, Bajakian D, Jacobowitz 4772 GR, et al. Initial successful management of type I endoleak after endovascular 4773 aortic aneurysm repair with n-butyl cyanoacrylate adhesive. J Vasc Surg. 4774 2003;38(4):664-70. 4775 623. Sheehan MK, Barbato J, Compton CN, Zajko A, Rhee R, Makaroun MS. 4776 Effectiveness of coiling in the treatment of endoleaks after endovascular repair. J 4777 Vasc Surg. 2004;40(3):430-4.
155
4778 624. Kelso RL, Lyden SP, Butler B, Greenberg RK, Eagleton MJ, Clair DG. Late 4779 conversion of aortic stent grafts. J Vasc Surg. 2009;49(3):589-95. 4780 625. Makaroun M, Zajko A, Sugimoto H, Eskandari M, Webster M. Fate of endoleaks 4781 after endoluminal repair of abdominal aortic aneurysms with the EVT device. Eur 4782 J Vasc Endovasc Surg. 1999;18(3):185-90. 4783 626. Kray J, Kirk S, Franko J, Chew DK. Role of type II endoleak in sac regression 4784 after endovascular repair of infrarenal abdominal aortic aneurysms. J Vasc Surg. 4785 2015;61(4):869-74. 4786 627. Piazza M, Frigatti P, Scrivere P, Bonvini S, Noventa F, Ricotta JJ, 2nd, et al. 4787 Role of aneurysm sac embolization during endovascular aneurysm repair in the 4788 prevention of type II endoleak-related complications. J Vasc Surg. 4789 2013;57(4):934-41. 4790 628. Zandvoort HJ, Goncalves FB, Verhagen HJ, Werson DA, Moll FL, de Vries JP, et 4791 al. Results of endovascular repair of infrarenal aortic aneurysms using the 4792 Endurant stent graft. J Vasc Surg. 2014;59(5):1195-202. 4793 629. Lowenthal D, Herzog L, Rogits B, Bulla K, Weston S, Meyer F, et al. Identification 4794 of predictive CT angiographic factors in the development of high-risk type 2 4795 endoleaks after endovascular aneurysm repair in patients with infrarenal aortic 4796 aneurysms. Rofo. 2015;187(1):49-55. 4797 630. Ward TJ, Cohen S, Patel RS, Kim E, Fischman AM, Nowakowski FS, et al. 4798 Anatomic risk factors for type-2 endoleak following EVAR: a retrospective review 4799 of preoperative CT angiography in 326 patients. Cardiovasc Intervent Radiol. 4800 2014;37(2):324-8. 4801 631. AbuRahma AF, Mousa AY, Campbell JE, Stone PA, Hass SM, Nanjundappa A, 4802 et al. The relationship of preoperative thrombus load and location to the 4803 development of type II endoleak and sac regression. J Vasc Surg. 4804 2011;53(6):1534-41. 4805 632. Bobadilla JL, Hoch JR, Leverson GE, Tefera G. The effect of warfarin therapy on 4806 endoleak development after endovascular aneurysm repair (EVAR) of the 4807 abdominal aorta. J Vasc Surg. 2010;52(2):267-71. 4808 633. Beeman BR, Murtha K, Doerr K, McAfee-Bennett S, Dougherty MJ, Calligaro KD. 4809 Duplex ultrasound factors predicting persistent type II endoleak and increasing 4810 AAA sac diameter after EVAR. J Vasc Surg. 2010;52(5):1147-52. 4811 634. Rayt HS, Sandford RM, Salem M, Bown MJ, London NJ, Sayers RD. 4812 Conservative management of type 2 endoleaks is not associated with increased 4813 risk of aneurysm rupture. Eur J Vasc Endovasc Surg. 2009;38(6):718-23. 4814 635. Zhou W, Blay E, Jr., Varu V, Ali S, Jin MQ, Sun L, et al. Outcome and clinical 4815 significance of delayed endoleaks after endovascular aneurysm repair. J Vasc 4816 Surg. 2014;59(4):915-20. 4817 636. Sidloff DA, Gokani V, Stather PW, Choke E, Bown MJ, Sayers RD. Type II 4818 endoleak: conservative management is a safe strategy. Eur J Vasc Endovasc 4819 Surg. 2014;48(4):391-9. 4820 637. Mansueto G, Cenzi D, Scuro A, Gottin L, Griso A, Gumbs AA, et al. Treatment of 4821 type II endoleak with a transcatheter transcaval approach: results at 1-year 4822 follow-up. J Vasc Surg. 2007;45(6):1120-7.
156
4823 638. Giles KA, Fillinger MF, De Martino RR, Hoel AW, Powell RJ, Walsh DB. Results 4824 of transcaval embolization for sac expansion from type II endoleaks after 4825 endovascular aneurysm repair. J Vasc Surg. 2015;61(5):1129-36. 4826 639. Richardson WS, Sternbergh WC, 3rd, Money SR. Laparoscopic inferior 4827 mesenteric artery ligation: an alternative for the treatment of type II endoleaks. J 4828 Laparoendosc Adv Surg Tech A. 2003;13(6):355-8. 4829 640. Jouhannet C, Alsac JM, Julia P, Sapoval M, El Batti S, Di Primio M, et al. 4830 Reinterventions for type 2 endoleaks with enlargement of the aneurismal sac 4831 after endovascular treatment of abdominal aortic aneurysms. Ann Vasc Surg. 4832 2014;28(1):192-200. 4833 641. Sarac TP, Gibbons C, Vargas L, Liu J, Srivastava S, Bena J, et al. Long-term 4834 follow-up of type II endoleak embolization reveals the need for close surveillance. 4835 J Vasc Surg. 2012;55(1):33-40. 4836 642. Maitrias P, Kaladji A, Plissonnier D, Amiot S, Sabatier J, Coggia M, et al. 4837 Treatment of sac expansion after endovascular aneurysm repair with obliterating 4838 endoaneurysmorrhaphy and stent graft preservation. J Vasc Surg. 4839 2016;63(4):902-8. 4840 643. Hinchliffe RJ, Singh-Ranger R, Whitaker SC, Hopkinson BR. Type II endoleak: 4841 transperitoneal sacotomy and ligation of side branch endoleaks responsible for 4842 aneurysm sac expansion. J Endovasc Ther. 2002;9(4):539-42. 4843 644. Ferrari M, Sardella SG, Berchiolli R, Adami D, Vignali C, Napoli V, et al. Surgical 4844 treatment of persistent type 2 endoleaks, with increase of the aneurysm sac: 4845 indications and technical notes. Eur J Vasc Endovasc Surg. 2005;29(1):43-6. 4846 645. Cieri E, De Rango P, Isernia G, Simonte G, Ciucci A, Parlani G, et al. Type II 4847 endoleak is an enigmatic and unpredictable marker of worse outcome after 4848 endovascular aneurysm repair. J Vasc Surg. 2014;59(4):930-7. 4849 646. Higashiura W, Greenberg RK, Katz E, Geiger L, Bathurst S. Predictive factors, 4850 morphologic effects, and proposed treatment paradigm for type II endoleaks after 4851 repair of infrarenal abdominal aortic aneurysms. J Vasc Interv Radiol. 4852 2007;18(8):975-81. 4853 647. van Marrewijk CJ, Fransen G, Laheij RJ, Harris PL, Buth J, Collaborators E. Is a 4854 type II endoleak after EVAR a harbinger of risk? Causes and outcome of open 4855 conversion and aneurysm rupture during follow-up. Eur J Vasc Endovasc Surg. 4856 2004;27(2):128-37. 4857 648. Steinmetz E, Rubin BG, Sanchez LA, Choi ET, Geraghty PJ, Baty J, et al. Type II 4858 endoleak after endovascular abdominal aortic aneurysm repair: a conservative 4859 approach with selective intervention is safe and cost-effective. J Vasc Surg. 4860 2004;39(2):306-13. 4861 649. Gilling-Smith G, Brennan J, Harris P, Bakran A, Gould D, McWilliams R. 4862 Endotension after endovascular aneurysm repair: definition, classification, and 4863 strategies for surveillance and intervention. J Endovasc Surg. 1999;6(4):305-7. 4864 650. van Sambeek MR, Hendriks JM, Tseng L, van Dijk LC, van Urk H. Sac 4865 enlargement without endoleak: when and how to convert and technical 4866 considerations. Semin Vasc Surg. 2004;17(4):284-7. 4867 651. Sternbergh WC, 3rd, Money SR, Greenberg RK, Chuter TA, Zenith I. Influence of 4868 endograft oversizing on device migration, endoleak, aneurysm shrinkage, and
