December 19, 2017
4 min read

New Guideline Endorses Endovascular Repair for Ruptured AAA

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Thomas L. Forbes

The new Society for Vascular Surgery guideline on care of patients with abdominal aortic aneurysms recommends endovascular repair over surgery for ruptured AAA if it is anatomically feasible.

The guideline, the first in 9 years, also recommends AAA repair procedures be limited to centers that meet standards for quality and volume, and that the Society for Vascular Surgery (SVS) Vascular Quality Initiative mortality risk score be used when making decisions about AAA repair.

EVAR endorsed

Elliot L. Chaikof, MD, PhD, Johnson & Johnson Professor of Surgery at Harvard Medical School and chairman of the Roberta and Stephen R. Weiner Department of Surgery and surgeon-in-chief at Beth Israel Deaconess Medical Center, and colleagues gave a level 1 (strong), quality of evidence C (low) to a recommendation of endovascular aneurysm repair over open repair for treatment of ruptured AAA if anatomically feasible.

“An analysis of national trends in the United States confirms that EVAR is being used with increasing frequency for treatment of ruptured AAA, with a decrease in associated mortality,” the authors wrote. “Outcomes are superior when EVAR for a ruptured aneurysm is performed in teaching hospitals and high-volume centers.”

Thomas L. Forbes, MD, vascular surgeon at the Peter Munk Cardiac Centre, chair of vascular surgery at the University of Toronto and chair of the SVS Document Oversight Committee, told Cardiology Today’s Intervention that “during the writing of these guidelines back in the fall, at that point there had been four randomized trials looking at open vs. endovascular repair for ruptured aneurysms, but up until recently, none were able to show a sustained survival benefit for endovascular repair, which was in contradistinction to a lot of the single-center studies and multicenter registries. Recently, however, the 3-year outcomes of one of those randomized controlled trials, the IMPROVE trial in the United Kingdom, did finally show a benefit for endovascular repair of a ruptured aneurysm. The recommendation is now stronger because of that recent addition.”

Also impacting the recommendation was “data showing [EVAR] is a cost-effective approach with respect to shorter hospitalization, quicker return to normal activity and quicker return to home living,” Forbes said.

Volume, outcome standards

The guideline also advises that AAA procedures be limited to centers that meet specific case volume thresholds and outcome targets.

Elective EVAR should be limited to hospitals that have a documented rate of mortality and conversion to open surgery of 2% or less and that perform at least 10 EVAR procedures per year, Chaikof and colleagues wrote.

Open AAA should be performed in hospitals with a documented mortality rate less than 5% that perform at least 10 open repairs per year, according to the guideline.

“Those outcome criteria remain from the 2009 guideline,” Forbes told Cardiology Today’s Intervention. “However, they are now also linked with recommendations that these procedures be done in hospitals that are performing at least 10 cases per year.”

In a press release, he said “the original suggestion was for higher volume numbers, but eventually epidemiologically sound and clinically relevant case volumes were set to recognize the excellent work that SVS members are doing in a variety of practice settings. We recognize that these case volume requirements are open to discussion and will likely be revisited in future updates to these guidelines.”

Risk score

The authors also recommended that the SVS Vascular Quality Initiative mortality risk score be used when making decisions about AAA repair.

“This takes into account patient comorbidities as well as the anatomy of their disease to allow for more of a personalized risk stratification of patients,” Forbes said in an interview.

Screening suggestions

The guideline also recommends that men and women aged 65 to 75 years with a history of tobacco use should have a one-time ultrasound screening for AAA; other guidelines recommend this for older male smokers only.

“Any screening recommendation has to be epidemiologically sound and supported by the data but also practically relevant and doable,” Forbes told Cardiology Today’s Intervention. “We recognize that primary care physicians are inundated with multiple screening recommendations. Any secondary or tertiary levels of complexity are a hurdle to implementation of a screening strategy. However, while [AAA] is less common in women than in men, women with aneurysms tend to do poorer than men. They tend to be older when they present and tend to have poorer results after elective or urgent repair. Because their outcomes are worse, you can make a case for trying to identify those aneurysms in these patients.”

Other recommendations include:

  • Door-to-intervention time for emergency AAA repairs should be less than 90 minutes.
  • Type I and type III endoleaks should be treated. Type IV endoleaks should not be treated. Type II endoleaks should be treated if associated with aneurysm expansion and monitored if not. If endovascular intervention fails to treat an endoleak associated with aneurysm expansion, open repair should be performed.
  • Antibiotic prophylaxis should be used in any patients with an aortic prosthesis undergoing dental repair to prevent graft infection.
  • Surveillance imaging every 12 months should be performed for patients with an AAA 4 cm to 4.9 cm in diameter. – by Erik Swain

Disclosures: Chaikof and Forbes report no relevant financial disclosures. Please see the guideline for all other authors’ relevant financial disclosures.