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4 Descending Thoracic Aortic Aneurysms (DTAA) and Thoracoabdominal Aortic…

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13. Khoury MK, Acher C, Wynn MM, Acher CW.Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2021;74:843–50.

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15. Tanious A, Boitano L, Canha L, Chou EL, Wang LJ, Latz C, Eagleton MJ, Conrad MF.Thoracic aortic remodeling with endografting after a decade of thoracic endovascular aortic repair experience. J Vasc Surg. 2021;73:844–9.

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17. Adam D, Iafrancesco M, Juszczak M, Claridge M, Quinn D, Senanayake E, Clift P, Mascaro J.Open surgical replacement of the descending thoracic and thoracoabdominal aorta in patients with conrmed Marfan and Loeys-Dietz syndromes: a 20-year single-centre experience. Eur J Cardiothorac Surg. 2022;62:ezac137.

18. Keschenau PR, Kotelis D, Bisschop J, Barbati ME, Grommes J, Mees B, Gombert A, Peppelenbosch AG, Schurink GWH, Kalder J, Jacobs MJ. Editor’s choice—open thoracic and thoraco-abdominal aortic repair in patients with connective tissue disease. Eur J Vasc Endovasc Surg. 2017;54:588–96.

19. Naazie IN, Gupta JD, Azizzadeh A, Arbabi C, Zarkowsky D, Malas MB.Risk calculator predicts 30-day mortality after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms in the vascular quality initiative. J Vasc Surg. 2022a;7:833–41.

20. Harris DG, Olson SL, Panthofer AM, Matsumura JS, DiMusto PD.A frailty-based risk score predicts morbidity and mortality after elective endovascular repair of descending thoracic aortic aneurysms. Ann Vasc Surg. 2020;67:90–9.

21. Naazie IN, Yei K, Osaghae I, Ramakrishnan G, Hughes K, Malas MB.Association of body mass index with outcomes after thoracic endovascular aortic repair in the vascular quality initiative. J Vasc Surg. 2022b;75:439–47.

22. Dakour-Aridi H, Yin K, Hussain F, Locham S, Azizzadeh A, Malas MB.Outcomes of intact thoracic endovascular aortic repair in octogenarians. J Vasc Surg. 2021;74:882–92.

23. Deery SE, Shean KE, Wang GJ, Black JH 3rd, Upchurch GR Jr, Giles KA, Patel VI, Schermerhorn ML, Society for Vascular Surgery Vascular Quality Initiative. Female sex independently predicts mortality after thoracic endovascular aortic repair for intact descending thoracic aortic aneurysms. J Vasc Surg. 2017;66:2–8.

24. Patel PB, Marcaccio CL, de Guerre LEVM, Patel VI, Wang G, Giles K, Schermerhorn ML.Complications after thoracic endovascular aortic repair for ruptured thoracic aortic aneurysms remain high compared with elective repair. J Vasc Surg. 2022;75:842–50.

25. Ultee KHJ, Zettervall S, Soden PA, Buck DB, Deery SE, Shean KE, HJM V, Schermerhorn ML. The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms. J Vasc Surg. 2017;66:343–52.

26. Hawkins RB, Mehaffey JH, Narahari AK, Jain A, Ghanta RK, Kron IL, Kern JA, Upchurch GR Jr. Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2017;66:1357–63.

27. Diamond KR, Simons JP, Crawford AS, Arous EJ, Judelson DR, Aiello F, Jones DW, Messina L, Schanzer A.Effect of thoracoabdominal aortic aneurysm extent on outcomes in patients undergoing fenestrated/branched endovascular aneurysm repair. J Vasc Surg. 2021;74:833–42.

28. Wipper S, Kölbel T, Sandhu HK, Manzoni D, Duprée A, Estrera AL, Sa H, Miller CC 3rd, Tsilimparis N, Debus ES.Impact of hybrid thoracoabdominal aortic repair on visceral and spinal cord perfusion: the new and improved SPIDER-graft. J Thorac Cardiovasc Surg. 2019;158:692–701.