157
4869 aortic neck dilation: results from the Zenith Multicenter Trial. J Vasc Surg. 4870 2004;39(1):20-6. 4871 652. Resch T, Ivancev K, Brunkwall J, Nyman U, Malina M, Lindblad B. Distal 4872 migration of stent-grafts after endovascular repair of abdominal aortic 4873 aneurysms. J Vasc Interv Radiol. 1999;10(3):257-64. 4874 653. Tonnessen BH, Sternbergh WC, 3rd, Money SR. Mid- and long-term device 4875 migration after endovascular abdominal aortic aneurysm repair: a comparison of 4876 AneuRx and Zenith endografts. J Vasc Surg. 2005;42(3):392-400. 4877 654. Holtham SJ, Rose JD, Jackson RW, Lees TA, Wyatt MG. The Vanguard 4878 endovascular stent-graft: mid-term results from a single centre. Eur J Vasc 4879 Endovasc Surg. 2004;27(3):311-8. 4880 655. Chandra V, Rouer M, Garg T, Fleischmann D, Mell M. Aortoiliac elongation after 4881 endovascular aortic aneurysm repair. Ann Vasc Surg. 2015;29(5):891-7. 4882 656. Litwinski RA, Donayre CE, Chow SL, Song TK, Kopchok G, Walot I, et al. The 4883 role of aortic neck dilation and elongation in the etiology of stent graft migration 4884 after endovascular abdominal aortic aneurysm repair with a passive fixation 4885 device. J Vasc Surg. 2006;44(6):1176-81. 4886 657. Thomas BG, Sanchez LA, Geraghty PJ, Rubin BG, Money SR, Sicard GA. A 4887 comparative analysis of the outcomes of aortic cuffs and converters for 4888 endovascular graft migration. J Vasc Surg. 2010;51(6):1373-80. 4889 658. Matsumura JS, Pearce WH, Cabellon A, McCarthy WJ, 3rd, Yao JS. Reoperative 4890 aortic surgery. Cardiovasc Surg. 1999;7(6):614-21. 4891 659. participants Et. Endovascular aneurysm repair versus open repair in patients with 4892 abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 4893 2005;365(9478):2179-86. 4894 660. Mantas GK, Antonopoulos CN, Sfyroeras GS, Moulakakis KG, Kakisis JD, 4895 Mylonas SN, et al. Factors Predisposing to Endograft Limb Occlusion after 4896 Endovascular Aortic Repair. Eur J Vasc Endovasc Surg. 2015;49(1):39-44. 4897 661. Maleux G, Koolen M, Heye S, Nevelsteen A. Limb occlusion after endovascular 4898 repair of abdominal aortic aneurysms with supported endografts. J Vasc Interv 4899 Radiol. 2008;19(10):1409-12. 4900 662. Fairman RM, Baum RA, Carpenter JP, Deaton DH, Makaroun MS, Velazquez 4901 OC, et al. Limb interventions in patients undergoing treatment with an 4902 unsupported bifurcated aortic endograft system: a review of the Phase II EVT 4903 Trial. J Vasc Surg. 2002;36(1):118-26. 4904 663. Hobo R, Buth J, collaborators E. Secondary interventions following endovascular 4905 abdominal aortic aneurysm repair using current endografts. A EUROSTAR 4906 report. J Vasc Surg. 2006;43(5):896-902. 4907 664. Conway AM, Modarai B, Taylor PR, Carrell TW, Waltham M, Salter R, et al. 4908 Stent-graft limb deployment in the external iliac artery increases the risk of limb 4909 occlusion following endovascular AAA repair. J Endovasc Ther. 2012;19(1):79- 4910 85. 4911 665. Daoudal A, Cardon A, Verhoye JP, Clochard E, Lucas A, Kaladji A. Sealing 4912 zones have a greater influence than iliac anatomy on the occurrence of limb 4913 occlusion following endovascular aortic aneurysm repair. Vascular. 4914 2016;24(3):279-86.
158
4915 666. Hinchliffe RJ, Alric P, Wenham PW, Hopkinson BR. Durability of femorofemoral 4916 bypass grafting after aortouniiliac endovascular aneurysm repair. J Vasc Surg. 4917 2003;38(3):498-503. 4918 667. Clouse WD, Brewster DC, Marone LK, Cambria RP, Lamuraglia GM, Watkins 4919 MT, et al. Durability of aortouniiliac endografting with femorofemoral crossover: 4920 4-year experience in the Evt/Guidant trials. J Vasc Surg. 2003;37(6):1142-9. 4921 668. Lehnert T, Gruber HP, Maeder N, Allenberg JR. Management of primary aortic 4922 graft infection by extra-anatomic bypass reconstruction. Eur J Vasc Surg. 4923 1993;7(3):301-7. 4924 669. Herdrich BJ, Fairman RM. How to manage infected aortic endografts. J 4925 Cardiovasc Surg (Torino). 2013;54(5):595-604. 4926 670. Vogel TR, Symons R, Flum DR. The incidence and factors associated with graft 4927 infection after aortic aneurysm repair. J Vasc Surg. 2008;47(2):264-9. 4928 671. Champion MC, Sullivan SN, Coles JC, Goldbach M, Watson WC. Aortoenteric 4929 fistula. Incidence, presentation recognition, and management. Ann Surg. 4930 1982;195(3):314-7. 4931 672. Leon LR, Jr., Mills JL, Sr., Psalms SB, Kasher J, Kim J, Ihnat DM. Aortic 4932 paraprosthetic-colonic fistulae: a review of the literature. Eur J Vasc Endovasc 4933 Surg. 2007;34(6):682-92. 4934 673. Murphy EH, Szeto WY, Herdrich BJ, Jackson BM, Wang GJ, Bavaria JE, et al. 4935 The management of endograft infections following endovascular thoracic and 4936 abdominal aneurysm repair. J Vasc Surg. 2013;58(5):1179-85. 4937 674. Fatima J, Duncan AA, de Grandis E, Oderich GS, Kalra M, Gloviczki P, et al. 4938 Treatment strategies and outcomes in patients with infected aortic endografts. J 4939 Vasc Surg. 2013;58(2):371-9. 4940 675. Jamieson GG, DeWeese JA, Rob CG. Infected arterial grafts. Ann Surg. 4941 1975;181(6):850-2. 4942 676. Geroulakos G, Lumley JS, Wright JG. Factors influencing the long-term results of 4943 abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 1997;13(1):3-8. 4944 677. Clagett GP, Valentine RJ, Hagino RT. Autogenous aortoiliac/femoral 4945 reconstruction from superficial femoral-popliteal veins: feasibility and durability. J 4946 Vasc Surg. 1997;25(2):255-66. 4947 678. Edwards WH, Jr., Martin RS, 3rd, Jenkins JM, Edwards WH, Sr., Mulherin JL, Jr. 4948 Primary graft infections. J Vasc Surg. 1987;6(3):235-9. 4949 679. McCann RL, Schwartz LB, Georgiade GS. Management of abdominal aortic graft 4950 complications. Ann Surg. 1993;217(6):729-34. 4951 680. Reilly LM, Stoney RJ, Goldstone J, Ehrenfeld WK. Improved management of 4952 aortic graft infection: the influence of operation sequence and staging. J Vasc 4953 Surg. 1987;5(3):421-31. 4954 681. Szilagyi DE, Smith RF, Elliott JP, Vrandecic MP. Infection in arterial 4955 reconstruction with synthetic grafts. Ann Surg. 1972;176(3):321-33. 4956 682. D’Addio V, Clagett GP. Surgical treatment of the infected aortic graft: ACS 4957 surgery, principles and practice. New York: WebMD; 2005. 4958 683. Kieffer E, Gomes D, Chiche L, Fleron MH, Koskas F, Bahnini A. Allograft 4959 replacement for infrarenal aortic graft infection: early and late results in 179 4960 patients. J Vasc Surg. 2004;39(5):1009-17.
