The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal ...

78 Pages·2017·2.35 MB·English

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SOCIETY FOR VASCULAR SURGERY DOCUMENT
The Society for Vascular Surgery practice guidelines on the
care of patients with an abdominal aortic aneurysm
Elliot L. Chaikof, MD, PhD,a Ronald L. Dalman,MD,b Mark K.Eskandari, MD,c BenjaminM. Jackson, MD,d
W. Anthony Lee,MD,eM. Ashraf Mansour, MD,fTara M. Mastracci, MD,gMatthewMell, MD,b
M. Hassan Murad, MD,MPH,hLouis L. Nguyen,MD, MBA, MPH,iGustavo S.Oderich, MD,j
Madhukar S. Patel,MD, MBA,ScM,a,k MarcL. Schermerhorn, MD, MPH,aandBenjamin W.Starnes, MD,l
Boston,Mass;PaloAlto,Calif;Chicago,Ill;Philadelphia,Pa;BocaRaton,Fla;GrandRapids,Mich;London,UnitedKingdom;
Rochester,Minn;andSeattle,Wash
ABSTRACT
Background: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex.
Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy,
operativerisk,andneedtointervene.Carefulattentiontothechoiceofoperativestrategyalongwithoptimaltreatment
ofmedicalcomorbiditiesiscriticaltoachievingexcellentoutcomes.Moreover,appropriatepostoperativesurveillanceis
necessarytominimizesubsequentaneurysm-relateddeathormorbidity.
Methods:ThecommitteemadespecificpracticerecommendationsusingtheGradingofRecommendationsAssessment,
Development,andEvaluationsystem.Threesystematicreviewswereconductedtosupportthisguideline.Twofocusedon
evaluatingthebestmodalitiesandoptimalfrequencyforsurveillanceafterendovascularaneurysmrepair(EVAR).Athird
focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus
included(1)generalapproachtothepatient,(2)treatmentofthepatientwithanAAA,(3)anestheticconsiderationsand
perioperativemanagement,(4)postoperativeandlong-termmanagement,and(5)costandeconomicconsiderations.
Results: Alongwithprovidingguidanceregardingthemanagementofpatientsthroughoutthecontinuumofcare,we
haverevisedanumberofpriorrecommendationsandaddressedanumberofnewareasofsignificance.Newguidelinesare
providedforthesurveillanceofpatientswithanAAA,includingrecommendedsurveillanceimagingat12-monthintervalsfor
patientswithanAAAof4.0to4.9cmindiameter.Werecommendendovascularrepairasthepreferredmethodoftreatment
forrupturedaneurysms.IncorporatingknowledgegainedthroughtheVascularQualityInitiativeandotherregionalquality
collaboratives,wesuggestthattheVascularQualityInitiativemortalityriskscorebeusedformutualdecision-makingwith
patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented
mortalityandconversionratetoopensurgicalrepairof2%orlessandthatperformatleast10EVARcaseseachyear.Wealso
suggestthatelectiveopenaneurysmrepairbelimitedtohospitalswithadocumentedmortalityof5%orlessandthat
performatleast10openaorticoperationsofanytypeeachyear.Toencouragethedevelopmentofeffectivesystemsofcare
thatwouldleadtoimprovedoutcomesforthosepatientsundergoingemergentrepair,wesuggestadoor-to-intervention
timeof<90minutes,basedonaframeworkof30-30-30minutes,forthemanagementofthepatientwitharuptured
aneurysm.WerecommendtreatmentoftypeIandIIIendoleaksaswellasoftypeIIendoleakswithaneurysmexpansionbut
recommendcontinuedsurveillanceoftypeIIendoleaksnotassociatedwithaneurysmexpansion.Whereasantibioticpro-
phylaxisisrecommendedforpatientswithanaorticprosthesisbeforeanydentalprocedureinvolvingthemanipulationof
thegingivalorperiapicalregionofteethorperforationoftheoralmucosa,antibioticprophylaxisisnotrecommendedbefore
respiratorytractprocedures,gastrointestinalorgenitourinaryprocedures,anddermatologicormusculoskeletalprocedures
unlessthepotentialforinfectionexistsorthepatientisimmunocompromised.Increasedutilizationofcolorduplexultra-
soundissuggestedforpostoperativesurveillanceafterEVARintheabsenceofendoleakoraneurysmexpansion.
