Guideline sources The following summarized guidelines for the evaluation and management of abdominal aortic aneurysm are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ACC 2022), the European Society for Vascular Surgery (ESVS 2019), the U.S. Preventive Services Task Force (USPSTF 2019), the Society for Vascular Surgery (SVS 2018), the European Society of Cardiology (ESC 2014), and the Society for Cardiovascular Angiography and https://web.pathway.md/diseases/recAViRuLGldn39TW 1/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway Interventions (SCAI/STS/SVM/AATS/SCA/AHA/ACR/ACC/ASA/SIR 2010). 1 2 3 4 5 6 8 8 9 9 10 Definition An AAA is a structural disease of the abdominal aorta characterized by a pathological, localized dilatation of > 30 mm or > 50% of the original aortic size. 8 Epidemiology Multiple environmental factors (including smoking, hypertension, coronary artery disease, and collagen diseases) and genetic factors can induce and accelerate degeneration of the layers of the aortic wall. An inflammatory response in the aortic vessel wall leads to destruction of elastin and collagen in the media and adventitia, loss of smooth muscle cells, thinning of the media, and neovascularization. 9 Pathophysiology In the United States, the overall prevalence of AAA is estimated at 2200 persons per 100,000 population. 8 Disease course The majority of AAAs are asymptomatic and are detected as an incidental finding on diagnostic imaging performed for other purposes. AAAs can also present with abdominal pain or complications such as thrombosis, embolization and rupture. 10 Prognosis and risk of recurrence The overall mortality associated with ruptured AAA is approximately 85-90%. 9 Guidelines 1. Screening and diagnosis Indications for screening: As per AHA 2022 guidelines, obtain ultrasound screening for AAA in 65 years old male individuals who have ever smoked. Show 4 more As per ESVS 2019 guidelines, screen for AAA with one-time ultrasound in all men at 65 years of age. A Show 3 more Landmark trials: MASS https://web.pathway.md/diseases/recAViRuLGldn39TW 2/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway In men aged 65-74 years, ultrasound screening for AAA was superior to no ultrasound screening with respect to death related to AAA at 10 years. Thompson SG et al. BMJ. 2009 Jun 24. As per USPSTF 2019 guidelines, obtain one-time screening for AAA with ultrasound in 65-75 years old males who have ever smoked. Show 3 more As per SVS 2018 guidelines, screen for AAA with one-time ultrasound in men or women 65-75 years of age who have ever smoked. A Show 2 more As per ESC 2014 guidelines, screen for AAA with ultrasound in all males > 65 years old. A Show 5 more Indications for rescreening: As per ESVS 2019 guidelines, consider re-screening men with an aortic diameter 2.5-2.9 cm after 5-10 years. C As per SVS 2018 guidelines, consider re-screening patients with an aortic diameter 2.6-2.9 cm after 10 years. C As per ESC 2014 guidelines, consider re-screening patients with an abdominal aortic diameter of 2.5-2.9 cm after 4 years. C 2. Diagnostic investigations Physical examination: perform a physical examination in patients with a suspected or known AAA, including an assessment of femoral and popliteal arteries. Evaluate for an AAA in patients with a popliteal or femoral artery aneurysm. A Diagnostic imaging: As per AHA 2022 guidelines, measure aortic diameters at reproducible anatomic landmarks perpendicular to axis of blood flow in patients with known or suspected aortic disease. Report the longest diameter and its perpendicular diameter in case of asymmetric or oval contour. Show 6 more As per ESVS 2019 guidelines, use ultrasound as the first-line test for the diagnosis and surveillance of small AAAs. Show 3 more As per SVS 2018 guidelines, obtain a CT scan in patients thought to have an AAA who present with recent-onset abdominal or back pain, particularly in the presence of a pulsatile epigastric mass or significant risk factors for AAA. Evaluation for carotid artery stenosis: avoid routine screening for asymptomatic carotid artery stenosis prior to AAA repair. D Psychosocial assessment: consider screening for anxiety, depression, and posttraumatic stress disorder in patients with clinically significant