159
4961 684. Perera GB, Fujitani RM, Kubaska SM. Aortic graft infection: update on 4962 management and treatment options. Vasc Endovascular Surg. 2006;40(1):1-10. 4963 685. Vogt PR, Brunner-LaRocca HP, Lachat M, Ruef C, Turina MI. Technical details 4964 with the use of cryopreserved arterial allografts for aortic infection: influence on 4965 early and midterm mortality. J Vasc Surg. 2002;35(1):80-6. 4966 686. Batt M, Jean-Baptiste E, O'Connor S, Bouillanne PJ, Haudebourg P, Hassen- 4967 Khodja R, et al. In-situ revascularisation for patients with aortic graft infection: a 4968 single centre experience with silver coated polyester grafts. Eur J Vasc Endovasc 4969 Surg. 2008;36(2):182-8. 4970 687. Lawrence PF. Conservative treatment of aortic graft infection. Semin Vasc Surg. 4971 2011;24(4):199-204. 4972 688. Cernohorsky P, Reijnen MM, Tielliu IF, van Sterkenburg SM, van den Dungen JJ, 4973 Zeebregts CJ. The relevance of aortic endograft prosthetic infection. J Vasc 4974 Surg. 2011;54(2):327-33. 4975 689. Pryluck DS, Kovacs S, Maldonado TS, Jacobowitz GR, Adelman MA, Charles 4976 HC, et al. Percutaneous drainage of aortic aneurysm sac abscesses following 4977 endovascular aneurysm repair. Vasc Endovascular Surg. 2010;44(8):701-7. 4978 690. Armstrong PA, Back MR, Wilson JS, Shames ML, Johnson BL, Bandyk DF. 4979 Improved outcomes in the recent management of secondary aortoenteric fistula. 4980 J Vasc Surg. 2005;42(4):660-6. 4981 691. Bunt TJ. Synthetic vascular graft infections. II. Graft-enteric erosions and graft- 4982 enteric fistulas. Surgery. 1983;94(1):1-9. 4983 692. Busuttil RW, Rees W, Baker JD, Wilson SE. Pathogenesis of aortoduodenal 4984 fistula: experimental and clinical correlates. Surgery. 1979;85(1):1-13. 4985 693. Moulton S, Adams M, Johansen K. Aortoenteric fistula. A 7 year urban 4986 experience. Am J Surg. 1986;151(5):607-11. 4987 694. Higgins RS, Steed DL, Julian TB, Makaroun MS, Peitzman AB, Webster MW. 4988 The management of aortoenteric and paraprosthetic fistulae. J Cardiovasc Surg 4989 (Torino). 1990;31(1):81-6. 4990 695. Moulakakis KG, Kakisis J, Dalainas I, Smyrniotis V, Liapis CD. Endovascular 4991 management of secondary aortoduodenal fistula: the importance of gut 4992 restoration. Int J Angiol. 2015;24(1):55-8. 4993 696. Williams CA, Zatina MA. Endovascular stent graft deployment as the initial 4994 intervention for a bleeding aortoenteric fistula. Am Surg. 2014;80(7):e207-9. 4995 697. Richey R, Wray D, Stokes T, Guideline Development G. Prophylaxis against 4996 infective endocarditis: summary of NICE guidance. BMJ. 2008;336(7647):770-1. 4997 698. Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. 4998 Incidence of infective endocarditis in England, 2000-13: a secular trend, 4999 interrupted time-series analysis. Lancet. 2015;385(9974):1219-28. 5000 699. Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2016;387(10021):882- 5001 93. 5002 700. Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, et al. 5003 ACC/AHA 2008 guideline update on valvular heart disease: focused update on 5004 infective endocarditis: a report of the American College of Cardiology/American 5005 Heart Association Task Force on Practice Guidelines: endorsed by the Society of 5006 Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and
160
5007 Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(8):887- 5008 96. 5009 701. Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. 5010 Guidelines on the prevention, diagnosis, and treatment of infective endocarditis 5011 (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment 5012 of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed 5013 by the European Society of Clinical Microbiology and Infectious Diseases 5014 (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and 5015 Cancer. Eur Heart J. 2009;30(19):2369-413. 5016 702. Patane S. Is there a need for bacterial endocarditis prophylaxis in patients 5017 undergoing gastrointestinal endoscopy? J Cardiovasc Transl Res. 2014;7(3):372- 5018 4. 5019 703. Patane S. Is there a need for bacterial endocarditis prophylaxis in patients 5020 undergoing urological procedures? J Cardiovasc Transl Res. 2014;7(3):369-71. 5021 704. Hayashida N, Masuda M, Pearce Y, Kuwabara S. Wound complications of the 5022 retroperitoneal approach for the abdominal aortic aneurysm repair-an evaluation 5023 of abdominal bulge formation. Ann Vasc Dis. 2014;7(1):17-20. 5024 705. Henriksen NA, Helgstrand F, Vogt KC, Jorgensen LN, Bisgaard T, Danish Hernia 5025 D, et al. Risk factors for incisional hernia repair after aortic reconstructive surgery 5026 in a nationwide study. J Vasc Surg. 2013;57(6):1524-30.e1-3. 5027 706. Gruppo M, Mazzalai F, Lorenzetti R, Piatto G, Toniato A, Ballotta E. Midline 5028 abdominal wall incisional hernia after aortic reconstructive surgery: a prospective 5029 study. Surgery. 2012;151(6):882-8. 5030 707. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. 5031 European Hernia Society guidelines on the closure of abdominal wall incisions. 5032 Hernia. 2015;19(1):1-24. 5033 708. Baker DM, Hinchliffe RJ, Yusuf SW, Whitaker SC, Hopkinson BR. True juxta- 5034 anastomotic aneurysms in the residual infra-renal abdominal aorta. Eur J Vasc 5035 Endovasc Surg. 2003;25(5):412-5. 5036 709. Edwards JM, Teefey SA, Zierler RE, Kohler TR. Intraabdominal paraanastomotic 5037 aneurysms after aortic bypass grafting. J Vasc Surg. 1992;15(2):344-50. 5038 710. Mii S, Mori A, Sakata H, Kawazoe N. Para-anastomotic aneurysms: incidence, 5039 risk factors, treatment and prognosis. J Cardiovasc Surg (Torino). 5040 1998;39(3):259-66. 5041 711. Szilagyi DE, Smith RF, Elliott JP, Hageman JH, Dall'Olmo CA. Anastomotic 5042 aneurysms after vascular reconstruction: problems of incidence, etiology, and 5043 treatment. Surgery. 1975;78(6):800-16. 5044 712. Ylonen K, Biancari F, Leo E, Rainio P, Salmela E, Lahtinen J, et al. Predictors of 5045 development of anastomotic femoral pseudoaneurysms after aortobifemoral 5046 reconstruction for abdominal aortic aneurysm. Am J Surg. 2004;187(1):83-7. 5047 713. Gawenda M, Zaehringer M, Brunkwall J. Open versus endovascular repair of 5048 para-anastomotic aneurysms in patients who were morphological candidates for 5049 endovascular treatment. J Endovasc Ther. 2003;10(4):745-51. 5050 714. Sachdev U, Baril DT, Morrissey NJ, Silverberg D, Jacobs TS, Carroccio A, et al. 5051 Endovascular repair of para-anastomotic aortic aneurysms. J Vasc Surg. 5052 2007;46(4):636-41.
