1) The document discusses aortoiliac aneurysms, including definitions, epidemiology, risk factors, rupture risk, associated aneurysms, pathophysiology, diagnosis, imaging, decision making for treatment, medical management, and indications for intervention. 2) Key risk factors for aneurysm rupture include diameter greater than 5.5 cm, female sex, smoking, and saccular aneurysm morphology. Imaging recommendations include ultrasound screening and CT or MRI for diagnosis. 3) Treatment is generally recommended for aneurysms greater than 5.5 cm in men or 5 cm in women, or those showing rapid growth. Immediate repair is indicated for ruptured aneurysms.

1. AORTOILIAC ANEURYSMS
EVALUATION,
DECISION MAKING AND MEDICAL
MANAGEMENT
DR SURENDRA NAGULAPATI
MEDANTA-THE MEDICITY
GURUGRAM

2. Definitions
 A true arterial aneurysm is defined as an increase to 1.5
times the normal arterial diameter with involvement of
all three anatomic layers.
 In the infra renal abdominal aorta, an aneurysm is
traditionally defined as a diameter greater than 3 cm or
more than 50% larger than a normal proximal segment
measured in either anteroposterior or transverse
dimension in a plane perpendicular to the longitudinal
axis of the aorta.

3. Epidemiology & risk factors
 Age
 Smoking
 Atherosclerotic disease
 Hypertension, male gender, hypercholesterolemia,
family history
 Negative risk factors include female sex, African
American race, and diabetes.

6. Rupture Risk
 Risk of rupture most occurring in patients with an AAA
diameter of 5 to 5.5 cm.
 The risk of rupture was independently associated with
female sex, larger initial AAA diameter, smoking, lower
FEV1, and higher mean blood pressure.
 Saccular aneurysm morphology appears to portend an
increased risk of rupture compared with fusiform
aneurysms
 CTA can also indicate an increased risk of rupture,
including the presence of a dissection, mural thrombus,
or a dissection of the peripheral calcification of the
aneurysm sac

7. AAA DIAMETER IN CM RISK OF RUPTURE (%)
3-3.9 0.3
4-4.9 0.5-1.5
5-5.9 1-11
6-6.9 11-22
>7 >30

8. Associated Aneurysms
 The involvement of adjacent arterial segments is not
uncommon in infrarenal AAAs, with 5% to 15%
extending to the juxta- or suprarenal aorta and 10% to
25% involving the iliac arteries.
 Synchronous lesions of the thoracic aorta (12%) and
femoral or popliteal artery (14% among male patients)
are also common

9.  Iliac artery aneurysms occur most frequently in the
common iliac artery (CIA) (70%), typically in conjunction
with an AAA.
 The largest published series of common iliac artery
aneurysms (CIAAs) reports that 86% of patients with
CIA aneurysms presented with concurrent or previously
treated AAAs

11. Pathophysiology
 Developmental heterogenecity of aorta
neural crest derived smooth muscle cells of the
thoracic aorta
mesoderm-derived smooth muscle cells in the
abdominal aorta

12.  In the thoracic aorta, the media contains 55 to 60
lamellar units, with adventitial vasavasora penetrating
the vascular zone of the outer layers, whereas there are
28 to 32 lamellar units in the abdominal aortic media.
This makes the abdominal aorta relatively avascular
compared with the more proximal aorta, relying more on
the transintimal diffusion of oxygen and nutrients
 Biomechanical stress of aortic bifurcation

13.  Pathogenesis of Abdominal Aortic Aneurysms” identified
four mechanisms relevant to AAA formation:
1.proteolytic degradation of aortic wall connective tissue
2 inflammation and immune responses
3.biomechanical wall stress
4 .molecular genetics.