29. Debus ES, Kölbel T, Wipper S.The SPIDER graft: a new hybrid device for thoraco-abdominal aortic repair. Eur J Vasc Endovasc Surg. 2019;57:588.

30. Coselli JS, LeMaire SA, Preventza O, de la Cruz KI, Cooley DA, Price MD, Stolz AP, Green SY, Arredondo CN, Rosengart TK. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg. 2016;151:1323–37.

31. Estrera AL, Sandhu HK, Charlton-Ouw KM, A RO, Azizzadeh A, Miller CC 3rd, Sa HJ. A quarter century of organ protection in open thoracoabdominal repair. Ann Surg. 2015;262:660–8.

32. Allar BG, Swerdlow NJ, de Guerre LEVM, Dansey KD, Li C, Wang GJ, Patel VI, Schermerhorn ML.Preoperative statin therapy is associated with higher 5-year survival after thoracic endovascular aortic repair. J Vasc Surg. 2021;74:1996–2005.

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33. Monaco F, Pieri M, Barucco G, Karpatri V, Redaelli MB, De Luca M, Mattioli C, Bove T,

34. Minami K, Yoshitani K, Inatomi Y, Sugiyama Y, Iida H, Ohnishi Y.A retrospective exami-

35. Tanaka A, Al-Rstum Z, Leonard SD, Gardiner BD, Yazij I, Sandhu HK, Miller CC 3rd, Sa HJ,

36. Clemence J Jr, Malik A, Farhat L, Wu X, Kim KM, Patel H, Yang B.Cryoablation of intercos-

37. Estrera AL, Sheinbaum R, Miller CC 3rd, Harrison R, Sa HJ.Neuromonitor-guided repair of

38. Agarwal S, Kendall J, Quarterman C.Perioperative management of thoracic and thoracoab-

39. Yoshitani K, Masui K, Kawaguchi M, etal. Clinical utility of intraoperative motor-evoked

40. Aucoin VJ, Eagleton MJ, Farber MA, Oderich GS, Schanzer A, Timaran CH, Schneider DB,

41. Aucoin VJ, Bolaji B, Novak Z, Spangler EL, Sutzko DC, McFarland GE, Pearce BJ, Passman

42. Alqaim M, Cosar E, Crawford AS, Robichaud DI, Walz JM, Schanzer A, Simons JP.Lumbar

43. Plotkin A, Han SM, Weaver FA, Rowe VL, Ziegler KR, Fleischman F, Mack WJ, Hendrix JA,

44. Kärkkäinen JM, Cirillo-Penn NC, Sen I, Tenorio ER, Mauermann WJ, Gilkey GD, Kaufmann

45. Kitpanit N, Ellozy SH, Connolly PH, Agrusa CJ, Lichtman AD, Schneider DB.Risk factors

46. Monaco F, Barucco G, Nardelli P, Licheri M, Notte C, De Luca M, Mattioli C, Melissano G,

47. Etz CD, Debus ES, Mohr FW, Kölbel T. First-in-man endovascular preconditioning of the

48. Dijkstra ML, Vainas T, Zeebregts CJ, Hooft L, van der Laan MJ.Editor’s choice—spinal cord

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Melissano G, Chiesa R, Landoni G, Zangrillo A.Epidural analgesia in open thoraco- abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2019a;57:360–7.

nation of the efcacy of paravertebral block for patients requiring intraoperative high-dose unfractionated heparin administration during thoracoabdominal aortic aneurysm repair. J Cardiothorac Vasc Anesth. 2015;29:937–41.

Estrera AL.Intraoperative intercostal nerve cryoanalgesia improves pain control after descending and thoracoabdominal aortic aneurysm repairs. Ann Thorac Surg. 2020;109:249–54.

tal nerves decreased narcotic usage after thoracic or thoracoabdominal aortic aneurysm repair. Semin Thorac Cardiovasc Surg. 2020;32:404–12.

thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg. 2010;140(6 Suppl):S131–5; discussion S142-S146.

dominal aneurysms. BJA Educ. 2019;19:119–25.

potential monitoring to prevent postoperative spinal cord injury in thoracic and thoracoabdominal aneurysm repair: an audit of the Japanese association of spinal cord protection in aortic surgery database. Anesth Analg. 2018;126:763–8.

