Treatment of Saccular Infrarenal Abdominal Aortic Aneurysm

Key Treatment Thresholds

The European Society of Cardiology recommends elective repair for saccular infrarenal AAA ≥45 mm, with endovascular repair (EVAR) preferred over open repair when anatomy is suitable and life expectancy exceeds 2 years 1, 2, 3
Saccular AAA ≥45 mm warrants consideration for elective repair, which is notably lower than the 55 mm threshold for fusiform aneurysms in men, with a Class IIb, Level C recommendation 1, 2, 3
Symptomatic saccular AAAs require urgent repair regardless of size, as 25% of acutely presenting saccular aneurysms have diameters <5.5 cm and 8.4% are <4.5 cm—far higher rates than fusiform aneurysms 4, 5

For asymptomatic saccular AAA ≥45 mm, if life expectancy <2 years, repair is not recommended, but if life expectancy >2 years, proceed to anatomic evaluation 1, 3
The European Heart Society recommends obtaining cardiovascular CT (CCT) as the optimal pre-operative imaging modality to assess entire aorta and determine EVAR feasibility 1, 3
EVAR is preferred when anatomy is suitable and life expectancy >2 years, reducing peri-operative mortality to <1% 1, 2, 3

EVAR has a peri-operative mortality <1% compared to open repair, and reduces 30-day morbidity in high-risk patients 1, 2, 3, 5
EVAR requires lifelong surveillance for endoleaks, graft migration, and aneurysm sac changes, with a higher long-term re-intervention risk compared to open repair 1, 3
Type I and Type III endoleaks require prompt correction to prevent rupture 2, 6

The American Heart Association advises against waiting for the standard 55 mm threshold, as saccular morphology increases rupture risk at smaller diameters than fusiform aneurysms 4, 5
The European Society of Cardiology recommends against delaying repair of symptomatic aneurysms, as symptoms indicate impending rupture regardless of diameter 5, 6
The Society for Vascular Surgery advises against performing EVAR without confirming adherence to manufacturer's instructions for use, as off-label use increases complication rates 5
The American College of Cardiology recommends against neglecting post-EVAR surveillance, as endoleaks occur in up to one-third of patients and require monitoring with CCT or DUS at 6-12 months, then annually for 5 years 2, 3