aortic disease and provide resources for support https://web.pathway.md/diseases/recAViRuLGldn39TW 3/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway when indicated. Consider providing education and resources to minimize patients' concerns, support optimal decision-making, and enhance the quality of life. C 3. Medical management General principles: consider initiating antihypertensive, antiplatelet, and statin therapy in all patients with AAA. C Setting of care: Determine the most suitable intervention in patients with acute aortic disease requiring urgent repair by a multidisciplinary team. Consider referring asymptomatic patients with extensive aortic disease, patients likely to benefit from complex open and endovascular aortic repairs, and patients with multiple comorbidities eligible for an intervention to a high-volume center (performing at least 30-40 aortic procedures annually) with experienced surgeons in a multidisciplinary aortic team to optimize treatment outcomes. C Shared decision-making: Ensure shared decision-making when determining the appropriate thresholds for intervention, deciding on the type of surgical repair, choosing between open surgical versus endovascular approaches, and in medical management and surveillance in patients with aortic disease. Ensure shared decision-making when considering the cardiovascular risks of pregnancy, the diameter thresholds for prophylactic aortic surgery, and the mode of delivery in patients with aortic disease contemplating pregnancy or who are pregnant. Beta-blockers: As per ESVS 2019 guidelines, avoid initiating -blockers prior to AAA repair. D As per SVS 2018 guidelines, avoid administering -blocker therapy for the sole purpose of reducing the risk of AAA expansion and rupture. D Antithrombotic therapy: As per AHA 2022 guidelines, consider initiating low-dose aspirin in patients with AAA with concomitant atheroma and/or penetrating atherosclerotic ulcer, unless contraindicated. C As per ESVS 2019 guidelines, continue antiplatelet therapy with aspirin or a thienopyridine (e.g. clopidogrel) during the perioperative period after open and endovascular AAA repair. Statins: As per AHA 2022 guidelines, initiate statin therapy at moderate or high intensity in patients with AAA and evidence of aortic atherosclerosis. Consider initiating statin therapy also in patients with AAA with no evidence of atherosclerosis. As per ESVS 2019 guidelines, initiate statins one month before operative intervention for AAA, in order to reduce cardiovascular morbidity. A As per ESC 2014 guidelines, consider statins to reduce aortic complications in patients with small AAA. C https://web.pathway.md/diseases/recAViRuLGldn39TW 4/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway Antihypertensive therapy: initiate antihypertensive therapy to reduce the risk of cardiovascular events in patients with AAA and an average systolic BP of 130 mmHg or an average diastolic BP of 80 mmHg. Other medical therapies: As per ESVS 2019 guidelines, avoid initiating medical therapy to slow the expansion rate of an AAA, as no such treatment option has been proven to be effective. D As per SVS 2018 guidelines, consider not using statins, doxycycline, roxithromycin, ACEIs, or ARBs for the sole purpose of reducing the risk of AAA expansion and rupture. D As per ESC 2014 guidelines, consider ACEIs to reduce aortic complications in patients with small AAA. C 4. Inpatient care Setting of care: Admit patients having undergone AAA repair to an ICU for postoperative monitoring and management in the following clinical scenarios: patients with significant cardiac, pulmonary, or renal disease patients requiring postoperative mechanical ventilation patients who developed a significant arrhythmia or hemodynamic instability during operative treatment. A Nutritional considerations: Use nasogastric decompression intraoperatively for all patients undergoing open aneurysm repair, but only for those with nausea and abdominal distention in the postoperative setting. A Provide parenteral nutrition to patients who are unable to tolerate enteral nutrition within 7 days of AAA repair. A Pain management: As per ESVS 2019 guidelines, consider perioperative epidural analgesia in patients undergoing open AAA