Sweet MP, Beck AW.Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. aortic research consortium. J Vasc Surg. 2021a;73:323–30.

MA, Scali ST, Beck AW. Trends in the use of cerebrospinal drains and outcomes related to spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair in the vascular quality initiative database. J Vasc Surg. 2021b;74:1067–78.

drain complications in patients undergoing fenestrated or branched endovascular aortic aneurysm repair: development of an institutional protocol for lumbar drain management. J Vasc Surg. 2020;72:1576–83.

Magee GA.Complications associated with lumbar drain placement for endovascular aortic repair. J Vasc Surg. 2021;73:1513–1524.e2.

TJ, Oderich GS.Cerebrospinal uid drainage complications during rst stage and completion fenestrated-branched endovascular aortic repair. J Vasc Surg. 2020;71:1109–18.

for spinal cord injury and complications of cerebrospinal uid drainage in patients undergoing fenestrated and branched endovascular aneurysm repair. J Vasc Surg. 2021;73:399–409.e1.

Chiesa R, Zangrillo A.Editor’s choice—a rotational thromboelastometry driven transfusion strategy reduces allogenic blood transfusion during open thoraco-abdominal aortic aneurysm repair: a propensity score matched study. Eur J Vasc Endovasc Surg. 2019b;58:13–22.

paraspinal collateral network by segmental artery coil embolization to prevent ischemic spinal cord injury. J Thorac Cardiovasc Surg. 2015;149:1074–9.

ischaemia in endovascular thoracic and thoraco-abdominal aortic repair: review of preventive strategies. Eur J Vasc Endovasc Surg. 2018;55:829–41.

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49. Branzan D, Etz CD, Moche M, Von Aspern K, Staab H, Fuchs J, Then Bergh F, Scheinert D, Schmidt A.Ischaemic preconditioning of the spinal cord to prevent spinal cord ischaemia during endovascular repair of thoracoabdominal aortic aneurysm: rst clinical experience. EuroIntervention. 2018;14:828–35.

50. Petroff D, Czerny M, Kölbel T, Melissano G, Lonn L, Haunschild J, von Aspern K, Neuhaus P, Pelz J, Epstein DM, Romo-Avilés N, Piotrowski K, Etz CD.Paraplegia prevention in aortic aneurysm repair by thoracoabdominal staging with ‘minimally invasive staged segmental artery coil embolisation’ (MIS2ACE): trial protocol for a randomised controlled multicentre trial. BMJ Open. 2019;9:e025488.

51. Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, Samama CM.Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e227S.Erratum in: chest. 2012;141(5):1369.

52. Ramanan B, Gupta PK, Sundaram A, Lynch TG, MacTaggart JN, Baxter BT, Johanning JM, Pipinos II.In-hospital and postdischarge venous thromboembolism after vascular surgery. J Vasc Surg. 2013;57:1589–96.

53. Aziz F, Patel M, Ortenzi G, Reed AB.Incidence of postoperative deep venous thrombosis is higher among cardiac and vascular surgery patients as compared with general surgery patients. Ann Vasc Surg. 2015;29:661–9.

54. Ameli-Renani S, Pavlidis V, Morgan RA.Secondary endoleak management following TEVAR and EVAR.Cardiovasc Intervent Radiol. 2020;43:1839–54.

55. Belvroy VM, de Beaufort HWL, van Herwaarden JA, Trimarchi S, Moll FL, Bismuth J.Type 1b endoleaks after thoracic endovascular aortic repair are inadequately reported: a systematic review. Ann Vasc Surg. 2020;62:474–83.

56. Qamhawi Z, Barge TF, Makris GC, Patel R, Wigham A, Anthony S, Uberoi R. Editor’s choice—systematic review of the use of endoanchors in endovascular aortic aneurysm repair. Eur J Vasc Endovasc Surg. 2020;59:748–56.