161
5053 715. Tshomba Y, Mascia D, Kahlberg A, Marone EM, Melissano G, Chiesa R. On- 5054 label use of commercially-available abdominal endografts for para-anastomotic 5055 aneurysms and pseudoaneurysms after infrarenal abdominal aortic aneurysm 5056 open repair. Eur J Vasc Endovasc Surg. 2013;46(6):657-66. 5057 716. Ten Bosch JA, Waasdorp EJ, de Vries JP, Moll FL, Teijink JA, van Herwaarden 5058 JA. The durability of endovascular repair of para-anastomotic aneurysms after 5059 previous open aortic reconstruction. J Vasc Surg. 2011;54(6):1571-8. 5060 717. Siani A, Accrocca F, Gabrielli R, Marcucci G. Is the chimney graft technique a 5061 safe and feasible approach to treat urgent aneurysm and pseudoaneurysm of the 5062 abdominal aorta? An analysis of our experience and technical considerations. 5063 Interact Cardiovasc Thorac Surg. 2013;16(5):692-4. 5064 718. Donas KP, Torsello G, Bisdas T, Osada N, Schonefeld E, Pitoulias GA. Early 5065 outcomes for fenestrated and chimney endografts in the treatment of pararenal 5066 aortic pathologies are not significantly different: a systematic review with pooled 5067 data analysis. J Endovasc Ther. 2012;19(6):723-8. 5068 719. Wu Z, Xu L, Raithel D, Qu L. Endovascular repair of proximal para-anastomotic 5069 aneurysms after previous open abdominal aortic aneurysm reconstruction. 5070 Vascular. 2015. 5071 720. Soler RJ, Bartoli MA, Mancini J, Lerussi G, Thevenin B, Sarlon-Bartoli G, et al. 5072 Aneurysm sac shrinkage after endovascular repair: predictive factors and long- 5073 term follow-up. Ann Vasc Surg. 2015;29(4):770-9. 5074 721. Sadek M, Dexter DJ, Rockman CB, Hoang H, Mussa FF, Cayne NS, et al. 5075 Preoperative relative abdominal aortic aneurysm thrombus burden predicts 5076 endoleak and sac enlargement after endovascular anerysm repair. Ann Vasc 5077 Surg. 2013;27(8):1036-41. 5078 722. Schanzer A, Greenberg RK, Hevelone N, Robinson WP, Eslami MH, Goldberg 5079 RJ, et al. Predictors of abdominal aortic aneurysm sac enlargement after 5080 endovascular repair. Circulation. 2011;123(24):2848-55. 5081 723. Go MR, Barbato JE, Rhee RY, Makaroun MS. What is the clinical utility of a 6- 5082 month computed tomography in the follow-up of endovascular aneurysm repair 5083 patients? J Vasc Surg. 2008;47(6):1181-6. 5084 724. Sternbergh WC, 3rd, Greenberg RK, Chuter TA, Tonnessen BH, Zenith I. 5085 Redefining postoperative surveillance after endovascular aneurysm repair: 5086 recommendations based on 5-year follow-up in the US Zenith multicenter trial. J 5087 Vasc Surg. 2008;48(2):278-84. 5088 725. Chaer RA, Gushchin A, Rhee R, Marone L, Cho JS, Leers S, et al. Duplex 5089 ultrasound as the sole long-term surveillance method post-endovascular 5090 aneurysm repair: a safe alternative for stable aneurysms. J Vasc Surg. 5091 2009;49(4):845-9. 5092 726. Chung J, Kordzadeh A, Prionidis I, Panayiotopoulos Y, Browne T. Contrast- 5093 enhanced ultrasound (CEUS) versus computed tomography angiography (CTA) 5094 in detection of endoleaks in post-EVAR patients. Are delayed type II endoleaks 5095 being missed? A systematic review and meta-analysis. J Ultrasound. 5096 2015;18(2):91-9. 5097 727. Zimmermann H, D'Anastasi M, Rjosk-Dendorfer D, Helck A, Meimarakis G, 5098 Reiser M, et al. Value of high-resolution contrast-enhanced ultrasound in
162
5099 detection and characterisation of endoleaks after EVAR. Clin Hemorheol 5100 Microcirc. 2014;58(1):247-60. 5101 728. Abbas A, Hansrani V, Sedgwick N, Ghosh J, McCollum CN. 3D contrast 5102 enhanced ultrasound for detecting endoleak following endovascular aneurysm 5103 repair (EVAR). Eur J Vasc Endovasc Surg. 2014;47(5):487-92. 5104 729. Nyheim T, Staxrud LE, Rosen L, Slagsvold CE, Sandbaek G, Jorgensen JJ. 5105 Review of postoperative CT and ultrasound for endovascular aneurysm repair 5106 using Talent stent graft: can we simplify the surveillance protocol and reduce the 5107 number of CT scans? Acta Radiol. 2013;54(1):54-8. 5108 730. Garg T, Baker LC, Mell MW. Adherence to postoperative surveillance guidelines 5109 after endovascular aortic aneurysm repair among Medicare beneficiaries. J Vasc 5110 Surg. 2015;61(1):23-7. 5111 731. Wu CY, Chen H, Gallagher KA, Eliason JL, Rectenwald JE, Coleman DM. 5112 Predictors of compliance with surveillance after endovascular aneurysm repair 5113 and comparative survival outcomes. J Vasc Surg. 2015;62(1):27-35. 5114 732. Schanzer A, Messina LM, Ghosh K, Simons JP, Robinson WP, 3rd, Aiello FA, et 5115 al. Follow-up compliance after endovascular abdominal aortic aneurysm repair in 5116 Medicare beneficiaries. J Vasc Surg. 2015;61(1):16-22.e1. 5117 733. Garg T, Baker LC, Mell MW. Postoperative Surveillance and Long-term 5118 Outcomes After Endovascular Aneurysm Repair Among Medicare Beneficiaries. 5119 JAMA Surg. 2015;150(10):957-63. 5120 734. Cho JS, Park T, Kim JY, Chaer RA, Rhee RY, Makaroun MS. Prior endovascular 5121 abdominal aortic aneurysm repair provides no survival benefits when the 5122 aneurysm ruptures. J Vasc Surg. 2010;52(5):1127-34. 5123 735. Candell L, Tucker LY, Goodney P, Walker J, Okuhn S, Hill B, et al. Early and 5124 delayed rupture after endovascular abdominal aortic aneurysm repair in a 10- 5125 year multicenter registry. J Vasc Surg. 2014;60(5):1146-52. 5126 736. Brox AC, Filion KB, Zhang X, Pilote L, Obrand D, Haider S, et al. In-hospital cost 5127 of abdominal aortic aneurysm repair in Canada and the United States. Arch 5128 Intern Med. 2003;163(20):2500-4. 5129 737. Lederle FA, Stroupe KT, Open Versus Endovascular Repair Veterans Affairs 5130 Cooperative Study G. Cost-effectiveness at two years in the VA Open Versus 5131 Endovascular Repair Trial. Eur J Vasc Endovasc Surg. 2012;44(6):543-8. 5132 738. Matsumura JS, Stroupe KT, Lederle FA, Kyriakides TC, Ge L, Freischlag JA, et 5133 al. Costs of repair of abdominal aortic aneurysm with different devices in a 5134 multicenter randomized trial. J Vasc Surg. 2015;61(1):59-65. 5135 739. Sternbergh WC, 3rd, Money SR. Hospital cost of endovascular versus open 5136 repair of abdominal aortic aneurysms: a multicenter study. J Vasc Surg. 5137 2000;31(2):237-44. 5138 740. Kayssi A, DeBord Smith A, Roche-Nagle G, Nguyen LL. Health-related quality-of- 5139 life outcomes after open versus endovascular abdominal aortic aneurysm repair. 5140 J Vasc Surg. 2015;62(2):491-8. 5141 741. Patel ST, Haser PB, Bush HL, Jr., Kent KC. The cost-effectiveness of 5142 endovascular repair versus open surgical repair of abdominal aortic aneurysms: 5143 A decision analysis model. J Vasc Surg. 1999;29(6):958-72.
163
5144 742. Prinssen M, Buskens E, de Jong SE, Buth J, Mackaay AJ, van Sambeek MR, et 5145 al. Cost-effectiveness of conventional and endovascular repair of abdominal 5146 aortic aneurysms: results of a randomized trial. J Vasc Surg. 2007;46(5):883-90. 5147 743. Stroupe KT, Lederle FA, Matsumura JS, Kyriakides TC, Jonk YC, Ge L, et al. 5148 Cost-effectiveness of open versus endovascular repair of abdominal aortic 5149 aneurysm in the OVER trial. J Vasc Surg. 2012;56(4):901-9.e2. 5150 744. Epstein D, Sculpher MJ, Powell JT, Thompson SG, Brown LC, Greenhalgh RM. 5151 Long-term cost-effectiveness analysis of endovascular versus open repair for 5152 abdominal aortic aneurysm based on four randomized clinical trials. Br J Surg. 5153 2014;101(6):623-31. 5154 745. Michel M, Becquemin JP, Clement MC, Marzelle J, Quelen C, Durand-Zaleski I, 5155 et al. Editor's choice - thirty day outcomes and costs of fenestrated and branched 5156 stent grafts versus open repair for complex aortic aneurysms. Eur J Vasc 5157 Endovasc Surg. 2015;50(2):189-96. 5158 746. Visser JJ, van Sambeek MR, Hunink MG, Redekop WK, van Dijk LC, Hendriks 5159 JM, et al. Acute abdominal aortic aneurysms: cost analysis of endovascular 5160 repair and open surgery in hemodynamically stable patients with 1-year follow- 5161 up. Radiology. 2006;240(3):681-9. 5162 747. Guessous I, Cornuz J. Abdominal aortic aneurysm screening: 2006 5163 recommendations. Expert Rev Pharmacoecon Outcomes Res. 2006;6(5):555-61. 