repair, in order to maximize pain relief and minimize early postoperative complications. C As per SVS 2018 guidelines, provide multimodality treatment, including epidural analgesia, for postoperative pain control after open surgical repair of an AAA. A Thromboprophylaxis: As per ESVS 2019 guidelines, consider administering prolonged DVT prophylaxis with LMWH prophylaxis (up to 4 weeks) in patients with malignancy who have undergone AAA repair. C As per SVS 2018 guidelines: Providing thromboprophylaxis, including intermittent pneumatic compression and early ambulation, in all patients undergoing open surgical repair or endovascular aneurysm repair. A Consider administering thromboprophylaxis with unfractionated or LMWH for patients undergoing AAA repair at moderate to high risk for VTE and low risk for bleeding. C https://web.pathway.md/diseases/recAViRuLGldn39TW 5/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway Monitoring for abdominal compartment syndrome: monitor intra-abdominal pressure in all patients undergoing open or endovascular treatment for ruptured AAA, in order to achieve early diagnosis and management of intra-abdominal hypertension/abdominal compartment syndrome. Show 2 more Monitoring for myocardial injury: Monitor ST-segment changes postoperatively in all patients undergoing open aneurysm repair and in those undergoing endovascular aneurysm repair who are at high cardiac risk. Measure troponin levels postoperatively in all patients with electrocardiographic changes or chest pain after AAA repair. A 5. Nonpharmacologic interventions Smoking cessation: As per AHA 2022 guidelines, advise smoking cessation in smoker patients with AAA. As per ESVS 2019 guidelines, advise smoking cessation in patients with a small AAA, in order to reduce the risk of AAA growth and rupture, and provide assistance towards that goal. As per SVS 2018 guidelines, advise smoking cessation in patients an AAA, in order to reduce the risk of AAA growth and rupture. As per ESC 2014 guidelines, advise smoking cessation to slow growth of the AAA. Physical activity: As per AHA 2022 guidelines: Provide education and guidance on avoiding intense isometric exercises (such as heavy weightlifting or activities requiring the Valsalva maneuver), burst exertion and activities, and collision sports in patients with significant aortic disease. Consider encouraging 30-60 minutes of mild-to-moderate intensity aerobic activity at least 3-4 days per week in patients with AAA and adequately controlled BP. C As per ESVS 2019 guidelines, consider advising strategies targeted at a healthy lifestyle, including exercise and a healthy diet, in all patients with AAA. C 6. Therapeutic procedures Endovascular aneurysm repair: as per AHA 2022 guidelines, perform US-guided percutaneous closure over open cutdown for endovascular AAA repair to reduce operative time, blood loss, length of stay, time to wound healing, and pain in patients with suitable common femoral artery anatomy. Aortic balloon occlusion: consider performing aortic balloon occlusion for proximal control in hemodynamically unstable patients with a ruptured AAA undergoing open or endovascular repair. C Preoperative renal/mesenteric angioplasty: https://web.pathway.md/diseases/recAViRuLGldn39TW 6/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway Consider performing renal artery angioplasty and stenting in selected patients with symptomatic renal artery stenosis before endovascular aneurysm repair or open surgical repair. C Consider superior mesenteric artery angioplasty and stenting in selected patients with symptomatic superior mesenteric artery stenosis before endovascular aneurysm repair or open surgical repair. C 7. Perioperative care Preoperative counseling: consider informing patients contemplating open repair or endovascular aneurysm repair of their perioperative mortality risk score (Vascular Quality Initiative score). C Preoperative pulmonary function testing: As per ESVS 2019 guidelines, consider obtaining pulmonary function testing with spirometry in all patients prior to elective AAA repair. C Show 2 more As per SVS 2018 guidelines, consider obtaining preoperative pulmonary function testing, including room air arterial blood gas determinations, in patients scheduled