15. Diagnosis
 History
 Patients with AAAs are typically asymptomatic.
 Those who are symptomatic and previously
undiagnosed often present with diffuse nonspecific
abdominal and/or lower back pain.
 Patients may also state that they can feel pulsations in
their abdomen. Those who are thin may state that they
can see a pulsatile mass in their abdomen

16.  Physical Examination
 An AAA may be detected on physical examination as a
palpable pulsatile (expansile) mass, most commonly
supra umbilical and in the midline
 The location, however, may be variable, as aortic
tortuosity can result in a lateral and/or infra umbilical
location

17. Physical examination
Recommendation Level of
recommendation
Quality of
evidence
In patients with a suspected or known AAA, 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
AAA.
1 A

18. Assessment of medical comorbidities
Recommendation Level of
recommendation
Quality of
evidence
In patients with active cardiac conditions, including unstable
angina, decompensated heart failure, severe vulvular disease, and
significant arrythmia, we recommend cardiology consultation before
endovascular aneurysm repair (EVAR) or open surgical repair
(OSR).
1 B
In patients with significant clinical risk factors, such as coronary
artery disease, congestive heart failure, cerebrovascular disease,
diabetes mellitus, chronic renal insufficiency, and unknown or poor
functional capacity (metabolic equivalent [MET] < 4), who are to
undergo OSR or EVAR, we suggest noninvasive stress testing.
2 B
We recommend a preoperative resting 12-lead electrocardiogram
(ECG) in all patients undergoing EVAR or
OSR within 30 days of planned treatment.
1 B
We recommend echocardiography before planned operative repair
in patients with dyspnea of unknown origin or worsening dyspnea
1 A

19. Assessment of medical comorbidities
Recommendation Level of
recommendation
Quality of
evidence
In patients with a drug-eluting coronary stent requiring open aneurysm
repair, we recommend discontinuation of 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 shouldbe
discussed with the patient.
1 B
We suggest continuation of beta blocker therapy during theperioperative
period if it is part of an established medical regimen.
2 B
If a decision was made to start beta blocker therapy (because of 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 andtolerability.
2 B
We suggest preoperative pulmonary function studies, including room air
arterial blood gas determinations, in patients with a history of symptomatic
chronic obstructive pulmonary disease (COPD), long-standing tobacco use,
or inability to climb one flight of stairs.
2 C
We recommend smoking cessation for at least 2 weeks beforeaneurysm
repair.
1 C
We suggest administration of pulmonary bronchodilators for at least2
weeks before aneurysm repair in patients with a history of COPD or
abnormal results of pulmonary functiontesting.
2 C

20. Assessment of medical comorbidities
Recommendation Level of
recommendation
Quality of
evidence
We suggest holding angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor antagonists on the morning of surgery andrestarting
these agents after the procedure once euvolemia has beenachieved.
2 C
We recommend preoperative hydration in non dialysis dependent
patients with renal insufficiency before aneurysmrepair.
1 A
We recommend preprocedure and postprocedure hydration with normal
saline or 5% dextrose/sodium bicarbonate for patients at increased risk
of contrast-induced nephropathy (CIN) undergoing EVAR
1 A
We recommend holding metformin at the time of administration of
contrast material among patients with an estimated glomerular filtration
rate (eGFR) of <60 mL/min or up to 48 hours before administration of
contrast material if the eGFR is <45 mL/min.
1 C
We recommend restarting metformin no sooner than 48 hours after
administration of contrast material as long as renal function has remained
stable (<25% increase in creatinine concentration abovebaseline).
1 C
We recommend perioperative transfusion of packed red blood cells if the
hemoglobin level is <7 g/dL
1 B
We suggest hematologic assessment if the preoperative platelet countis
<150,000/μL.
2 C

21. Aneurysm imaging
 Ultrasound
 Computed tomography
 MRI

22. Computed Tomography
 Computed tomography (CT) provides excellent imaging
of AAAs with greater reproducibility of diameter
measurements than US.
 CT particularly with the adjunctive use of iodinated
contrast to perform a CT angiogram (CTA), provides a
wealth of anatomic information, including defects in
vessel calcification, thrombus, and concurrent arterial
occlusive disease.
 CTA also permits invaluable multiplanar and three-
dimensional reconstruction and analysis for operative
planning

23.  Drawbacks associated with CTA include substantial
exposure to radiation, particularly in the setting of serial
examinations, and the use of iodinated contrast media is
problematic in a population with a high incidence of
associated kidney disease

24. Magnetic Resonance Imaging
 Magnetic resonance imaging (MRI) and magnetic
resonance angiography (MRA) are, like CT, quite
sensitive in the detection of AAAs Unlike CT, MRI does
not demonstrate aortic wall calcification, which may be
quite important in operative planning
 MRA utilizes gadolinium, which has been associated
with the development of nephrogenic systemic fibrosis in
patients with a low GFR.