From the Department of Surgery, Beth Israel Deaconess Medical Center, W.L.Gore,andGEHealthcare.M.L.S.hasbeenaconsultantforCookMedical,
Bostona; the Department of Surgery, Stanford University, Palo Altob; the Abbott,Philips,hasreceivedfinancialsupportfromAbbott,Endologix,Cook
DepartmentofSurgery,NorthwesternUniversity,Chicagoc;theDepartment Medical,andPhilips,andhasbeenamemberoftheScientificAdvisoryCom-
of Surgery, University of Pennsylvania, Philadelphiad; the Christine E. Lynn mitteeMembershipforEndologix.W.B.S.isastockholderinAORTICACorpo-
Heart&VascularInstitute,BocaRatonRegionalHospital,BocaRatone;the ration.Allotherauthorshavenothingtodisclose.
DepartmentofSurgery,SpectrumHealthMedicalGroup,GrandRapidsf;The Additionalmaterialforthisarticlemaybefoundonlineatwww.jvascsurg.org.
Royal Free Hospital, Londong; the Evidence-based Practice Centerh and Correspondence:ElliotL.Chaikof,MD,PhD,DepartmentofSurgery,Harvard
DepartmentofSurgery,jMayoClinic,Rochester;theDepartmentofSurgery, Medical School, Beth Israel Deaconess Medical Center, 110 Francis St, Ste
BrighamandWomen’sHospital,Bostoni;theDepartmentofSurgery,Massa- 9F,Boston,MA02115(e-mail:[email protected]).
chusettsGeneralHospital,Bostonk;andtheDepartmentofSurgery,University Independentpeer-reviewandoversighthasbeenprovidedbymembersofthe
ofWashington,Seattle.l SVS Document OversightCommittee: Thomas L. Forbes,MD(Chair),Martin
Authorconflictofinterest:M.K.E.hasreceivedhonorariumandfinancialsup- Bjorck,MD,RuthBush,MD,HansHenningEckstein,MD,KakraHughes,MD,
portfromPrairieEducationandResearchCooperative(Bard),SilkRoadMed- GregMoneta,MD,EvaRzucidlo,MD.
ical,Inc,andW.L.Gore&Associates.W.A.L.andT.M.M.havereceivedresearch 0741-5214
grants from Cook Medical. G.S.O. has received consulting fees and grants Copyright"2017bytheSocietyforVascularSurgery.PublishedbyElsevierInc.
(all paid to Mayo Clinic with no personal income) from Cook Medical, https://doi.org/10.1016/j.jvs.2017.10.044
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Journal of Vascular Surgery Chaikofetal 3
Volume67,Number1
Conclusions:ImportantnewrecommendationsareprovidedforthecareofpatientswithanAAA,includingsuggestions
to improve mutual decision-making between the treating physician and the patients and their families as well as a
number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair.
Areasofuncertaintyarehighlightedthatwouldbenefitfromfurtherinvestigationinadditiontoexistinglimitationsin
diagnostictests,pharmacologicagents,intraoperativetools,anddevices.(JVascSurg2018;67:2-77.)
TABLE OF CONTENTS Roleof elective EVAR inthehigh-risk
SUMMARY OF GUIDELINES FOR THE CARE OF andunfit patient 34
PATIENTS WITH AN ABDOMINAL AORTIC OSR 35
ANEURYSM 4 Indications 35
DEFINITION OF THE PROBLEM 12 Surgicalapproach 35
Purpose of theseguidelines 12 Aortic clamping 35
Methodology andevidence 12 Grafttype andconfiguration 36
Literature search and evidencesummary 12 Maintenance of pelvic circulation 37
GENERAL APPROACH TO THE PATIENT 12 Managementof associated
History andrisk factors forabdominal intra-abdominal vascular disease 37
aortic aneurysms 12 Managementof associated intra-abdominal
Physical examination 17 nonvascular disease 38
Assessment of medical comorbidities 17 Perioperative outcomes of open AAArepair 38
Preoperative evaluation of cardiacrisk 17 Thepatient with aruptured aneurysm 39
Preoperative coronaryrevascularization 18 Preoperative management and
Perioperative medical management considerations forpatient transfer 39
of coronary arterydisease 19 Systemsof care andtime goals
Pulmonary disease 19 forintervention 39
Renalinsufficiency 20 Initialoperative management 41
Diabetes mellitus 21 Roleof EVAR 42
Hematologicdisorders 21 Managementof postoperative complications 42
BiomarkersandheritablerisksforanAAA 22 Abdominalcompartmentsyndrome 42
Biomarkers for thepresence and expansion Ischemic colitis 42
ofanaorticaneurysm 22 Multisystem organfailure 42
