Management of Abdominal Aortic Aneurysm

Surveillance Strategy Based on Size and Sex

The European Society of Cardiology recommends duplex ultrasound (DUS) as the primary surveillance modality for abdominal aortic aneurysm (AAA), with surveillance intervals determined by aneurysm diameter and patient sex 1, 2
For men, the recommended surveillance intervals are: 25-29 mm every 4 years, 30-39 mm every 3 years, 40-49 mm annually, and 50-55 mm every 6 months 1, 2
For women, the recommended surveillance intervals are: 25-29 mm every 4 years, 30-39 mm every 3 years, 40-44 mm annually, and 45-50 mm every 6 months 1, 2
Women have a four-fold higher rupture risk than men at similar aneurysm sizes, justifying lower repair thresholds and more aggressive surveillance 1, 3
If DUS does not allow adequate measurement, cardiovascular CT (CCT) or cardiovascular MRI (CMR) is required 1, 2
Surveillance intervals should be shortened to every 3-6 months if rapid growth occurs: ≥10 mm per year or ≥5 mm per 6 months 1, 2

The European Society of Cardiology recommends elective repair when AAA diameter reaches ≥55 mm in men or ≥50 mm in women 1, 2, 3
Additional repair indications include symptomatic AAA, rapid expansion (≥10 mm per year or ≥5 mm per 6 months), and saccular morphology ≥45 mm due to higher rupture risk at smaller sizes 1, 2, 3
Elective repair is not recommended in patients with limited life expectancy (<2 years) 2, 3

Optimal cardiovascular risk management is mandatory for all AAA patients, as the 10-year risk of death from cardiovascular causes is up to 15 times higher than the risk of aorta-related death 1, 2, 3
Core medical interventions include smoking cessation, intensive lipid management to LDL-C target <1.4 mmol/L (<55 mg/dL), blood pressure control, and single antiplatelet therapy with low-dose aspirin if concomitant coronary artery disease is present 1, 2

Fluoroquinolones are generally discouraged for patients with aortic aneurysms but may be considered only if there is a compelling clinical indication with no reasonable alternative 1, 2

Endovascular aneurysm repair (EVAR) is preferred over open repair for most patients with suitable anatomy, reducing peri-operative mortality to <1% compared to 4-5% with open repair 1, 2
EVAR is recommended over open repair for ruptured AAA with suitable anatomy to reduce peri-operative morbidity and mortality 1, 2

Perform 30-day imaging with CCT plus DUS/contrast-enhanced ultrasound to assess intervention success 2, 3
Follow-up schedule: 1 month and 12 months post-operatively, yearly until fifth post-operative year, and after 5 years, consider CCT or MRI every 5 years if DUS is used for routine surveillance 2
Re-intervene for type I or type III endoleaks to achieve seal 2, 3

For patients presenting with suspected ruptured AAA, immediate surgical evaluation is indicated, with a 75-90% mortality risk 2

Men 60 years or older who are siblings or offspring of AAA patients should undergo physical examination and ultrasound screening 2
One-time screening abdominal ultrasound at age 65 is covered for men who have smoked at least 100 cigarettes and women with family history of AAA 5