Management

Medical management involved control of blood pressure and elimination of risk factors such as smoking. Current trials have investigated the use of tetracycline and macrolide antibiotics to control the expansion of AAAs. Use of propranolol and anti-inflammatory agents has been used as well.

Coronary artery disease (CAD) is present in 50% of patients with AAA. CAD remains the leading perioperative cause of death after operations of the abdominal aorta. The incidence of fatal MI has been reported to be as high as 5% and nonfatal MI as high as 16%. Thorough cardiac evaluation is required in patients planned for elective AAA repair.

Current recommendations are for elective repair of aneurysms > 5 cm. The Small Aneurysm Trial demonstrated no long term survival advantage with surgery over ultrasound surveillance unless the aneurysm exceeded 5.5 cm. A report from the Society of Vascular Surgery suggested repair of asymptomatic aneyrysms that are twice the normal diameter of the infrarenal aorta provided there are no contraindications to surgery. If elective repair is contraindicated patients with AAA < 5 cm should be followed with US every 6 months and every 3 months for AAA > 5 cm. Expansion > 0.5 cm is an indication for surgery. Contraindications for surgery include:

Myocardial infarction within the past 6 months

• Chronic renal failure

• COPD with dypsnea at rest

Surgical repair can be through a transperitoneal or retroperitoneal approach. Both offer advantages and are tailored to the clinical circumstance. Retroperitoneal repair is associated with fewer postoperative complications, short stay in the hospital and intensive care unit.4 The transperitoneal approach is advantageous for concomitant intraperitonal disease treatment, extension to the right iliac artery and ruptured AAA. The AAA is typically repaired with a Dacron or polytetrafluoroethylene tube or bifurcated graft with the aneurysmal sac closed over the graft.

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