management of aaa clinical practice guidelines of the esvs

• Improve decision making to achieve better outcomes based on the available evidence

• Take into account newer technical and medical advances against the backdrop of rising costs

• Decrease the variability in vascular surgical care within Europe

• Create a current “state-of-the-art” inventory of the knowledge in AAA treatment

• However, there have been new evidences since the publication of these guidelines

Purpose of the guidelines

1a Systematic review of randomised controlled trials (RCT)1b individual RCT2a Systematic review of cohort studies2b individual cohort study3a Systematic review of case-control studies3b individual case-control study4 Case-series and casecontrol studies5 Expert opinion

A Consistent level 1 studiesB Consistent level 2 or 3 studies or extrapolations level

1studiesC Level 4 studies or extrapolations from level 2 or 3 studiesD Level 5 evidence or inconsistent/inconclusive studies any

level

Levels of Evidence

Levels of Recommendation

Chapters

1. Epidemiology

2. Screening

3. Decision-making for elective AAA repair

4. Pre- and postoperative imaging

5. Management of non-ruptured AAA

6. Management of ruptured AAA

7. Follow-up after AAA repair

130 recommendations (17 level 1 & 60 level 2)(20 grade A & 59 grade B)

Risk factors

Important risk factors for AAA are advanced age and male gender, a positive family history for AAAs, especially in first-degree relatives. Smoking is a strong risk factor, the associated risk being much higher than for either coronary artery disease or stroke.

EJVES 2011;41:suppl1 – Chapter 1 - Epidemiology

Fleming C - Ann Int Med 2005;142:203Golledge J – Art Thromb Vasc Biol 2006;26:2605 (mod)

Level 2a, Recommendation B

Age

Family history

Smoking

CHD

Hypercholesterol

Hypertension

Female gender

Black race

Diabetes

Population screening of older men for AAA, in regions where the population prevalence is ≥ 4%, reduces aneurysm-related mortality by almost half within 4 years.

Men should be screened with a single scan at 65 years old.

Screening for AAA in men

EJVES 2011;41:suppl1 – Chapter 2 - Screening

Level 1a, Recommendation A

MASS study – Lancet 2002;360:1531 Viborg county – BMJ 2005;330:750

Population screening of older women for AAA does not reduce the incidence of aneurysm rupture.

Opportunistic screening of patients with peripheral arterial disease should be considered.

Screening for AAA in women

EJVES 2011;41:suppl1 – Chapter 2 - Screening

Level 1b, Recommendation B


Scott RAP – BJS 2002;89:283

Threshold for aneurysm repair

A policy of ultrasonographic surveillance of small aneurysms (4.0-5.5cm) is safe and advised for asymptomatic aneurysms.

UKSAT - BJS 2007;94:702 CAESAR - EJVES 2011;41:13


EJVES 2011;41:suppl1 – Chapter 3 – Decision making

3 cm

4 cm

5 cm

5.2 cm

5.5 cm

6 cm

7 cm

8 cm

9 cm

Management of co-morbiditiesAAA surveillance programmeManagement of co-morbiditiesAAA surveillance programmeAAA surveillance programmeReferral to surgeon for optimisationconsider repair in FEMALES ONLYReferral to vascular surgeonassess fitness & morphologyReferral to vascular surgeon

consider urgent open repairif requiring custom made endograftIn-patient managementconsider immediate repair

Surveillance

Repair


Pharmacotherapy for AAA patients

Statins started one month before intervention reduce cardiovascular morbidity; they should be continued in the perioperative period, for an indefinite duration.

Only use beta-blockade in the patients of highest cardiac risk and if beta-blockade can be started one month before intervention.

Patients with vascular disease should be started on low-dose aspirin therapy, unless specific contra-indications exist and this should be continued through the peri-operative period.


Level 1b, Recommendation A



Pre-operative cardiac evaluation

All patients undergoing AAA repair should have a formal assessment of their cardiac risk.

Patients undergoing EVAR, in the presence of cardiac risk factors, or a positive cardiac history should have a trans-thoracic echocardiogram and consideration of a pharmacological stress test or myocardial perfusion scan prior to AAA repair.

Coronary revascularisation should be considered prior to AAA repair for patients who have ischaemic coronary symptomatic or left main coronary artery disease.


Level 1c, Recommendation A

Level 2c, Recommendation B


Management of iliac pathologies

If the iliac arteries are unaffected tube grafts should be used because of the shorter operative time and the reduced risk of adjacent injuries of the neighbouring structures.

The perfusion of one hypogastric artery or the inferior mesenteric artery is mandatory.

Iliac aneurysms should be repairedonce the diameter exceeds 3cm

Endovascular treatment options shouldbe considered in all patients.


Level 3a, Recommendation C



Level 3a, Recommendation C

Patient‘s preference

The patient’s preference for type of aneurysm repair should be considered.

