Monitoring

In the US, guidelines recommend that infra-/juxtarenal AAAs measuring 4.0 to 4.9 cm in diameter with ultrasonography/computed tomography (CT) should be monitored every 6 to 12 months.[5]​ Once larger than 4.5 cm in women and 5 cm in men, these guidelines recommend surveillance every 6 months.[5]​ AAAs <3.9 cm can be monitored with ultrasonography every 2 to 3 years.[5]​ The American College of Radiology recommends that color duplex doppler ultrasound, CT of the abdomen and pelvis with contrast, and magnetic resonance angiography (MRA) are all appropriate imaging modalities for surveillance of patients with asymptomatic AAA.[5][293]​​ ​There is also evidence to suggest that color duplex doppler ultrasound may be as sensitive as CT for detecting endoleaks post EVAR and could be utilized as a safe and effective alternative which avoids exposing the patients to further radiation.​[294][295][296]

A systematic review and meta-analysis of individual patient data concluded that surveillance intervals of 2 years for 3.0- to 4.4-cm AAAs, and 6 months for 4.5- to 5.4-cm AAAs, are safe and cost-effective.[131]

Analysis of AAA growth and rupture rates indicated that, in order to maintain a AAA rupture risk <1%, an 8.5-year surveillance interval is required for men with baseline AAA diameter of 3.0 cm.[131] The corresponding estimated surveillance interval for men with an initial aneurysm diameter of 5.0 cm was 17 months. Despite having similar growth rates of small aneurysms, rupture rates were 4 times greater in women than in men.[131] Surveillance programs and criteria for considering surgery need to be tailored for women with opportunistically detected AAA.

The European Society for Vascular Surgery (ESVS) recommends incorporation of subaneurysmal aortas (2.5 to 2.9 cm) into AAA surveillance recommendations since long-term cohort studies show that most subaneurysmal aortas eventually progress to an AAA of which a substantial proportion will reach the diameter threshold for consideration of repair.[3]​ Surveillance decisions should take into account life expectancy, suitability for future repair, and patient preferences.[3]

Post repair

The US Society for Vascular Surgery recommends baseline surveillance with contrast-enhanced CT and color duplex ultrasound in the first month after endovascular aneurysm repair (EVAR).[5][76][215]​​​​ If neither endoleak nor AAA enlargement is documented, imaging should be repeated at 12 months using either contrast-enhanced CT or color duplex ultrasound imaging.[5][76]​​​​

Follow-up noncontrast CT imaging is recommended at 5-year intervals after open repair or EVAR.[5][76]​​​

The ESVS recommends that all patients should have computed tomography angiography (CTA) within 30 days after the initial repair.[3] For patients who have been stratified as low risk of complications (no endoleak, anatomy within manufacturer’s instruction for use [IFU], without high risk features [proximal neck diameter <30 mm and angulation <60 degrees, and iliac diameter <20 mm], adequate overlap, and seal of 10 mm proximal and distal stent graft apposition to arterial wall), the ESVS recommends consideration for limited follow-up, with delayed imaging until 5 years after repair.[3]​ Patients stratified as high risk of complications (presence of T2EL, insufficient overlap or seal <10 mm, anatomy outside IFU, large proximal neck [>30 mm], ectatic iliac fixation zones [>20 mm], or extreme angulation [>60 degrees]) may be considered yearly exams with either CTA or duplex ultrasound.[3] CTA is preferred for this purpose and its findings have been shown to have the strongest prognostic importance.[3] Duplex ultrasound exam can be used in alternative to verify the absence of endoleaks and assess limb patency and flow, but since it lacks assessment of stent graft overlap, seal length, and kink, it may need to be completed with noncontrast CT.[3]​​​

Women are at greater risk of postoperative complications (limb ischemia, renal and cardiovascular complications) and mortality (in-hospital and 30-day) than men; strict long-term surveillance is essential in female patients undergoing AAA repair.[163]​

Antibiotic prophylaxis of graft infection is required prior to bronchoscopy, gastrointestinal or genitourinary endoscopy, and any dental procedure that may lead to bleeding.[76]

Generalized sepsis, groin drainage, pseudoaneurysm formation, or ill-defined pain after open repair or EVAR should prompt evaluation of graft infection.[76] Gastrointestinal bleeding after open repair or EVAR should prompt evaluation of an aorto-enteric fistula.[76]

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