5164 748. Wilmink AB, Quick CR, Hubbard CS, Day NE. Effectiveness and cost of 5165 screening for abdominal aortic aneurysm: results of a population screening 5166 program. J Vasc Surg. 2003;38(1):72-7. 5167 749. Eisenstein EL, Davidson-Ray L, Edwards R, Anstrom KJ, Ouriel K. Economic 5168 analysis of endovascular repair versus surveillance for patients with small 5169 abdominal aortic aneurysms. J Vasc Surg. 2013;58(2):302-10. 5170 750. Bertges DJ, Zwolak RM, Deaton DH, Teigen C, Tapper S, Koslow AR, et al. 5171 Current hospital costs and medicare reimbursement for endovascular abdominal 5172 aortic aneurysm repair. J Vasc Surg. 2003;37(2):272-9. 5173 751. Stone DH, Horvath AJ, Goodney PP, Rzucidlo EM, Nolan BW, Walsh DB, et al. 5174 The financial implications of endovascular aneurysm repair in the cost 5175 containment era. J Vasc Surg. 2014;59(2):283-90, 90.e1. 5176 752. Guirguis-Blake JM, Beil TL, Senger CA, Whitlock EP. Ultrasonography screening 5177 for abdominal aortic aneurysms: A systematic evidence review for the U.S. 5178 preventive services task force. Ann Intern Med. 2014;160(5):321-9. 5179 753. Cosford PA, Leng GC, Thomas J. Screening for abdominal aortic aneurysm. 5180 Cochrane Database Syst Rev. 2011(3). 5181 754. Takagi H, Goto SN, Matsui M, Manabe H, Umemoto T. A further meta-analysis of 5182 population-based screening for abdominal aortic aneurysm. J Vasc Surg. 5183 2010;52(4):1103-8. 5184 755. Alamoudi AO, Haque S, Srinivasan S, Mital DP. Diagnostic efficacy value in 5185 terms of sensitivity and specificity of imaging modalities in detecting the 5186 abdominal aortic aneurysm: A systematic review. International Journal of Medical 5187 Engineering and Informatics. 2015;7(1):15-35. 5188 756. Concannon E, McHugh S, Healy DA, Kavanagh E, Burke P, Clarke Moloney M, 5189 et al. Diagnostic accuracy of non-radiologist performed ultrasound for abdominal
164
5190 aortic aneurysm: systematic review and meta-analysis. Int J Clin Pract. 5191 2014;68(9):1122-9. 5192 757. Sweeting MJ, Thompson SG, Brown LC, Powell JT, collaborators R. Meta- 5193 analysis of individual patient data to examine factors affecting growth and rupture 5194 of small abdominal aortic aneurysms. Br J Surg. 2012;99(5):655-65. 5195 758. Collaborators R, Bown MJ, Sweeting MJ, Brown LC, Powell JT, Thompson SG. 5196 Surveillance intervals for small abdominal aortic aneurysms: a meta-analysis. 5197 Jama. 2013;309(8):806-13. 5198 759. Stather PW, Sidloff D, Dattani N, Choke E, Bown MJ, Sayers RD. Systematic 5199 review and meta-analysis of the early and late outcomes of open and 5200 endovascular repair of abdominal aortic aneurysm. Br J Surg. 2013;100(7):863- 5201 72. 5202 760. Coughlin PA, Jackson D, White AD, Bailey MA, Farrow C, Scott DJA, et al. Meta- 5203 analysis of prospective trials determining the short- and mid-term effect of 5204 elective open and endovascular repair of abdominal aortic aneurysms on quality 5205 of life. Br J Surg. 2013;100(4):448-55. 5206 761. Biancari F, Catania A, D'Andrea V. Elective endovascular vs. open repair for 5207 abdominal aortic aneurysm in patients aged 80 years and older: systematic 5208 review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42(5):571-6. 5209 762. Kontopodis N, Antoniou SA, Georgakarakos E, Ioannou CV. Endovascular vs 5210 Open Aneurysm Repair in the Young: Systematic Review and Meta-analysis. J 5211 Endovasc Ther. 2015;22(6):897-904. 5212 763. Saedon M, Mt-Isa S, Saratzis A, Leung E, Mahmood A. Outcome of open versus 5213 endovascular abdominal aortic aneurysm repair in obese patients: a systemic 5214 review and meta-analysis. Int Angiol. 2015;34(1):9-15. 5215 764. Rayt HS, Sutton AJ, London NJ, Sayers RD, Bown MJ. A systematic review and 5216 meta-analysis of endovascular repair (EVAR) for ruptured abdominal aortic 5217 aneurysm. Eur J Vasc Endovasc Surg. 2008;36(5):536-44. 5218 765. Sweeting MJ, Balm R, Desgranges P, Ulug P, Powell JT, Ruptured Aneurysm T. 5219 Individual-patient meta-analysis of three randomized trials comparing 5220 endovascular versus open repair for ruptured abdominal aortic aneurysm. Br J 5221 Surg. 2015;102(10):1229-39. 5222 766. Antoniou GA, Georgiadis GS, Antoniou SA, Pavlidis P, Maras D, Sfyroeras GS, 5223 et al. Endovascular repair for ruptured abdominal aortic aneurysm confers an 5224 early survival benefit over open repair. J Vasc Surg. 2013;58(4):1091-105. 5225 767. Antoniou GA, Ahmed N, Georgiadis GS, Torella F. Is endovascular repair of 5226 ruptured abdominal aortic aneurysms associated with improved in-hospital 5227 mortality compared with surgical repair? Interact Cardiovasc Thorac Surg. 5228 2015;20(1):135-9. 5229 768. Badger SA, Harkin DW, Blair PH, Ellis PK, Kee F, Forster R. Endovascular repair 5230 or open repair for ruptured abdominal aortic aneurysm: a Cochrane systematic 5231 review. BMJ Open. 2016;6(2):e008391. 5232 769. Li Y, Li Z, Wang S, Chang G, Wu R, Hu Z, et al. Endovascular versus Open 5233 Surgery Repair of Ruptured Abdominal Aortic Aneurysms in Hemodynamically 5234 Unstable Patients: Literature Review and Meta-Analysis. Ann Vasc Surg. 5235 2016;32:135-44.
165
5236 770. Luebke T, Brunkwall J. Risk-Adjusted Meta-analysis of 30-Day Mortality of 5237 Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms. 5238 Ann Vasc Surg. 2015;29(4):845-63. 5239 771. Ma B, Wang Y-N, Chen K-y, Zhang Y, Pan H, Yang K. Transperitoneal versus 5240 retroperitoneal approach for elective open abdominal aortic aneurysm repair. 5241 Cochrane Database Syst Rev. 2016;2:CD010373. 5242 772. Twine CP, Humphreys AK, Williams IM. Systematic review and meta-analysis of 5243 the retroperitoneal versus the transperitoneal approach to the abdominal aorta. 5244 Eur J Vasc Endovasc Surg. 2013;46(1):36-47. 5245 773. Jackson A, Yeoh SE, Clarke M. Totally percutaneous versus standard femoral 5246 artery access for elective bifurcated abdominal endovascular aneurysm repair. 5247 The Cochrane database of systematic reviews. 2014;2:CD010185. 5248 774. BaniHani M, Titi MA, Jaradat I, AlKhaffaf H. Interventions for preventing venous 5249 thromboembolism following abdominal aortic surgery. Cochrane Database Syst 5250 Rev. 2011(3). 5251 775. Twine CP, Williams IM. Systematic review and meta-analysis of the effects of 5252 statin therapy on abdominal aortic aneurysms. Br J Surg. 2011;98(3):346-53. 5253 776. Bergqvist D. Pharmacological interventions to attenuate the expansion of 5254 Abdominal Aortic Aneurysm (AAA) - A systematic review. European Journal of 5255 Vascular and Endovascular Surgery. 2011;41(5):663-7. 5256 777. Pieper D, Mathes T, Neugebauer E, Eikermann M. State of evidence on the 5257 relationship between high-volume hospitals and outcomes in surgery: A 5258 systematic review of systematic reviews. J Am Coll Surg. 2013;216(5):1015- 5259 25.e18. 5260 778. Habets J, Zandvoort HJA, Reitsma JB, Bartels LW, Moll FL, Leiner T, et al. 5261 Magnetic resonance imaging is more sensitive than computed tomography 5262 angiography for the detection of endoleaks after endovascular abdominal aortic 5263 aneurysm repair: a systematic review. Eur J Vasc Endovasc Surg. 5264 2013;45(4):340-50. 5265 779. Karthikesalingam A, Al-Jundi W, Jackson D, Boyle JR, Beard JD, Holt PJE, et al. 5266 Systematic review and meta-analysis of duplex ultrasonography, contrast- 5267 enhanced ultrasonography or computed tomography for surveillance after 5268 endovascular aneurysm repair. Br J Surg. 2012;99(11):1514-23. 5269 780. Antoniou GA, Georgiadis GS, Antoniou SA, Neequaye S, Brennan JA, Torella F, 5270 et al. Late Rupture of Abdominal Aortic Aneurysm After Previous Endovascular 5271 Repair: A Systematic Review and Meta-analysis. J Endovasc Ther. 5272 2015;22(5):734-44. 5273
5274
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5275 Table Legends
5276 Table 1. Evidence profiles derived from evidence synthesis reports (systematic reviews and
5277 meta-analysis) that were identified through an umbrella systematic review.