Where morphologically suitable, patients should be offered EVAR, which has a lower operative Mortality for symptomatic casesthan open repair.




Technical considerations

Fast track surgery can positively influence perioperative outcome after abdominal aortic aneurysm repair. If patients and nursing staff are willing to follow the suggested requirements, it should be implemented in daily routine.

In the absence of convincing evidence favouring any one type of incision, the incision for open repair should be tailored to the patient needs and local expertise.


Level 2b, Recommendation C

EJVES 2011;41:suppl1 – Chapter 5 – Non-ruptured AAA

Stent-graft Modell

Appropriately sized aortic endograft should be selected on the basis of patient anatomy: according to the instruction for use of abdominal endografts, generally the device should be oversized 15-20% with respect to the aortic neck diameter. Level 2a, Recommendation A


Consideration for repair

Assessment of fitness Assessment of morphology

Fit for repair

optimisation Standard

AAA repair OPEN or

EVAR

Transabdominal

Unfit for repair

optimisation

FitUnfit for OPEN or

EVAR

Manage conservatively

Suitable for EVAR

Not suitable for EVAR

Custom Open Laparoscopic

Retroperitoneal

Patient preference

Center preference

> 8cm

urgent


Referral hospitals should offer both, open and endovascular repair.

AAA repair should only be performed in hospitals performing at least 50 elective cases per annum, whether by open repair or EVAR.

Centers experience




Tu JV - JVS 2001;33:447 Dimick JB - JVS 2003;38:739

Management of ruptured AAA

Immediate repair is recommended in patients with documented aneurysm rupture.

In symptomatic but unruptured AAA an optimization of the patient and delayed repair within 24 hours might be discussed.

EVAR should be considered as a treatment option for ruptured AAA, provided that anatomy of the aneurysm is suitable, and the centre is equipped and experienced in endovascular aneurysm procedures.

EJVES 2011;41:suppl1 – Chapter 6 – Ruptured AAA


Level 3b, Recommendation C


Preoperative fluid administration should be restricted to a minimum to maintain hypotensive hemostasis.

Measurement of the intraabdominal pressureis recommended in these patients. If theabdominal pressure is>20mmHg in combinationwith organ dysfunction, decompressive surgeryshould immediately be performed with theuse of temporary abdominal closure systems.

EJVES 2011;41:suppl1 – Chapter 6 – Ruptured AAA

Management of ruptured AAA



Follow-up

All patients treated for an AAA should receive the best medical treatment including aspirin, statins, and beta-blockers, with annual cardiac evaluation.

Follow-up of patients after AAA repair should include, in addition to clinical examination, a color duplex ultrasound with ABI on a regular basis.

Any gastrointestinal bleeding in a patient having an aortic graft should prompt the evaluation of a prosthetic-enteric fistula.




EJVES 2011;41:suppl1 – Chapter 7 – Follow-up

EVAR - Follow-up

All patients should have a CTA and plain radiographs with anteroposterior and lateral projections at 30 days.

If there is any endoleak or less than one stent component, CTA at 6 mo. and 12 mo. with plain radiographs should be done.

At 12 months, if there is no endoleak and a stable or shrinking AAA, a yearly DU is recommended with plain radiographs.





Endoleak after EVAR

All Type I endoleaks should be treated.

Treatment is recommended for Type III endoleaks.

Treatment is not recommended forType IV endoleaks.

An enlarging abdominal aortic aneurysmafter EVAR without evidence of anendoleak (≥10 mm) should be repaired.






Endoleak after EVAR

Type II endoleaks without increased sac diameter can be observed, computed tomographic scans with delayed arterial phase are the best detection method.

Endovascular or laparoscopic treatment is recommended for type II endoleaks with increased sac diameter ≥ 10 mm/year, with conversion to open surgery in case of failure.

Any increasing aneurysm diameter or new endoleak, after prior imaging studies have shown complete aneurysm sac exclusion, should prompt complete imaging with CTA and plain radiographs.





Critical issues

• There is a need to develop postoperative surveillance protocols, including optimal use of DU, contrast enhanced DU, and CT imaging at various time periods after EVAR.

• New techniques concerning visualization of endoleak, including magnetic resonance imaging with a blood pool contrast agent, should be developed.


Chaer RA – JVS 2009;49:845Van der Laan – EJVES 2006;32:361

ESVS Clinical Practice Guidelines

Invasive treatment for carotid stenosis

2009

Management of abdominal aortic aneurysms

2010

Critical leg ischemia

2011

Management of descending thoracic aortic diseases

2012

Venous diseases

2013

Access surgery

2013

An annual (electronic) update of the earlier guidelines is planned

management of aaa clinical practice guidelines of the esvs

Presentations & Public Speaking