Geneticmarkers identifying risk Special considerations 42
ofaorticaneurysm 22 Inflammatoryaneurysm 42
Aneurysmimaging 22 Horseshoe kidney 43
Modalitiesfor aneurysmimaging 22 Aortocaval fistula 43
Prediction of aneurysm expansion ANESTHETIC CONSIDERATIONS AND
and rupture risk 23 PERIOPERATIVE MANAGEMENT 43
Recommendations for aneurysm screening 24 Choice of anesthetictechnique and agent 43
Recommendations for aneurysm surveillance 25 Anesthetic considerations inthe patient
Recommendations for imagingthe with aruptured aneurysm 44
symptomaticpatient 27 Antibiotic prophylaxis 44
TREATMENTOFTHEPATIENTWITHANAAA 27 Intraoperative fluidresuscitation and blood
Thedecision to treat 27 conservation 44
Medical management duringthe period Cardiovascular monitoring 44
ofaneurysmsurveillance 29 Maintenance of bodytemperature 45
Timingforintervention 29 Roleof the ICU 45
Assessmentofoperativeriskandlifeexpectancy 30 Nasogastric decompression and
EVAR 31 perioperative nutrition 46
Considerations for percutaneous repair 31 Prophylaxis fordeep venous thrombosis 46
Infrarenal fixation 31 Postoperative bloodtransfusion 46
Suprarenal fixation 31 Perioperative pain management 46
Management of theinternal iliacartery 32 POSTOPERATIVE AND LONG-TERM
Management of associated vascular disease 33 MANAGEMENT 47
Perioperative outcomes of elective EVAR 33 Lateoutcomes 47
Incidence of30-day and in-hospital mortality 33 Endoleak 47
Perioperative morbidity 33 TypeI endoleak 47
Endoleak 34 TypeII endoleak 47
Accesssite complications 34 TypeIII endoleak 48
Acutelimb thrombosis 34 TypeIV endoleak 48
Postimplantation syndrome 34 Endotension 48
Ischemic colitis 34 Devicemigration 48
4 Chaikofetal Journal of Vascular Surgery
January2018
Limb occlusion 48 We recommend echocardiography before planned
Graft infection 49 operative repair in patients with dyspnea of unknown
Prevention of an aorticgraft infection originor worsening dyspnea.
Incisional hernia 50
Para-anastomotic aneurysm 51 Levelofrecommendation 1(Strong)
Recommendation for postoperative surveillance 51
Qualityofevidence A(High)
Surveillance imagingmodality 51
Surveillance outcomes 51
Summary 51
Wesuggestcoronaryrevascularizationbeforeaneurysm
COST AND ECONOMIC CONSIDERATIONS
repair in patients with acute ST-segment or non-ST-
IN ANEURYSM REPAIR 51
segment elevation myocardial infarction (MI), unstable
CARE OF THE PATIENT WITH AN AAA: AREAS
angina, or stable angina with left main coronary artery
IN NEED OF FURTHER RESEARCH 53
or three-vesseldisease.
REFERENCES 53
APPENDIX: SEARCH STRATEGY
Levelofrecommendation 2(Weak)
Qualityofevidence B(Moderate)
SUMMARY OF GUIDELINES FOR THE CARE OF
PATIENTS WITH AN ABDOMINAL AORTIC
Wesuggestcoronaryrevascularizationbeforeaneurysm
ANEURYSM
repair in patients with stable angina and two-vessel dis-
Physical examination. In patients with a suspected or
ease that includes the proximal left descending artery
known abdominal aortic aneurysm (AAA), we recom-
and either ischemia on noninvasive stress testing or
mend performing physical examination that includes
reduced left ventricular function (ejection fraction
an assessmentof femoral and popliteal arteries.
< 50%).
Inpatientswithapoplitealorfemoralarteryaneurysm,
werecommend evaluation foran AAA. Levelofrecommendation 2(Weak)
Qualityofevidence B(Moderate)
Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
In patientswhomayneedaneurysm repairinthesub-
sequent12monthsandinwhompercutaneouscoronary
interventionisindicated,wesuggestastrategyofballoon
Assessmentofmedicalcomorbidities. Inpatientswith
angioplastyorbare-metalstentplacement,followedby4
active cardiac conditions, including unstable angina,
to 6weeks of dualantiplatelet therapy.
decompensated heart failure, severe valvular disease,
and significant arrhythmia, we recommend cardiology Levelofrecommendation 2(Weak)
consultation before endovascular aneurysm repair Qualityofevidence B(Moderate)
(EVAR) oropen surgical repair(OSR).