5278 Table 2. Risk factors for the development of an abdominal aortic aneurysm. From Kent KC,
5279 Zwolak RM, Egorova NN, Riles TS, Manganaro A, Moskowitz AJ, et al. Analysis of
5280 risk factors for abdominal aortic aneurysm in a cohort of more than 3 million
5281 individuals. J Vasc Surg. 2010;52(3):539-48.
5282 Table 3. Preoperative cardiac evaluation for the patient undergoing aneurysm repair. From
5283 Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The
5284 care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery
5285 practice guidelines. J Vasc Surg. 2009;50(4 Suppl):S2-49 and originally adapted
5286 from Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et
5287 al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care
5288 for noncardiac surgery: executive summary. Circulation 2007; 116:1971-96.
5289 Table 4. Functional capacity estimation from an assessment of physical activity. From
5290 Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The
5291 care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery
5292 practice guidelines. J Vasc Surg. 2009;50(4 Suppl):S2-49 and originally adapted
5293 from The Duke Activity Status Index Hlatky MA, Boineau RE, Higginbotham MB, Lee
5294 KL, Mark DB, Califf RM, et al. A brief self-administered questionnaire to determine
5295 functional capacity (the Duke Activity Status Index). Am J Cardiol 1989;64:651-4.
5296 Table 5. Genetic loci implicated in the pathogenesis of an abdominal aortic aneurysm. From
5297 Golledge J, Kuivaniemi H. Genetics of abdominal aortic aneurysm. Curr Opin
5298 Cardiol. 2013;28(3):290-6.
5299 Table 6A. Mortality risk scoring scheme for patients undergoing repair of an abdominal aortic
5300 aneurysm. From Eslami MH, Rybin D, Doros G, Kalish JA, Farber A, Vascular Study
167
5301 Group of New E. Comparison of a Vascular Study Group of New England risk
5302 prediction model with established risk prediction models of in-hospital mortality after
5303 elective abdominal aortic aneurysm repair. J Vasc Surg. 2015;62(5):1125-33.e2.
5304 Table 6B. Risk categorization based on mortality risk scoring scheme (Table 5A) for patients
5305 undergoing repair of an abdominal aortic aneurysm. From Eslami MH, Rybin D,
5306 Doros G, Kalish JA, Farber A, Vascular Study Group of New E. Comparison of a
5307 Vascular Study Group of New England risk prediction model with established risk
5308 prediction models of in-hospital mortality after elective abdominal aortic aneurysm
5309 repair. J Vasc Surg. 2015;62(5):1125-33.e2.
5310 Table 7. Surgical approaches for open aneurysm repair. Adapted from Chaikof EL, Brewster
5311 DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with
5312 an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines.
5313 J Vasc Surg. 2009;50(4 Suppl):S2-49.
5314 Table 8. Estimated perioperative complications after elective open surgery for AAA. From
5315 Schermerhorn ML, Cronenwett JL. Abdominal aortic and iliac aneurysms. In:
5316 Rutherford RB, editor. Vascular Surgery. 6th ed. Philadelphia: Elsevier Saunders;
5317 2005. p. 1431.
5318
168
5319 Figure Legends
5320 Figure 1. The annual adult per capita cigarette consumption and age-adjusted abdominal
5321 aortic aneurysm (AAA) deaths per 100,000 white men by year in the United States.
5322 AAA: abdominal aortic aneurysm. From Lederle FA. The rise and fall of abdominal
5323 aortic aneurysm. Circulation. 2011;124(10):1097-9.
5324 Figure 2A. Influence of smoking (current versus ex/never) on aneurysm enlargement in
5325 individual studies and meta-analysis (please see primary source for individual
5326 study citations). MASS: Multicenter Aneurysm Screening Study; PIVOTAL: Positive
5327 Impact of endovascular Options for Treating Aneurysm earLy; UKSAT: United
5328 Kingdom Small Aneurysm Trial. From Sweeting MJ, Thompson SG, Brown LC,
5329 Powell JT. Meta-analysis of individual patient data to examine factors affecting
5330 growth and rupture of small abdominal aortic aneurysms. Br J Surg.
5331 2012;99(5):655-65.
5332 Figure 2B. Influence of diabetes on aneurysm enlargement in individual studies and meta-
5333 analysis (please see primary source for individual study citations). PIVOTAL:
5334 Positive Impact of endovascular Options for Treating Aneurysm earLy; UKSAT:
5335 United Kingdom Small Aneurysm Trial. Adapted from Sweeting MJ, Thompson
5336 SG, Brown LC, Powell JT. Meta-analysis of individual patient data to examine
5337 factors affecting growth and rupture of small abdominal aortic aneurysms. Br J
5338 Surg. 2012;99(5):655-65.
5339 Figure 3. Meta-regression of abdominal aortic aneurysm growth rate estimates by aneurysm
5340 diameter (please see primary source for individual study citations). The solid line
5341 represents the overall regression, the dotted line connects estimates from the
5342 same study, and circles have diameters that represent amount of information.
5343 Adapted from Thompson SG, Brown LC, Sweeting MJ, Bown MJ, Kim LG, Glover
5344 MJ, et al. Systematic review and meta-analysis of the growth and rupture rates of
169
5345 small abdominal aortic aneurysms: implications for surveillance intervals and their
5346 cost-effectiveness. Health Technol Assess. 2013;17(41):1-118.
5347 Figure 4. Estimated time to have a 10% probability of attaining an aortic diameter of 5.5 cm
5348 in male patients (please see primary source for individual study citations). Black
5349 diamonds represent 95% confidence intervals and errors represent 95% prediction
5350 intervals. MASS: Multicenter Aneurysm Screening Study; PIVOTAL: Positive
5351 Impact of endovascular Options for Treating Aneurysm earLy; UKSAT: United
5352 Kingdom Small Aneurysm Trial. Adapted from Thompson SG, Brown LC,
5353 Sweeting MJ, Bown MJ, Kim LG, Glover MJ, et al. Systematic review and meta-
5354 analysis of the growth and rupture rates of small abdominal aortic aneurysms:
5355 implications for surveillance intervals and their cost-effectiveness. Health Technol
5356 Assess. 2013;17(41):1-118.
5357 Figure 5. Algorithm for management of the patient with a suspected or confirmed ruptured
5358 aneurysm.
5359 Figure 6. Referring hospital checklist for the patient with a suspected or confirmed ruptured
5360 aneurysm.
5361 Figure 7. Receiving hospital personnel alert checklist for management of the patient with a
5362 suspected or confirmed ruptured aneurysm.
