Abdominal aortic aneurysms (AAAs) are characterized by weakness and enlargement of the abdominal aorta at least 50% greater than the normal diameter of the average adult, which is approximately 2 cm in men and 1.5 cm in women. AAAs account for roughly 15,000 deaths annually in the United States. AAAs are more common in men over the age of 50, particularly those who have previously smoked or are actively smoking. Women are affected also, but to a lesser extent perhaps because of less screening and detection. Unfortunately, women more often present with rupture and have poorer outcomes when ruptured. There are national and local efforts to resolve this disparity. Regardless death and morbidity are preventable but requires an experienced dedicated vascular team.
The treatment of a AAA varies greatly as most small aneurysms are safely monitored with a low risk for rupture, whereas large aneurysms warrant repair. Clearly, the decision to surgically treat a AAA is based on the risk of rupture versus the risk of repair.
There is currently no medical cure for AAAs, but an opportunity exists to optimize medical care and potentially prevent or slow AAA progression. Determination of modifiable risk factors is vitally important for adequate surveillance and nonoperative management among patients with a AAA. Conditions such as hyperlipidemia, hypercholesterolemia, hypertension, chronic obstructive pulmonary disease (COPD), renal insufficiency, peripheral vascular disease, and coronary artery disease are modifiable risk factors that should be addressed. However, the most important risk factor is a patient’s smoking status. Patients who smoke are 7X times more likely to develop a AAA, whereas ex-smokers carry a half the risk. Ongoing smoking is also the strongest predictor that an aneurysm will continue to grow. We work closely with our patients with small aneurysms (<5cm) to aggressively reduce the likelihood of progression and need for surgery.
Medical management is also critically import when a patient needs their aneurysm repaired. There is overwhelming evidence demonstrating worse outcomes when risk factors are poorly controlled or patients continue to smoke. In general, poorly controlled or actively smoking patients are twice as likely to have major complications or die from elective surgery. We at OVVI partner with our patients and other specialties to optimize risk factors prior to surgery.
This has historically been the standard way to fix a AAA. Repair is accomplished through an incision on the abdomen. The aorta above and below the AAA is clamped off, temporarily interrupting blood flow to the pelvis and legs. The aneurysm is then opened and replaced with either dacron polyesther or gortex tubing which is sewn to healthy parts of the aorta or iliac arteries. Most patients will be in the hospital a few days up to a week before being ready to go home. The need for secondary procedures once an open AAA is performed are very uncommon but survelliance is still recommended every few years.
EVAR is presently the most common way to repair many types of aneurysms including a AAA. This is a minimally invasive alternative to open AAA whereby a specially designed stent with dacron or gortex lining, known as stent grafts, are delivered through small incisions in the groin. By relining the inner aorta at the AAA you essentially depressurize the aneurysm to prevent growth, rupture and death. Patients typically go home within 24hours and recovery is significantly shorter that an open AAA. Secondary interventions are more common than with open AAA and therefore life-long monitoring is mandatory. OVVI employs a team approach with a standardized follow-up protocol for patient who have undergone an EVAR.
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