Chapter 5

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Abdominal Aortic Aneurysm (AAA)

5.1 Guidelines

5.1.1 European Society forVascular Surgery (ESVS) 2019

Clinical Practice Guidelines ontheManagement ofAbdominal Aorto-iliac Artery Aneurysms [1]

5.1.1.1 General Information

• Recommendation 3: Abdominal aortic aneurysm repair should only be consid-

ered in centres with a minimum yearly caseload of 30 repairs. (Class IIa recommendation; Level of evidence C)

• Recommendation 4: Abdominal aortic aneurysm repair should not be performed

in centres with a yearly caseload <20. (Class III; Level B)

• Recommendation 9: In patients with abdominal aortic aneurysms computed

tomography angiography is recommended for therapeutic decision making and treatment planning, and for the diagnosis of rupture. (Class I; Level C)

5.1.1.2 Screening/Surveillance

• Recommendation 12: Population screening for abdominal aortic aneurysm with

a single ultrasound scan for all men at age 65years is recommended. (Class I; Level A)

• Recommendation 14: Population screening for abdominal aortic aneurysm in

women is not recommended. (Class III; Level B)

• Recommendation 15: All men and women aged 50years and older with a rst

degree relative with an abdominal aortic aneurysm may be considered for abdominal aortic aneurysm screening at 10year intervals. (Class IIb; Level C)

Switzerland AG 2023 E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,

https://doi.org/10.1007/978-3-031-47397-5_5

101© The Author(s), under exclusive license to Springer Nature

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5 Abdominal Aortic Aneurysm (AAA)

• Recommendation 17: Ultrasonography is recommended for aneurysm surveil-

lance; every 3years for aneurysms 3–3.9cm in diameter, annually for aneurysms

4.0–4.9cm, and every 3–6month for aneurysms ≥5.0cm. (Class I; Level B)

5.1.1.3 Indication forElective Repair

• Recommendation 22: In men, the threshold for considering elective abdominal

aortic aneurysm repair is recommended to be ≥5.5 cm diameter. (Class I; Level A)

• Recommendation 23: In women with acceptable surgical risk the threshold for

considering elective abdominal aortic aneurysm repair may be considered to be ≥5.0cm diameter. (Class IIb; Level C)

• Recommendation 24: When rapid abdominal aortic aneurysm growth is observed

(≥1cm/year), fast track referral to a vascular surgeon with additional imaging should be considered. (Class IIa; Level C)

• Recommendation 25: Emergency referral to a vascular surgeon of patients with

symptomatic abdominal aortic aneurysm is recommended. (Class I; Level C)

• Recommendation 65: Symptomatic non-ruptured abdominal aortic aneurysms

should be considered for deferred urgent repair ideally under elective repair conditions. (Class IIa; Level B)

• Recommendation 26: Patients who initially are not candidates for abdominal

aortic aneurysm repair should be considered for continued surveillance, referral to other specialists for optimisation of their tness status and then reassessed. (Class IIa; Level C)

• Recommendation 116: Early treatment may be considered for saccular abdomi-

nal aortic aneurysms, with a lower threshold for elective repair than for standard fusiform abdominal aortic aneurysms. (Class IIb; Level C)

5.1.1.4 Elective AAA Repair

• Recommendation 60: In most patients with suitable anatomy and reasonable life

expectancy, endovascular abdominal aortic aneurysm repair should be considered as the preferred treatment modality. (Class IIa; Level B)

• Recommendation 61: In patients with long life expectancy, open abdominal aor-

tic aneurysm repair should be considered as the preferred treatment modality. Class IIa; Level B)

• Recommendation 62: In patients with limited life expectancy, elective abdomi-

nal aortic aneurysm repair is not recommended. (Class III; Level B)

5.1 Guidelines

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5.1.1.5 Techniques forElective AAA Open Repair

• Recommendation 50: Intravenous heparin (50–100 IU/kg) is recommended

before aortic cross clamping. (Class I; Level C)

• Recommendation 52: In selected cases of suspected insufcient perfusion of pel-

vic organs with risk of colonic ischaemia, reimplantation of the inferior mesenteric artery may be considered during open abdominal aortic aneurysm repair. (Class IIb; Level C)