to undergo AAA repair in whom there is a history of symptomatic COPD, long-standing tobacco use, or inability to climb one flight of stairs. C Preoperative cardiac risk assessment: As per ESVS 2019 guidelines: Avoid routine referral for cardiac work up, coronary angiography or cardiopulmonary exercise testing prior to AAA repair. D Refer patients with poor functional capacity (defined as < 4 metabolic equivalents) or with significant clinical risk factors (such as unstable angina, decompensated HF, severe valvular disease, and significant arrhythmia) for cardiac work up and optimization prior to elective AAA repair. As per SVS 2018 guidelines, obtain a preoperative cardiology consultation before endovascular aneurysm repair or open surgical repair in patients with active cardiac conditions (including unstable angina, decompensated HF, severe valvular disease, and significant arrhythmia). Show 2 more Preoperative renal function testing: assess preoperative kidney function by measuring serum creatinine and estimated GFR in patients scheduled to undergo AAA repair, and refer patients with severe renal impairment (estimated GFR < 30 mL/min/1.73 m ) for specialist assessment. Preoperative nutritional assessment: measure serum albumin to assess preoperative nutritional status in patients undergoing elective AAA repair, and use an albumin level of < 2.8 g/dL as a threshold for preoperative correction. Preoperative hematologic assessment: consider referring patients for a hematologic assessment if the preoperative platelet count is < 150 10 . C Preoperative cardiac optimization: https://web.pathway.md/diseases/recAViRuLGldn39TW 7/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway As per ESVS 2019 guidelines, avoid routinely performing routine coronary revascularization before elective AAA repair in patients with stable coronary artery disease. D Show 3 more As per SVS 2018 guidelines, consider performing coronary revascularization before aneurysm repair in patients with acute ST-segment or non-ST segment elevation myocardial infarction, unstable angina, or stable angina with left main coronary artery or three-vessel disease. C Show 4 more Preoperative renal optimization: Administer preoperative hydration in nondialysis dependent patients with renal insufficiency before AAA repair. A Administer preprocedure and postprocedure hydration with normal saline or 5% dextrose/sodium bicarbonate for patients at increased risk of contrast-induced nephropathy undergoing endovascular aneurysm repair. A Preoperative pulmonary optimization: Advise smoking cessation for at least 2 weeks before aneurysm repair. Consider initiating pulmonary bronchodilators for at least 2 weeks before aneurysm repair in patients with a history of COPD or abnormal pulmonary function testing results. C Preoperative nutritional optimization: optimize preoperative nutritional status before elective open aneurysm repair if repair will not be unduly delayed. A Preoperative dental optimization: eliminate any potential source of dental sepsis at least 2 weeks before implantation of an aortic prosthesis. E Considerations for anesthesia: As per ESVS 2019 guidelines, consider using local anesthesia as the anesthetic modality of choice for endovascular repair of ruptured AAA, whenever tolerated by the patient. C As per SVS 2018 guidelines, use general endotracheal anesthesia for patients undergoing open aneurysm repair. A Show 2 more Preoperative antibiotic prophylaxis: As per ESVS 2019 guidelines, administer perioperative systemic antibiotic prophylaxis in all patients undergoing open or endovascular AAA repair. A As per SVS 2018 guidelines, administer perioperative systemic antibiotic prophylaxis in all patients undergoing open surgical repair or endovascular aneurysm repair, using an intravenous first-generation cephalosporin given within 30 minutes of surgery (or vancomycin in patients with a penicillin allergy). Avoid continuing prophylactic antibiotics for > 24 hours. A Perioperative transfusions: As per ESVS 2019 guidelines, consider intraoperative cell salvage and re-transfusion in patients undergoing open AAA repair. C As per SVS 2018 guidelines, transfuse packed blood cells along with FFP and platelets in a ratio of 1:1:1, in patients with an