25. Aneurysm imaging
Recommendation
Level of
recommendation
Quality of
evidence
We recommend using ultrasound, when feasible, as the preferred
imaging modality for aneurysm screening and surveillance.
1 A
We suggest that the maximum aneurysm diameter derived from
computed tomography (CT) imaging should be based on an outer
wall to outer wall measurement perpendicular to the path of the
aorta.
Ungraded
Good Practice Statement
We recommend a one-time ultrasound screening forAAAs in men
or women 65 to 75 years of age with a history of tobaccouse.
1 A
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 and 75 years of age or
in those older than 75 years and in goodhealth.
2 C
We suggest a one-time ultrasound screening forAAAs in men or
women older than 75 years with a history of tobacco use and in
otherwise good health who have not previously received a
screening ultrasound examination.
2 C

26. Aneurysm imaging
Recommendation
Level of
recommendation
Quality of
evidence
If initial ultrasound screening identified an aortic diameter >2.5cm
but <3 cm, we suggest rescreening after 10years.
2 C
We suggest surveillance imaging at 3-year intervals for patients
with an AAA between 3.0 and 3.9cm.
2 C
We suggest surveillance imaging at 12-month intervals for patients
with an AAA of 4.0 to 4.9 cm indiameter.
2 C
We suggest surveillance imaging at 6-month intervals for patients
with an AAA between 5.0 and 5.4 cm indiameter. 2 C
We recommend a CT scan to evaluate patients thought tohave
AAA presenting with recent-onset abdominal or back pain,
particularly in the presence of a pulsatile epigastric mass or
significant risk factors forAAA.
1 B

27. The decision to treat
Recommendation
Level of
recommendation
Quality of
evidence
We suggest referral to a vascular surgeon at the time ofinitial
diagnosis of an aortic aneurysm.
Ungraded
Good Practice Statement
We recommend repair for the patient who presents with an
AAA and abdominal or back pain that is likely to beattributed
to the aneurysm.
1 C
We recommend elective repair for the patient at low or
acceptable surgical risk with a fusiformAAA that is greater or
equal to 5.5 cm.
1 A
We suggest elective repair for the patient who presents with a
saccular aneurysm.
2 C
We suggest repair in women with AAA between 5.0 cm and
5.4 cm in maximum diameter.
2 B
In patients with a small aneurysm (4.0-5.4 cm) whowill
require chemotherapy, radiation therapy, or solid organ
transplantation, we suggest a shared decision-making
approach to decide about treatmentoptions
2 C

28. Medical management during the
period of AAA surveillance
Recommendation
Level of
recommendation
Quality of
evidence
We recommend smoking cessation to reduce the risk ofAAA growth
and rupture.
1 B
We suggest not administering statins, doxycycline, roxithromycin,
ACE inhibitors, or angiotensin receptor blockers for the sole purpose
of reducing the risk of AAAexpansion and rupture.
2 C
We suggest not administering beta blocker therapy for thesole
purpose of reducing the risk of AAA expansionand rupture. 1 B

29. Indications for Intervention
 In general, the size criterion for elective repair is 5.5 cm
for men and 5 cm for women or a 12-month growth rate
of equal to or greater than 10 mm in both sexes.
 Both the UK small aneurysm trial and the ADAM trial
documented that surveillance of aneurysms between 4
and 5.5 cm is safe with compliant patients
 Additional indications for elective or early intervention
included saccular aneurysms, dissection of mural
thrombus, or fracture of saccular calcification.

31. Timing for intervention
Recommendation
Level of
recommendation
Quality of
evidence
We recommend immediate repair for patients who present witha
ruptured aneurysm. 1 A
Should repair of a symptomatic AAA be delayed to optimize
coexisting medical conditions, we recommend that the patient be
monitored in an intensive care unit
(ICU) setting with blood products available.
1 C