• Recommendation 53: In open abdominal aortic aneurysm repair, it is recom-

mended to preserve the blood ow to at least one internal iliac artery to reduce the risk of buttock claudication and colonic ischaemia. (Class I; Level C)

• Recommendation 54: In patients treated for abdominal aortic aneurysm by open

repair, prophylactic use of mesh reinforcement of midline laparotomies may be considered for patients at high risk of incisional hernia. (Class IIb; Level A)

5.1.1.6 Techniques forElective AAA Endovascular Repair

• Recommendation 55: An ultrasound guided percutaneous approach should be

considered in endovascular aortic aneurysm repair. (Class IIa; Level B)

• Recommendation 56: Preservation of large accessory renal arteries (>3mm) or

those that supply a signicant portion of the kidney (>1/3) may be considered in endovascular aneurysm repair. Class IIb; Level C)

103

5.1.1.7 Management ofRuptured AAA

• Recommendation 63: In haemodynamically stable patients with suspected rup-

tured abdominal aortic aneurysm, prompt thoracoabdominal computed tomography angiography is recommended as the imaging modality of choice. (Class I; Level B)

• Recommendation 74: In patients with ruptured abdominal aortic aneurysm and

suitable anatomy, endovascular repair is recommended as a rst option. (Class I; Level B)

• Recommendation 69: In patients undergoing endovascular repair for ruptured

abdominal aortic aneurysms, a bifurcated device, in preference to an aorto-uniiliac device, should be considered whenever anatomically suitable. (Class IIa; Level C)

5.1.2 Society forVascular Surgery

These guidelines recommend [2]:

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5 Abdominal Aortic Aneurysm (AAA)

5.1.2.1 Screening/Surveillance

• We recommend a one-time ultrasound screening for AAAs in men or women

65–75years of age with a history of tobacco use. Level of recommendation 1 (strong), quality of evidence A (high).

• We suggest ultrasound screening for AAA in rst degree relatives of patients

who present with an AAA.Screening should be performed in st degree relatives who are between 65 and 75years of age or in those older than 75years and in good health. Level of recommendation 2 (weak), quality of evidence C (low).

• We suggest a one-time ultrasound screening for AAAs in men or women older

than 75years with a history of tobacco use and in otherwise good health who have not previously received a screening ultrasound examination. Level of recommendation 2 (weak), quality of evidence C (low).

• If initial ultrasound screening identied an aortic diameter >2.5cm but <3cm,

we suggest rescreening after 10years. Level of recommendation 2 (weak), quality of evidence C (low).

• We suggest surveillance imaging at 3-year intervals for patients with an AAA

between 3.0 and 3.9cm. Level of recommendation 2 (weak), quality of evidence C (low).

• We suggest surveillance imaging at 12-month intervals for patients with an AAA

between 4.0 and 4.9cm in diameter. Level of recommendation 2 (weak), quality of evidence C (low).

• We suggest surveillance imaging at 6-month intervals for patients with an AAA

between 5.0 and 5.4cm in diameter. Level of recommendation 2 (weak), quality of evidence C (low).

5.1.2.2 Indication forElective Repair

• We recommend repair for the patient who presents with an AAA and abdominal

or back pain that is likely to be attributed to the aneurysm. Level of recommendation 1 (strong), quality of evidence C (low).

• We recommend elective repair for the patient at low or acceptable surgical risk

with a fusiform AAA that is ≥5.5cm. Level of recommendation 1 (strong), quality of evidence A (high).

• We suggest elective repair for the patient who presents with a saccular aneurysm.

Level of recommendation 2 (weak), quality of evidence C (low).

• We suggest repair in women with AAA between 5.0cm and 5.4cm in maximum

diameter. Level of recommendation 2 (weak), quality of evidence B (moderate).