5363
170
5364 Table 1: Evidence profiles derived from evidence synthesis reports (systematic 5365 reviews and meta-analysis) that were identified through an umbrella systematic 5366 review:
Systematic Question/comparison Findings (Quality of evidence) reviews Screening, diagnosis and preoperative surveillance Guirguis-Blake, Effectiveness of • Screening (primarily in men >65) was 2014752 screening for AAA associated with reduction in AAA- Cosford, 2011753 mortality (High). Absolute reduction (4 Takaji, 2010754 per 1,000). Number needed to screen (238). Alamoudi, Diagnostic accuracy of • AAA < 2.5 cm, the mean reported 2015755 imaging for AAA sensitivities and specificities: Concannon, compared to digital -DUS: 81% and 91.1% 2014756 subtraction angiography -CTA: 84.3% and 98.4% -MRA: 95.8% and 95.8% • Non-radiologist performed ultrasound achieved acceptable sensitivity and specificity for both detection and measurement of AAA. Sweeting, Factors affecting growth • Rupture was higher in women, 2012757 and rupture of small smokers and elevated blood pressure AAA (moderate) RESCAN Surveillance intervals for • For each 0.5-cm increase in AAA Collaborators, small AAA diameter, growth rates increased on 2013758 average by 0.59 mm per year and rupture rates increased by a factor of 1.91 (moderate). Treatment Stather, 2013759 Open vs endovascular • EVAR had lower 30-day or in-hospital Coughlin, repair mortality rate (high) 2013760 • Reduction in quality of life at 3 months more pronounced with open repair • At 2 and 4 years, no difference in mortality (low) • EVAR required more reinterventions and rupture (high). Biancari, 2011 761 Open vs endovascular • Elective EVAR was associated with repair (age >80) lower immediate postoperative mortality and morbidity (low, observational data) Kontopodis, Open vs endovascular • EVAR was associated with a 2015762 repair (age <70) decreased risk of 30-day mortality
171
and 30-day morbidity and shorter length of hospitalization (moderate). Long-term survival and the need for reintervention was similar (low). Saedon, 2015763 Open vs endovascular • EVAR had fewer 30-day repair (obese patients) postoperative mortality and early postoperative complications (myocardial infarction, chest infection, renal failure, wound infection). Risk of postoperative bowel ischemia and stroke were similar (Low). Rayet, 2008764 Open vs endovascular • EVAR had lower mortality in 31 Sweeting 2015765 repair (ruptured AAA) studies that was insignificant in Antoniou, pooled analysis of 3 recent trials or in 2013766 an adjusted analysis (Low) Antoniou, 2015 767 Badger, 2016768 Li, 2016769 Luebke, 2015770 Ma, 2016771 Transperitoneal vs • No difference in mortality (low). retroperitoneal approach • Retroperitoneal approach may reduce for elective open AAA blood loss, hospital stay and ICU stay repair (Low). • No differences in aortic cross-clamp time and operating time. Twine 772 Retroperitoneal vs • Retroperitoneal approach is transperitoneal approach associated with lower rates of to the infrarenal postoperative ileus and pneumonia abdominal aorta (moderate)
Jackson, 2014773 Totally percutaneous • One small highly imprecise study versus standard femoral (low) artery access for elective bifurcated abdominal endovascular aneurysm repair. BaniHani, Interventions for • The body of direct evidence is 2011774 preventing venous insufficient (2 small studies with thromboembolism methodlogical limitations) following abdominal • Extrapolation from indirect evidence aortic surgery. is required. Twine, 2011775 Effects of statins on AAA • Reduction in mortality (moderate) • No change in expansion (low)
172
Bergqvist, Pharmacological • No consistent pattern of 2011776 interventions to pharmacological influence on attenuate the expansion expansion rate (low) of AAA Pieper, 2013777 Surgical outcomes and • Lower mortality for elective and hospital volume ruptured AAA repair in high volume hospitals (Low) Postoperative Surveillance Habets, 2013778 Magnetic resonance • Magnetic resonance imaging was imaging vs computed more sensitive for endoleaks Type II tomography angiography (moderate). for the detection of endoleaks after EVAR for AAA. Karthikesalinga, Diagnostic accuracy of • Both, duplex ultrasonography and 2012779 duplex ultrasonography contrast-enhanced ultrasonography and contrast-enhanced were highly specific for types 1 and 3 ultrasonography for endoleaks (moderate) types 1 and 3 endoleak • Sensitivity estimate were likely similar but less reliable Antoniou, Late rupture of AAA after • Graft-related endoleaks were the 2015780 EVAR predominant cause of late aneurysm rupture. 5367 5368
173
5369 Table 2. Risk factors for the development of an abdominal aortic aneurysm. From Kent KC, 5370 Zwolak RM, Egorova NN, Riles TS, Manganaro A, Moskowitz AJ, et al. Analysis of risk factors 5371 for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg. 5372 2010;52(3):539-48. 5373 5374 5375 5376
5377
174
5378 Table 3. Preoperative cardiac evaluation for the patient undergoing aneurysm repair. From
5379 Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of
5380 patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice
5381 guidelines. J Vasc Surg. 2009;50(4 Suppl):S2-49 and originally adapted from Fleisher LA,
5382 Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007
5383 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery:
5384 executive summary. Circulation 2007; 116:1971-96.
5385
5386
5387
175
5388 Table 4. Functional capacity estimation from an assessment of physical activity. From Chaikof
5389 EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with
5390 an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc
5391 Surg. 2009;50(4 Suppl):S2-49 and originally adapted from The Duke Activity Status Index
5392 Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, et al. A brief self-
5393 administered questionnaire to determine functional capacity (the Duke Activity Status Index).
5394 Am J Cardiol 1989;64:651-4.
5395
5396
5397
5398
5399
176
5400 Table 5. Genetic loci implicated in the pathogenesis of an abdominal aortic aneurysm.
5401 From Golledge J, Kuivaniemi H. Genetics of abdominal aortic aneurysm. Curr Opin Cardiol.
5402 2013;28(3):290-6.
5403
5404
5405 5406
177
5407 Table 6A. Mortality risk scoring scheme for patients undergoing repair of an abdominal aortic
5408 aneurysm. From Eslami MH, Rybin D, Doros G, Kalish JA, Farber A, Vascular Study Group of
5409 New E. Comparison of a Vascular Study Group of New England risk prediction model with
5410 established risk prediction models of in-hospital mortality after elective abdominal aortic
5411 aneurysm repair. J Vasc Surg. 2015;62(5):1125-33.e2.
5412
5413
5414
5415
178
5416 Table 6B. Risk categorization based on mortality risk scoring scheme (Table 6A) for patients
5417 undergoing repair of an abdominal aortic aneurysm. From Eslami MH, Rybin D, Doros G, Kalish
5418 JA, Farber A, Vascular Study Group of New E. Comparison of a Vascular Study Group of New
5419 England risk prediction model with established risk prediction models of in-hospital mortality
5420 after elective abdominal aortic aneurysm repair. J Vasc Surg. 2015;62(5):1125-33.e2.
5421
5422
5423
179
5424 Table 7. Surgical approaches for open aneurysm repair. Adapted from Chaikof EL, Brewster
5425 DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with an
5426 abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg.
5427 2009;50(4 Suppl):S2-49.
5428
5429 Transperitoneal Retroperitoneal
Advantages • Most rapid, greatest • Avoids hostile abdomen versatility • Facilitates supra-renal • Provides widest access exposure and control • Enables evaluation and • Potential reduction of treatment of concomitant postoperative ileus intra-abdominal pathology • Obesity • Inflammatory AAA • Horseshoe kidney Disadvantages • Longer postoperative ileus • Poor access to right renal • Potential for greater fluids and iliac arteries loses • Cannot evaluate intra- • Difficulty with exposure and abdominal pathology control for suprarenal • Flank bulge aneurysms • Higher incidence of incisional hernia 5430 5431
180
5432 Table 8. Estimated perioperative complications after elective open surgery for AAA. From
5433 Schermerhorn ML, Cronenwett JL. Abdominal aortic and iliac aneurysms. In: Rutherford RB,
5434 editor. Vascular Surgery. 6th ed. Philadelphia: Elsevier Saunders; 2005. p. 1431.
5435
5436
5437
5438
181
5439 Figure 1. The annual adult per capita cigarette consumption and age-adjusted abdominal aortic
5440 aneurysm (AAA) deaths per 100,000 white men by year in the United States. AAA: abdominal
5441 aortic aneurysm. From Lederle FA. The rise and fall of abdominal aortic aneurysm. Circulation.
5442 2011;124(10):1097-9.
5443
5444
5445
5446
5447
182
5448 Figure 2A. Influence of smoking (current versus ex/never) on aneurysm enlargement in
5449 individual studies and meta-analysis (please see primary source for individual study citations).
5450 MASS: Multicenter Aneurysm Screening Study; PIVOTAL: Positive Impact of endovascular
5451 Options for Treating Aneurysm earLy; UKSAT: United Kingdom Small Aneurysm Trial. From
5452 Sweeting MJ, Thompson SG, Brown LC, Powell JT. Meta-analysis of individual patient data to
5453 examine factors affecting growth and rupture of small abdominal aortic aneurysms. Br J Surg.
5454 2012;99(5):655-65.
5455
5456
5457
5458
183
5459 Figure 2B. Influence of diabetes on aneurysm enlargement in individual studies and meta-
5460 analysis (please see primary source for individual study citations). PIVOTAL: Positive Impact of
5461 endovascular Options for Treating Aneurysm earLy; UKSAT: United Kingdom Small Aneurysm
5462 Trial. Adapted from Sweeting MJ, Thompson SG, Brown LC, Powell JT. Meta-analysis of
5463 individual patient data to examine factors affecting growth and rupture of small abdominal aortic
5464 aneurysms. Br J Surg. 2012;99(5):655-65.
5465
5466
5467
5468
5469
184
5470 Figure 3. Meta-regression of abdominal aortic aneurysm growth rate estimates by aneurysm
5471 diameter (please see primary source for individual study citations). The solid line represents the
5472 overall regression, the dotted line connects estimates from the same study, and circles have
5473 diameters that represent amount of information. Adapted from Thompson SG, Brown LC,
5474 Sweeting MJ, Bown MJ, Kim LG, Glover MJ, et al. Systematic review and meta-analysis of the
5475 growth and rupture rates of small abdominal aortic aneurysms: implications for surveillance
5476 intervals and their cost-effectiveness. Health Technol Assess. 2013;17(41):1-118.