intraoperative Hgb level < 10 g/dL and ongoing blood loss. https://web.pathway.md/diseases/recAViRuLGldn39TW 8/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway Show 2 more Intraoperative temperature management: as per SVS 2018 guidelines, maintain core body temperature at or above 36 C during AAA repair. A Intraoperative anticoagulation: administer IV heparin (50-100 IU/kg) before aortic cross clamping. Management of beta-blockers: Consider continuing -blocker therapy during the perioperative period, if already established, in patients undergoing AAA repair. C Consider initiating -blocker therapy well in advance of surgery, if indicated for the management of a patient's comorbidities, to allow sufficient time to assess safety and tolerability. C Management of antiplatelet agents: As per ESVS 2019 guidelines, consider delaying AAA repair in patients on dual antiplatelet therapy after interventional coronary revascularization, until reduction to monotherapy can be safely performed. Alternatively, if AAA repair becomes necessary, EVAR may be considered under dual antiplatelet therapy. C As per SVS 2018 guidelines, discontinue P2Y12 platelet receptor inhibitor therapy 10 days preoperatively and continue aspirin in patients with a drug-eluting coronary stent requiring open aneurysm repair. Restart the P2Y12 inhibitor as soon as possible after surgery. Discuss the relative risks and benefits of perioperative bleeding and stent thrombosis with the patient. Management of antihypertensives and antihyperglycemics: consider holding ACEIs and angiotensin receptor antagonists on the morning of surgery and restarting these agents after the procedure once euvolemia has been achieved. C Show 2 more Preoperative imaging: obtain CT for preoperative planning in patients with an AAA meeting criteria for repair. 8. Surgical interventions General principles: As per ESVS 2019 guidelines: Refer patients with incidentally detected AAA to a vascular surgeon for evaluation, except for patients with very limited life expectancy. Consider performing aortic aneurysm repair only in centres with a minimum yearly caseload of 30 repairs. C As per SVS 2018 guidelines, consider referring the patient to a vascular surgeon at the time of initial diagnosis of an aortic aneurysm. E Show 2 more Indications for surgery, symptomatic AAA: https://web.pathway.md/diseases/recAViRuLGldn39TW 9/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway As per AHA 2022 guidelines, perform aneurysm repair in patients with unruptured AAA with a maximal aneurysm diameter of 5.5 cm in male patients and 5.0 cm in female patients. A Show 3 more As per ESC 2014 guidelines, perform surgical repair of AAA if: AAA diameter is > 5.5 cm aneurysm growth is > 1.0 cm/year. Show 3 more Timing of surgery: target an 8 week delay as the maximal reasonable waiting time between surgical referral and elective treatment of AAAs. Choice of surgical approach: As per AHA 2022 guidelines, ensure a shared decision-making process weighing the risks and benefits of each approach in patients with unruptured AAA with low-to-moderate operative risk and having anatomy suitable for either open or endovascular AAA repair. A Show 2 more As per ESVS 2019 guidelines, avoid routinely performing laparoscopic AAA repair outside of highly specialized centres, registries or trials. D Indications for tube graft placement: as per SVS 2018 guidelines, use straight tube grafts for open surgical repair of AAA in the absence of significant disease of the iliac arteries. A Management of enlarging AAA post-repair: As per ESVS 2019 guidelines, consider obtaining further diagnostic evaluation with alternative imaging modalities to exclude the presence of an unidentified endoleak in patients with aneurysm sac growth after endovascular AAA repair, without visible endoleak on standard imaging. C As per SVS 2018 guidelines, consider treating ongoing aneurysm expansion, even in the absence of a visible endoleak. C Management of endoleaks: As per ESVS 2019 guidelines, perform re-intervention (primarily by endovascular means) to achieve a seal in patients with type I endoleak after endovascular AAA repair. Show 2 more As per SVS 2018 guidelines, treat patients with type I endoleaks. Show 4 more 9. Specific circumstances