Levelofrecommendation 1(Strong) We suggest deferring elective aneurysm repair for 30
Qualityofevidence B(Moderate) daysafterbare-metalstentplacementorcoronaryartery
bypass surgery if clinical circumstances permit. As an
alternative,EVARmaybeperformedwithuninterrupted
In patients with significant clinical risk factors, such as
continuation of dualantiplatelet therapy.
coronaryarterydisease,congestiveheartfailure,cerebro-
vascular disease, diabetes mellitus, chronic renal insuffi- Levelofrecommendation 2(Weak)
ciency, and unknown or poor functional capacity Qualityofevidence B(Moderate)
(metabolic equivalent [MET] < 4), who are to undergo
OSR orEVAR, wesuggest noninvasive stress testing.
Wesuggestdeferringopenaneurysmrepairforatleast
Levelofrecommendation 2(Weak) 6monthsafterdrug-elutingcoronarystentplacementor,
alternatively,performingEVARwithcontinuationofdual
Qualityofevidence B(Moderate)
antiplatelet therapy.
We recommenda preoperative resting 12-lead electro- Levelofrecommendation 2(Weak)
cardiogram (ECG) in all patients undergoing EVAR or Qualityofevidence B(Moderate)
OSR within 30daysof planned treatment.
In patients with a drug-eluting coronary stent requiring
Levelofrecommendation 1(Strong)
open aneurysm repair, we recommend discontinuation
Qualityofevidence B(Moderate)
of P2Y platelet receptor inhibitor therapy 10 days
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Journal of Vascular Surgery Chaikofetal 5
Volume67,Number1
preoperatively with continuation of aspirin. The P2Y in- We recommend preoperative hydration in nondialysis-
12
hibitor should be restarted as soon as possible after sur- dependentpatientswithrenalinsufficiencybeforeaneu-
gery. The relative risks and benefits of perioperative rysmrepair.
bleeding and stent thrombosis shouldbe discussed with
thepatient.
Levelofrecommendation 1(Strong)
Levelofrecommendation 1(Strong) Qualityofevidence A(High)
Qualityofevidence B(Moderate)
We recommend preprocedure and postprocedure hy-
drationwithnormalsalineor5%dextrose/sodiumbicar-
We suggest continuation of beta blocker therapy dur-
bonateforpatientsatincreasedriskofcontrast-induced
ingtheperioperativeperiodifitispartofanestablished
nephropathy (CIN)undergoing EVAR.
medicalregimen.
Levelofrecommendation 1(Strong)
Levelofrecommendation 2(Weak)
Qualityofevidence A(High)
Qualityofevidence B(Moderate)
We recommend holding metformin at the time of
If a decision was made to start beta blocker therapy
administration of contrast material among patients
(because of the presence of multiple risk factors, such
as coronary artery disease, renal insufficiency, and dia- with an estimated glomerular filtration rate (eGFR)
of <60 mL/min or up to 48 hours before administration
betes), we suggest initiation well in advance of surgery
to allow sufficient timeto assess safety andtolerability. of contrast material if the eGFRis <45 mL/min.
Levelofrecommendation 1(Strong)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Qualityofevidence B(Moderate)
We recommend restarting metformin no sooner than
We suggest preoperative pulmonary function studies,
48 hours after administration of contrast material as
including room air arterial blood gas determinations, in
long as renal function has remained stable (<25%
patients with a history of symptomatic chronic obstruc-
increase increatinine concentration above baseline).
tive pulmonary disease (COPD), long-standing tobacco
use, orinability to climboneflightof stairs.
Levelofrecommendation 1(Strong)
Levelofrecommendation 2(Weak) Qualityofevidence C(Low)
Qualityofevidence C(Low)
We recommend perioperative transfusion of packed
Werecommendsmokingcessationforatleast2weeks redblood cellsif the hemoglobin levelis <7g/dL.
before aneurysmrepair.
Levelofrecommendation 1(Strong)
Levelofrecommendation 1(Strong)
Qualityofevidence B(Moderate)
Qualityofevidence C(Low)
We suggest hematologic assessment if the preopera-
We suggest administration of pulmonary bronchodila-
tiveplatelet countis <150,000/mL.
tors for at least 2 weeks before aneurysm repair in pa-
tients with a history of COPD or abnormal results of Levelofrecommendation 2(Weak)
pulmonary function testing. Qualityofevidence C(Low)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Aneurysmimaging. Werecommendusingultrasound,
when feasible, as the preferred imaging modality for
We suggest holding angiotensin-converting enzyme aneurysm screeningand surveillance.
