Management of aaa clinical practice guidelines of the esvs

2. • 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

3. 1a Systematic review of randomised controlled trials (RCT)
1b individual RCT
2a Systematic review of cohort studies
2b individual cohort study
3a Systematic review of case-control studies
3b individual case-control study
4 Case-series and casecontrol studies
5 Expert opinion
A Consistent level 1 studies
B Consistent level 2 or 3 studies or extrapolations level 1studies
C Level 4 studies or extrapolations from level 2 or 3 studies
D Level 5 evidence or inconsistent/inconclusive studies any level
Levels of Evidence
Levels of
Recommendation

4. 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)

5. 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

6. 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

7. 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
Level 2a, Recommendation B
Scott RAP – BJS 2002;89:283

8. 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
Level 1a, Recommendation A
EJVES 2011;41:suppl1 – Chapter 3 – Decision making

9. 3 cm
4 cm
5 cm
5.2 cm
5.5 cm
6 cm
7 cm
8 cm
9 cm
Management of co-morbidities
AAA surveillance programme
Management of co-morbidities
AAA surveillance programme
AAA surveillance programme
Referral to surgeon for optimisation
consider repair in FEMALES ONLY
Referral to vascular surgeon
assess fitness & morphology
Referral to vascular surgeon
consider urgent open repair
if requiring custom made endograft
In-patient management
consider immediate repair
Surveillance
Repair
EJVES 2011;41:suppl1 – Chapter 3 – Decision making

10. 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 1a, Recommendation A
Level 1b, Recommendation A
Level 1a, Recommendation A
EJVES 2011;41:suppl1 – Chapter 3 – Decision making

11. 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.
EJVES 2011;41:suppl1 – Chapter 3 – Decision making
Level 1c, Recommendation A
Level 2c, Recommendation B
Level 1b, Recommendation B

12. 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 repaired
once the diameter exceeds 3cm
Endovascular treatment options should
be considered in all patients.
EJVES 2011;41:suppl1 – Chapter 3 – Decision making
Level 3a, Recommendation C
Level 2b, Recommendation A
Level 2c, Recommendation B
Level 3a, Recommendation C

13. 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 cases
than open repair.
EJVES 2011;41:suppl1 – Chapter 3 – Decision making
Level 2a, Recommendation B
Level 2c, Recommendation B

14. 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 B
Level 2b, Recommendation C
EJVES 2011;41:suppl1 – Chapter 5 – Non-ruptured AAA

15. 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
EJVES 2011;41:suppl1 – Chapter 5 – Non-ruptured AAA

16. Consideration
for repair
Assessment of fitness Assessment of morphology
Fit for repair
optimisation Standard
AAA repair
OPEN or EVAR
Transabdominal
Unfit for repair
optimisation
Fit
Unfit for
OPEN or EVAR
Manage conservatively
Suitable for
EVAR
Not suitable for
EVAR
Custom Open Laparoscopic
Retroperitoneal
Patient preference
Center preference
> 8cm
urgent
EJVES 2011;41:suppl1 – Chapter 5 – Non-ruptured AAA

17. 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
Level 2c, Recommendation B
Level 2c, Recommendation B
EJVES 2011;41:suppl1 – Chapter 5 – Non-ruptured AAA
Tu JV - JVS 2001;33:447 Dimick JB - JVS 2003;38:739

18. 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 1a, Recommendation A
Level 3b, Recommendation C
Level 2b, Recommendation B

19. Preoperative fluid administration should be restricted to a
minimum to maintain hypotensive hemostasis.
Measurement of the intraabdominal pressure
is recommended in these patients. If the
abdominal pressure is>20mmHg in combination
with organ dysfunction, decompressive surgery
should immediately be performed with the
use of temporary abdominal closure systems.
EJVES 2011;41:suppl1 – Chapter 6 – Ruptured AAA
Management of ruptured AAA
Level 2b, Recommendation A
Level 2c, Recommendation A

20. 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.
Level 2a, Recommendation B
Level 2a, Recommendation B
Level 1c, Recommendation B
EJVES 2011;41:suppl1 – Chapter 7 – Follow-up

21. 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.
Level 2c, Recommendation A
Level 2b, Recommendation B
Level 2b, Recommendation B
EJVES 2011;41:suppl1 – Chapter 7 – Follow-up

22. Endoleak after EVAR
All Type I endoleaks should be treated.
Treatment is recommended for Type III endoleaks.
Treatment is not recommended for
Type IV endoleaks.
An enlarging abdominal aortic aneurysm
after EVAR without evidence of an
endoleak (≥10 mm) should be repaired.
Level 1b, Recommendation B
Level 1b, Recommendation B
Level 2b, Recommendation B
Level 2b, Recommendation B
EJVES 2011;41:suppl1 – Chapter 7 – Follow-up

23. 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.
Level 2b, Recommendation B
Level 2b, Recommendation B
Level 2b, Recommendation B
EJVES 2011;41:suppl1 – Chapter 7 – Follow-up

24. 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.
EJVES 2011;41:suppl1 – Chapter 7 – Follow-up
Chaer RA – JVS 2009;49:845Van der Laan – EJVES 2006;32:361

25. 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