Patients with ruptured AAA: As per AHA 2022 guidelines, obtain CT to evaluate whether the AAA is amenable to endovascular repair in hemodynamically stable patients presenting with ruptured AAA. Show 3 more https://web.pathway.md/diseases/recAViRuLGldn39TW 10/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway As per ESVS 2019 guidelines, implement a policy of permissive hypotension in conscious patients with ruptured AAA, by restricting fluid resuscitation. As per SVS 2018 guidelines, implement hypotensive hemostasis with restriction of fluid resuscitation in the conscious patient. Patients with carotid artery stenosis: Perform preoperative carotid artery intervention in patients with an AAA and carotid artery stenosis that was symptomatic within the last 6 months. Avoid routinely performing prophylactic carotid intervention for asymptomatic carotid artery stenosis prior to AAA repair. D Patients with gastrointestinal bleeding: As per ESVS 2019 guidelines, assess for aortoenteric fistula promptly in any patient with an aortic prosthesis presenting with gastrointestinal bleeding. Show 2 more As per SVS 2018 guidelines, assess for possible aortoenteric fistula promptly in patients presenting with gastrointestinal bleeding after AAA repair. A Patients with heparin-induced thrombocytopenia: use a thrombin inhibitor, such as bivalirudin or argatroban, as an alternative to heparin in patients with a history of heparin-induced thrombocytopenia. Patients with an infected AAA graft: assess for possible graft infection promptly in patients presenting with generalized sepsis, groin drainage, pseudoaneurysm formation, or ill-defined pain after AAA repair. A Show 4 more Patients with common iliac artery aneurysm: Perform elective repair of both abdominal and iliac aneurysms in patients with asymptomatic small AAA and concomitant common iliac artery aneurysms 3.5 cm. Preserve at least one hypogastric artery, if anatomically feasible, to decrease the risk of pelvic ischemia when treating common iliac artery aneurysms or ectasia as part of AAA repair. Patients with thoracoabdominal aortic aneurysm (indications for repair): perform aneurysm repair in patients with intact degenerative thoracoAAA of 6.0 cm. Show 2 more Patients with thoracoabdominal aortic aneurysm, open repair: As per AHA/ACC 2022 guidelines, perform open repair in patients with ruptured thoracoAAA requiring intervention. Show 5 more As per SVM/STS/SIR/SCAI/SCA/ASA/ACR/AATS/AHA/ACC 2010 guidelines, perform elective surgery in patients with thoracoabdominal aneurysms with a diameter of > 6.0 cm (or less in patients with a connective tissue disorder, such as Marfan or Loeys- Dietz syndrome) if endovascular stent graft options are limited and surgical morbidity is elevated. https://web.pathway.md/diseases/recAViRuLGldn39TW 11/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway Patients with thoracoabdominal aortic aneurysm (endovascular repair): consider performing endovascular repair in hemodynamically stable patients with ruptured thoracoAAA requiring intervention in centers with endovascular expertise and access to appropriate endovascular stent grafts. C Show 3 more Patients with Marfan syndrome: Consider obtaining surveillance imaging every 3-5 years for potential AAA in patients with Marfan syndrome undergone aortic root replacement. C Consider performing surgery to replace the aneurysmal segment in patients with Marfan syndrome and a nondissected AAA of 5.0 cm. C Patients with Loeys-Dietz syndrome: consider performing surgery to replace the intact aortic arch, descending aorta, or abdominal aorta at a diameter of 4.5 cm based on the specific genetic variant, patient age, aortic growth rate, family history, presence of high-risk features, and surgical risk in patients with Loeys-Dietz syndrome attributable to a pathogenic variant in TGFBR1, TGFBR2, or SMAD3. C 10. Preventative measures Preprocedural antibiotic prophylaxis: As per ESVS 2019 guidelines: Avoid routinely administering antibiotic prophylaxis for the prevention of graft infection in patients with previous AAA repair undergoing dental or other surgical procedures. D Consider administering antibiotic prophylaxis for the prevention of graft infection in patients with previous AAA repair