(ACE) inhibitors and angiotensin receptor antagonists
Levelofrecommendation 1(Strong)
on the morning of surgery and restarting these agents
Qualityofevidence A(High)
after the procedureonce euvolemia has been achieved.
Levelofrecommendation 2(Weak)
We suggest that the maximum aneurysm diameter
Qualityofevidence C(Low)
derived from computed tomography (CT) imaging
6 Chaikofetal Journal of Vascular Surgery
January2018
shouldbebasedonanouterwalltoouterwallmeasure- WerecommendaCTscantoevaluatepatientsthought
ment perpendicular to the pathof the aorta. tohaveAAApresentingwithrecent-onsetabdominalor
back pain, particularly in the presence of a pulsatile
Levelofrecommendation GoodPracticeStatement epigastricmass orsignificant risk factors for AAA.
Qualityofevidence Ungraded
Levelofrecommendation 1(Strong)
Qualityofevidence B(Moderate)
We recommend a one-time ultrasound screening for
AAAsinmenorwomen65to75yearsofagewithahis-
tory of tobaccouse.
The decision to treat. Wesuggestreferraltoavascular
Levelofrecommendation 1(Strong) surgeonatthetimeofinitialdiagnosisofanaorticaneurysm.
Qualityofevidence A(High)
Levelofrecommendation GoodPracticeStatement
Qualityofevidence Ungraded
We suggest ultrasound screening for AAA in first-
degree relatives of patients who present with an AAA.
We recommend repair for the patient who presents
Screening should be performed in first-degree relatives
with an AAA and abdominal or back pain that is likely
whoarebetween65and75yearsofageorinthoseolder
to beattributed to theaneurysm.
than75years andingood health.
Levelofrecommendation 1(Strong)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Qualityofevidence C(Low)
Werecommendelectiverepairforthepatientatlowor
We suggest a one-time ultrasound screening for AAAs
acceptable surgical risk with a fusiform AAA that is
inmenorwomenolderthan75yearswithahistoryofto-
$5.5 cm.
bacco use and in otherwise good health who have not
previously received ascreening ultrasound examination. Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Wesuggestelectiverepairforthepatientwhopresents
with asaccular aneurysm.
Ifinitialultrasoundscreeningidentifiedanaorticdiameter
Levelofrecommendation 2(Weak)
>2.5cmbut<3cm,wesuggestrescreeningafter10years.
Qualityofevidence C(Low)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low) WesuggestrepairinwomenwithAAAbetween5.0cm
and5.4 cmin maximumdiameter.
We suggest surveillance imaging at 3-year intervals for
Levelofrecommendation 2(Weak)
patients with anAAA between 3.0 and3.9cm.
Qualityofevidence B(Moderate)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low) Inpatientswithasmallaneurysm(4.0-5.4cm)whowill
require chemotherapy, radiation therapy, or solid organ
transplantation, we suggest a shared decision-making
We suggest surveillance imaging at 12-month intervals
approach todecide about treatment options.
for patients with anAAA of 4.0to 4.9 cmindiameter.
Levelofrecommendation 2(Weak)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Qualityofevidence C(Low)
We suggest surveillance imaging at 6-month intervals
Medical management during the period of AAA sur-
for patients with an AAA between 5.0 and 5.4 cm in
veillance. We recommendsmoking cessation toreduce
diameter.
the risk of AAAgrowth and rupture.
Levelofrecommendation 2(Weak) Levelofrecommendation 1(Strong)
Qualityofevidence C(Low) Qualityofevidence B(Moderate)
Journal of Vascular Surgery Chaikofetal 7
Volume67,Number1
Wesuggestnot administeringstatins, doxycycline,rox- Werecommendstagingbilateralinternaliliacarteryoc-
ithromycin, ACE inhibitors, or angiotensin receptor clusion byatleast 1to 2weeks if required forEVAR.
blockers for the sole purpose of reducing the risk of
Levelofrecommendation 1(Strong)
AAA expansion andrupture.
Qualityofevidence A(High)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
We suggest renal artery or superior mesenteric artery
(SMA) angioplasty and stenting for selected patients
Wesuggestnotadministeringbetablockertherapyfor withsymptomatic diseasebefore EVARorOSR.
the sole purpose of reducing the risk of AAA expansion
Levelofrecommendation 2(Weak)
and rupture.