5477
5478
5479
185
5480 Figure 4. Estimated time to have a 10% probability of attaining an aortic diameter of 5.5 cm in
5481 male patients (please see primary source for individual study citations). Black diamonds
5482 represent 95% confidence intervals and errors represent 95% prediction intervals. MASS:
5483 Multicenter Aneurysm Screening Study; PIVOTAL: Positive Impact of endovascular Options for
5484 Treating Aneurysm earLy; UKSAT: United Kingdom Small Aneurysm Trial. Adapted from
5485 Thompson SG, Brown LC, Sweeting MJ, Bown MJ, Kim LG, Glover MJ, et al. Systematic review
5486 and meta-analysis of the growth and rupture rates of small abdominal aortic aneurysms:
5487 implications for surveillance intervals and their cost-effectiveness. Health Technol Assess.
5488 2013;17(41):1-118.
5489
5490
5491
186
5492 Figure 5. Algorithm for management of the patient with a suspected or confirmed ruptured
5493 aneurysm.
5494
5495
187
5496 Figure 6. Referring hospital checklist for the patient with a suspected or confirmed ruptured
5497 aneurysm.
5498
5499
5500
5501
5502
5503
5504
188
5505 Figure 7. Receiving hospital personnel alert checklist for management of the patient with a
5506 suspected or confirmed ruptured aneurysm.
5507
5508
5509
5510
5511
189
5512 APPENDIX: SEARCH STRATEGY
5513 Ovid 5514 Database(s): Embase 1988 to 2016 Week 38, Ovid MEDLINE(R) In-Process & Other Non- 5515 Indexed Citations and Ovid MEDLINE(R) 1946 to Present, EBM Reviews - Cochrane Central 5516 Register of Controlled Trials August 2016, EBM Reviews - Cochrane Database of Systematic 5517 Reviews 2005 to September 15, 2016 5518 Search Strategy: # Searches Results exp Aortic Aneurysm, Abdominal/di, dh, dt, ri, rt, su, th, us [Diagnosis, Diet 1 Therapy, Drug Therapy, Radionuclide Imaging, Radiotherapy, Surgery, Therapy, 12817 Ultrasonography] exp abdominal aorta aneurysm/di, dm, dt, rt, su, th [Diagnosis, Disease 2 14097 Management, Drug Therapy, Radiotherapy, Surgery, Therapy] ("abdominal aorta aneurysm*" or "abdominal aortic aneurysm*" or "aortic 3 39942 abdominal aneurysm*").mp. (((volume* or PET or spiral or helical or 3d or beam or 4d or "whole body") adj (ct or cat or cts or scan*)) or agent* or "cat scan*" or chemotherap* or "ct scan*" or diagnos* or drug* or image or images or imaging or intervention* or manag* or 4 medication* or microtomograph* or "micro-tomograph*" or operat* or 28727775 pharmacotherap* or radiotherap* or reconstruction* or repair* or resect* or SPECT or surg* or therap* or tomograph* or treat* or ultrasonograph* or ultrasound* or xray* or "x-ray*").mp. 5 3 and 4 36488 6 1 or 2 or 5 41292 7 exp meta analysis/ 220499 8 exp Meta-Analysis as Topic/ 49995 9 exp Randomized Controlled Trial/ 863768 10 exp triple blind procedure/ 186 11 exp Double-Blind Method/ 381145 12 exp Single-Blind Method/ 63322 13 exp latin square design/ 560 14 exp Placebos/ 333090 15 exp Placebo Effect/ 9804 ((meta adj analys*) or (randomized adj3 study) or (randomized adj3 trial) or (randomised adj3 study) or (randomised adj3 trial) or "pragmatic clinical trial" or 16 (doubl* adj blind*) or (doubl* adj mask*) or (singl* adj blind*) or (singl* adj mask*) 2185771 or (tripl* adj blind*) or (tripl* adj mask*) or (trebl* adj blind*) or (trebl* adj mask*) or "latin square" or placebo* or nocebo*).mp,pt. 17 or/7-16 2185771 18 6 and 17 2529 limit 18 to (english language and yr="1996 -Current") [Limit not valid in CDSR; 19 2267 records were retained] 20 19 not "conference abstract".pt. 2158 21 (exp animals/ or exp nonhuman/) not exp humans/ 8441729
190
((alpaca or alpacas or amphibian or amphibians or animal or animals or antelope or armadillo or armadillos or avian or baboon or baboons or beagle or beagles or bee or bees or bird or birds or bison or bovine or buffalo or buffaloes or buffalos or "c elegans" or "Caenorhabditis elegans" or camel or camels or canine or canines or carp or cats or cattle or chick or chicken or chickens or chicks or chimp or chimpanze or chimpanzees or chimps or cow or cows or "D melanogaster" or "dairy calf" or "dairy calves" or deer or dog or dogs or donkey or donkeys or drosophila or "Drosophila melanogaster" or duck or duckling or ducklings or ducks or equid or equids or equine or equines or feline or felines or ferret or ferrets or finch or finches or fish or flatworm or flatworms or fox or foxes or frog or frogs or "fruit flies" or "fruit fly" or "G mellonella" or "Galleria mellonella" or geese or gerbil or gerbils or goat or goats or goose or gorilla or gorillas or 22 hamster or hamsters or hare or hares or heifer or heifers or horse or horses or 7471491 insect or insects or jellyfish or kangaroo or kangaroos or kitten or kittens or lagomorph or lagomorphs or lamb or lambs or llama or llamas or macaque or macaques or macaw or macaws or marmoset or marmosets or mice or minipig or minipigs or mink or minks or monkey or monkeys or mouse or mule or mules or nematode or nematodes or octopus or octopuses or orangutan or "orang-utan" or orangutans or "orang-utans" or oxen or parrot or parrots or pig or pigeon or pigeons or piglet or piglets or pigs or porcine or primate or primates or quail or rabbit or rabbits or rat or rats or reptile or reptiles or rodent or rodents or ruminant or ruminants or salmon or sheep or shrimp or slug or slugs or swine or tamarin or tamarins or toad or toads or trout or urchin or urchins or vole or voles or waxworm or waxworms or worm or worms or xenopus or "zebra fish" or zebrafish) not (human or humans)).mp. 23 20 not (21 or 22) 2133 24 remove duplicates from 23 1361 5519 5520
191
5521 Scopus 5522 1 TITLE-ABS-KEY("abdominal aorta aneurysm*" OR "abdominal aortic aneurysm*" OR 5523 "aortic abdominal aneurysm*") 5524 2 TITLE-ABS-KEY(((volume* or PET or spiral or helical or 3d or beam or 4d or "whole 5525 body") W/1 (ct or cat or cts or scan*)) OR agent* OR "cat scan*" OR chemotherap* 5526 OR "ct scan*" OR diagnos* OR drug* OR image OR images OR imaging OR 5527 intervention* OR manag* OR medication* OR microtomograph* OR "micro- 5528 tomograph*" OR operat* OR pharmacotherap* OR radiotherap* OR reconstruction* 5529 OR repair* OR resect* OR SPECT OR surg* OR therap* OR tomograph* OR treat* 5530 OR ultrasonograph* OR ultrasound* OR xray* OR "x-ray*") 5531 3 TITLE-ABS-KEY((meta W/1 analys*) OR (randomized W/3 study) OR (randomized 5532 W/3 trial) OR (randomised W/3 study) OR (randomised W/3 trial) OR "pragmatic 5533 clinical trial" OR (doubl* W/1 blind*) OR (doubl* W/1 mask*) OR (singl* W/1 blind*) 5534 OR (singl* W/1 mask*) OR (tripl* W/1 blind*) OR (tripl* W/1 mask*) OR (trebl* W/1 5535 blind*) OR (trebl* W/1 mask*) OR "latin square" OR placebo* OR nocebo*) 5536 4 PUBYEAR AFT 1995 AND LANGUAGE(english) 5537 5 1 and 2 and 3 and 4 5538 6 DOCTYPE(le) OR DOCTYPE(ed) OR DOCTYPE(bk) OR DOCTYPE(er) OR 5539 DOCTYPE(no) OR DOCTYPE(sh) OR DOCTYPE(ab) 5540 7 5 and not 6 5541 8 PMID(0*) OR PMID(1*) OR PMID(2*) OR PMID(3*) OR PMID(4*) OR PMID(5*) OR 5542 PMID(6*) OR PMID(7*) OR PMID(8*) OR PMID(9*) 5543 9 7 and not 8
5544
The Care of Patients with an Abdominal Aortic Aneurysm: The Society for Vascular Surgery Practice Guidelines
The SVS Document Oversight Committee is requesting your comments on the proposed SVS Clinical Practice Guidelines on “The Care of Patients with an Abdominal Aortic Aneurysm.”
Once you have completed review of the guideline, please use the following link to provide your comments. The open comment period ends on Monday, July 31, 2017.
Click this Link to Provide Your Comments