undergoing high-risk procedures, including abscess drainage, dental procedures requiring manipulation of the gingival or peri-apical region of the teeth or breaching the oral mucosa, as well as in immunocompromised patients undergoing surgical or interventional procedures. C As per SVS 2018 guidelines: Administer antibiotic prophylaxis for the prevention of graft infection in patients with an aortic prosthesis undergoing any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, including scaling and root canal procedures. Consider administering antibiotic prophylaxis before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures for any patient with an aortic prosthesis if the potential for infection exists or the patient is immunocompromised. C 11. Follow-up and surveillance Serial clinical assessment: https://web.pathway.md/diseases/recAViRuLGldn39TW 12/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway As per SVS 2018 guidelines: Perform thorough lower extremity pulse examination or ABI in follow-up visits of patients after aneurysm repair. Assess for possible graft limb occlusion in patients who develop new-onset lower extremity claudication, ischemia, or reduction in ABI after aneurysm repair. A Serial imaging assessment: As per AHA 2022 guidelines, obtain surveillance ultrasound every 3 years to assess for interval change in patients with an AAA of 3.0-3.9 cm. Show 3 more As per ESVS 2019 guidelines, schedule follow-up ultrasound is recommended for aneurysm surveillance: every three years for aneurysms 3-3.9 cm in size annually for aneurysms 4.0-4.9 cm in size every 3-6 month for aneurysms 5.0 cm in size. As per SVS 2018 guidelines, consider performing surveillance imaging at 3-year intervals for patients with an AAA of 3.0-3.9 cm diameter. C Show 2 more As per ESC 2014 guidelines: Obtain surveillance imaging in patients with AAA with a maximum diameter of < 5.5 cm and slow (< 1.0 cm/year) growth. A Consider obtaining surveillance imaging at following time intervals in patients with small (3.0- 5.5 cm) AAA: every 3 years for AAA of 3.0-3.9 cm diameter every 2 years for AAA of 4.0-4.4 cm diameter annually for AAA > 4.5 cm diameter. C Postoperative rehabilitation: offer postoperative cardiac rehabilitation in patients after surgery for aortic aneurysm. Early postoperative imaging: As per ESVS 2019 guidelines, schedule early postoperative follow up (within 30 days) after endovascular aortic repair, including imaging of the stent graft to assess for the presence of endoleak, component overlap and sealing zone length. As per SVS 2018 guidelines, obtain baseline imaging in the first month after endovascular aneurysm repair with contrast-enhanced CT and color duplex ultrasound imaging. Repeat imaging in 12 months in the absence of an endoleak or sac enlargement. Show 4 more Late postoperative imaging: As per AHA 2022 guidelines, obtain baseline surveillance CT at 1 month postoperatively in patients with after endovascular AAA repair. Obtain continued surveillance with duplex https://web.pathway.md/diseases/recAViRuLGldn39TW 13/15 6/22/23, 11:39 PM Abdominal aortic aneurysm Pathway ultrasound at 12 months and then annually thereafter, if there is no evidence of endoleak or sac enlargement. Show 4 more As per ESVS 2019 guidelines, consider obtaining follow-up imaging of the aorta and peripheral arteries every 5 years in all patients having undergone open repair for AAA. C As per SVS 2018 guidelines, consider obtaining noncontrast CT imaging of the entire aorta at 5- year intervals after open repair or endovascular aneurysm repair. C Likelihood Ratios Pertinent positives The following findings increase the probability of abdominal aortic aneurysm in adults. -1 Finding LR+ Value Increased aortic width (> 4.0 cm) 16 (8.6-29) Increased aortic width (> 3.0 cm) 12 (7.4-20) Pertinent negatives The following findings decrease the probability of abdominal aortic aneurysm in adults. -1 Finding LR- Value aortic width not increased ( 4.0 cm) 0.51 (0.38-0.67) aortic width not increased ( 3.0 cm) 0.72 (0.65-0.81) References 1. 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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018 Sep 7;39 34 3165 3241. Open https://web.pathway.md/diseases/recAViRuLGldn39TW 15/15