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Chapter 56. Endovascular Therapies for Abdominal Aortic Aneurysm

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What have randomized trials of open surgery versus endovascular aneurysm repair (EVAR) shown for the treatment of patients with asymptomatic abdominal aortic aneurysms (AAAs)?

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A. Similar operative mortality and long-term outcomes for both open surgery and EVAR

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B. Decreased operative mortality for EVAR, but similar long-term mortality for both open surgery and EVAR

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C. Decreased operative and long-term mortality with EVAR

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D. Increased operative mortality and long-term mortality with EVAR

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The correct answer is B

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Four randomized trials have compared the outcomes of EVAR to open AAA repair. Each of these trials enrolled patients with asymptomatic AAA who were candidates for endovascular or open repair. All 4 studies reported lower 30-day mortality with EVAR, with 30-day mortality rates ranging from 0.5% to 1.2% for EVAR and 1.3% to 4.7% for open surgery. The long-term mortality in each of the studies did not demonstrate a benefit of EVAR over open AAA repair, likely due to death from other comorbidities.

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A 67-year-old man with a past medical history of smoking undergoes abdominal aortic ultrasound. The ultrasound demonstrates a 5.1-cm aneurysm with a clear infrarenal neck. One year ago, the patient’s aneurysm was 3.5 cm. What is the recommended treatment at this time?

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A. Endovascular or open surgical repair of the aneurysm

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B. Repeat ultrasound in 6 months

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C. Repeat ultrasound in 1 year

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D. Reassurance that his aneurysm is not yet large enough to treat and unlikely to grow further

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The correct answer is A

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The patient has rapid expansion of his aneurysm and should undergo aneurysm repair. The criteria for intervention on an AAA include an aneurysm diameter greater than 5.5 cm in men (perhaps 5.0 cm in women), rapid expansion of an aneurysm (>0.5-0.7 cm/6 months or 1 cm/12 months), or symptomatic aneurysm with either distal embolization from an AAA, aneurysmal mass effect, threatened rupture, or frank rupture.

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A 72-year-old man undergoes endovascular aortic repair for a 5.6-cm infrarenal aortic aneurysm. During follow-up, computed tomography imaging reveals a type II endoleak originating from an inferior mesenteric artery, but the aneurysm sac has shrunk to 4.7 cm. What is the most appropriate management of the endoleak?

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A. Coil embolization of the inferior mesenteric artery via collaterals

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B. Conservative management; no intervention indicated at this time

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