Aortic aneurysm: sizing, growth and repair thresholds — practice case: an AAA from detection to EVAR

Presentation

Practice case (not a real patient). A 72-year-old man in Australia has an asymptomatic AAA of 44 mm found on an abdominal ultrasound done for another reason; the duplex image measures it adequately.^[1] He is an ex-smoker with hypertension averaging 138/84 mm Hg on one drug, stable exertional angina controlled on medical therapy, and aortic atherosclerosis on CT. He walks a kilometre without symptoms and expects to live well beyond 2 years.^[2][1]

Step 1 — First assessment

Discussion:

• ESC 2024: when an aortic aneurysm is found at any location, assessment of the entire aorta is recommended at baseline and during follow-up (Class I, Level C), and when an AAA is found, evaluation for femoro-popliteal aneurysm should be considered (Class IIa, Level C).^[1]
• ESC 2024 text says up to 20% of patients with AAA also have a femoral and/or popliteal aneurysm.^[1]
• Patients with aortic aneurysm are at increased risk of CVD, so general cardiovascular prevention should be considered (ESC 2024, Class IIa, Level C).^[1]

Step 2 — Medical therapy and surveillance

Discussion:

• ESC 2024 recommends an SBP target towards 120–129 mmHg, if tolerated, in peripheral arterial and aortic disease with hypertension (Class I, Level A); ACC/AHA 2022 recommends antihypertensive medication in AAA with an average SBP ≥130 mm Hg or DBP ≥80 mm Hg (COR 1, LOE B-NR).^[1][2]
• With evidence of aortic atherosclerosis, moderate- or high-intensity statin therapy is recommended (ACC/AHA 2022, COR 1, LOE B-NR).^[2]
• At 44 mm in a man, ESC 2024 says yearly duplex surveillance should be considered for AAA of 40 to <50 mm in men (40 to <45 mm in women) (Class IIa, Level B); ACC/AHA 2022 recommends yearly ultrasound to assess for interval change for 4.0–4.9 cm in men (4.0–4.4 cm in women) (COR 1, LOE B-NR).^[1][2]

Step 3 — Four years later

His AAA now measures 56 mm on duplex, confirmed on CT, and is unruptured. He remains asymptomatic, his angina is stable, his life expectancy is judged to exceed 2 years, his operative risk is judged low to moderate, and his anatomy is suitable for EVAR or open repair.^[1][2]

• ESC 2024 recommends elective repair at ≥55 mm in men (≥50 mm in women) (Class I, Level A); ACC/AHA 2022 recommends repair of an unruptured AAA at ≥5.5 cm in men (≥5.0 cm in women) (COR 1, LOE A).^[1][2]
• ESC 2024: with suitable anatomy and reasonable life expectancy (>2 years), EVAR should be considered as the preferred therapy, based on shared decision-making (Class IIa, Level B).^[1]
• ACC/AHA 2022: with low to moderate operative risk and anatomy suitable for either open repair or EVAR, a shared decision-making process weighing the risks and benefits of each is recommended (COR 1, LOE A).^[2]
• ACC/AHA 2022 recommends CT for preoperative planning once an AAA meets repair criteria (COR 1, LOE C-EO).^[2]

Step 4 — Does he need coronary angiography first?

• No: before AAA repair, routine coronary angiography and systematic revascularization in chronic coronary syndromes is not recommended (ESC 2024, Class III, Level C).^[1]
• ESC 2024 text says coronary revascularization before elective aortic surgery in patients with stable cardiac symptoms cannot be recommended, as it does not improve outcomes or reduce the 30-day MI rate.^[1]
• ESC 2022: routine referral for cardiac work-up, coronary angiography or CPET before elective surgery for PAD or AAA is not recommended (Class III, Level C); referral for cardiac work-up and optimization is recommended in patients with poor functional capacity or significant risk factors or symptoms, such as moderate-to-severe angina, decompensated HF, valvular disease and significant arrhythmia (Class I, Level C).^[12]

Step 5 — After EVAR

He has EVAR. The 30-day CCT and duplex show a good seal and no endoleak.^[1]

• ESC 2024 recommends 30-day imaging after EVAR by CCT and duplex or contrast-enhanced ultrasound to assess success (Class I, Level B).^[1]
• Imaging is then recommended at 12 months and, if there are no abnormalities, yearly duplex or contrast-enhanced ultrasound with CCT or CMR every 5 years (ESC 2024, Class I, Level A).^[1]
• ACC/AHA 2022: CT at 1 month and, without endoleak or sac enlargement, duplex at 12 months and then annually (COR 1, LOE B-NR).^[2]
• In OVER (881 patients with asymptomatic AAA who were candidates for either procedure, randomised to endovascular or open repair and followed for up to 14 years), long-term overall survival was similar, with a difference in the number of patients who underwent secondary therapeutic procedures.^[8]

Examiner criteria

• Pass: images the whole aorta and the femoro-popliteal segment; treats BP and lipids; picks yearly surveillance at 44 mm and repair at ≥55 mm in a man; offers EVAR or open repair through shared decision-making; avoids routine coronary angiography; sets lifelong post-EVAR imaging.^[1][2]
• Fail: repairs at 44 mm, orders routine coronary angiography before repair despite stable chronic coronary syndrome (ESC 2024 Class III, Level C), or stops imaging after a normal 12-month scan.^[1]