These guidelines generally recommend EVAR for elective AAA repair. OAR of an AAA is suggested for patients who do not meet the anatomic requirements for endovascular repair, including short or angulated landing zones, excessive thrombus, multiple large accessory renal arteries, and small and tortuous access vessels with concomitant occlusive disease. However, fenestrated, branched, and chimney or

5.1 Guidelines

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105

snorkel grafts have expanded the range of complex aortic anatomy potentially treatable by EVAR. OAR may be required for treatment of a persistent endoleak and aneurysm sac growth after EVAR or for treatment of a mycotic aneurysm or infected graft.

5.1.2.3 Management andPerioperative Outcome ofElective Repair

• We suggest that elective EVAR be performed at centers with a volume of at least

10 EVAR cases each year and a documented perioperative mortality and conversion rate to OAR of 2% or less. Level of recommendation 2 (weak), quality of evidence C (low).

• We suggest that elective OAR for AAA be performed at centers with an annual

volume of at least 10 open aortic operations of any type and a documented perioperative mortality of 5% or less. Level of recommendation 2 (weak), quality of evidence C (low).

5.1.2.4 Management ofRuptured AAA

• We recommend immediate repair for patients who present with a ruptured aneu-

rysm. Level of recommendation 1 (strong), quality of evidence A (high)

• We suggest a door-to-intervention time of <90min, based on a framework of

30–30–30 min, for the management of the patient with a ruptured aneurysm. Level of recommendation: Good Practice Statement, quality of evidence: Ungraded

• An established protocol for the management of ruptured AAA is essential for

optimal outcomes. Level of recommendation: Good Practice Statement, quality of evidence: Ungraded

• We recommend implementing hypotensive hemostasis with restriction of uid

resuscitation in the conscious patient. Level of recommendation 1 (strong), quality of evidence B (moderate).

• If it is anatomically feasible, we recommend EVAR over open repair for treat-

ment of a ruptured AAA.Level of recommendation 1 (strong), quality of evidence C (low).

5.1.2.5 Management inSymptomatic Patients

• Should repair of a symptomatic AAA be delayed to optimize coexisting medical

conditions, we recommend that the patient be monitored in an ICU setting with blood products available. Level of recommendation 1 (strong), quality of evidence C (low).

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• We suggest renal artery or SMA angioplasty and stenting for selected patients

with symptomatic disease before EVAR or OAR.Level of recommendation 2 (weak), quality of evidence C (low).

5 Abdominal Aortic Aneurysm (AAA)

5.1.3 ACC/AHA Guideline fortheDiagnosis andManagement

ofAortic Disease

These guidelines recommend [3]:

• In patients with nonruptured AAA with low to moderate operative risk and who

have anatomy suitable for either open or EVAR, a shared decision-making process weighing the risks and benets of each approach is recommended. Class of recommendation [COR] 1; Level of evidence [LOE] A)

• In patients undergoing elective endovascular repair for nonruptured AAA, adher-

ence to manufacturer’s instructions for use is recommended. (COR 1; LOE B-NR)

• In patients with nonruptured AAA and a high perioperative risk, EVAR is rea-

sonable to reduce the risk of 30-day morbidity, mortality, or both. (COR 2a; LOE B-NR)

• For patients with nonruptured AAA, a moderate to high perioperative risk, and

anatomy suitable for an FDA-approved fenestrated endovascular device, endovascular repair is reasonable over open repair to reduce the risk of perioperative complications. (COR 2a; LOE B-NR)

• In patients presenting with ruptured AAA who have suitable anatomy, endovas-

cular repair is recommended over open repair to reduce the risk of morbidity and mortality. (COR 1; LOE B-R)

5.2 Results

5.2.1 AAA-Screening

5.2.1.1 Systematic Review/Meta-Analysis

In 2014, the US Preventive Services Task Force (USPSTF) recommended one-time ultrasound screening for AAA in asymptomatic men aged 65–75years who had ever smoked (B recommendation). Guirguis-Blake etal. [4] prepared a systematic review based on 50 studies (n=323,279) to inform an updated recommendation by the USPSTF on the evidence related to the effectiveness of 1-time and repeat screening for AAA and possible related harms, as well as the effectiveness and related harms of treatment (pharmacotherapy or surgery) of small AAAs (3.0–5.4cm in diameter). Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65years or older was associated with a

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