Qualityofevidence C(Low)
Levelofrecommendation 1(Strong)
Qualityofevidence B(Moderate) We suggest prophylactic treatment of an asymptom-
atic, high-grade stenosis of the SMA in the presence of
ameanderingmesentericarterybasedoffofalargeinfe-
Timing for intervention. We recommend immediate riormesentericartery(IMA),whichwillbesacrificeddur-
repair for patients who present with a ruptured aneu- ingthe course of treatment.
rysm.
Levelofrecommendation 2(Weak)
Levelofrecommendation 1(Strong) Qualityofevidence C(Low)
Qualityofevidence A(High)
We suggest preservation of accessory renal arteries at
Should repair of a symptomatic AAA be delayed to the time of EVAR or OSR if the artery is 3 mm or larger
optimizecoexistingmedicalconditions,werecommend indiameterorsuppliesmorethanone-thirdoftherenal
that the patient be monitored in an intensive care unit parenchyma.
(ICU) settingwith bloodproducts available.
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Levelofrecommendation 1(Strong)
Qualityofevidence C(Low)
Perioperative outcomes of elective EVAR. We suggest
that elective EVAR be performed at centers with a vol-
Assessment of operative risk and life expectancy. We
ume of at least 10 EVAR cases each year and a docu-
suggest informing patients contemplating open repair
mented perioperative mortality and conversion rate to
orEVARoftheirVascularQualityInitiative(VQI)perioper-
OSRof 2% orless.
ative mortality risk score.
Levelofrecommendation 2(Weak)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Qualityofevidence C(Low)
Role of elective EVAR in the high-risk and unfit
EVAR. We recommend preservation of flow to at least
patient. Wesuggestinforminghigh-riskpatientsoftheir
oneinternal iliacartery.
VQI perioperative mortality risk score for them to make
aninformed decision toproceed with aneurysm repair.
Levelofrecommendation 1(Strong)
Qualityofevidence A(High) Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
We recommend using Food and Drug Administration
(FDA)-approved branch endograft devices in anatomi- OSR. We recommend a retroperitoneal approach for
cally suitable patients to maintain perfusion to at least patients requiring OSR of an inflammatory aneurysm, a
oneinternal iliacartery. horseshoekidney,oranaorticaneurysminthepresence
of ahostile abdomen.
Levelofrecommendation 1(Strong) Levelofrecommendation 1(Strong)
Qualityofevidence A(High) Qualityofevidence C(Low)
8 Chaikofetal Journal of Vascular Surgery
January2018
Wesuggestaretroperitonealexposureoratransperito- WesuggestconcomitantsurgicalrepairofanAAAand
neal approach with a transverse abdominal incision for coexistent cholecystitis or an intra-abdominal tumor in
patients with significant pulmonary disease requiring patients who are not candidates for EVAR or staged
OSR. intervention.
Levelofrecommendation 2(Weak)
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Qualityofevidence C(Low)
We recommend a thrombin inhibitor, such as bivaliru-
din or argatroban, as an alternative to heparin for pa-
Perioperative outcomes of open AAA repair. We sug-
tients with a history of heparin-induced
gest that elective OSR for AAA be performed at centers
thrombocytopenia.
with an annual volume of at least 10 open aortic opera-
tions of any type and a documented perioperative mor-
Levelofrecommendation 1(Strong)
talityof 5% or less.
Qualityofevidence B(Moderate)
Levelofrecommendation 2(Weak)
We recommend straight tube grafts for OSR of AAA in Qualityofevidence C(Low)
the absenceof significant disease of theiliac arteries.
Levelofrecommendation 1(Strong)
The patient with a ruptured aneurysm. We suggest a
Qualityofevidence A(High) door-to-intervention time of <90 minutes, based on a
frameworkof30-30-30minutes,forthemanagementof
We recommend performing the proximal aortic anas- the patient witha ruptured aneurysm.
tomosis asclose to therenal arteries aspossible.
Levelofrecommendation GoodPracticeStatement
Levelofrecommendation 1(Strong)
Qualityofevidence Ungraded
Qualityofevidence A(High)
An established protocol for the management of
We recommend that all portions of an aortic graft be ruptured AAA isessential foroptimal outcomes.
excluded from direct contact with the intestinal con-
tents of the peritoneal cavity.
Levelofrecommendation GoodPracticeStatement
Qualityofevidence Ungraded
Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
We recommend implementing hypotensive hemosta-
sis with restriction of fluid resuscitation in the conscious
WerecommendreimplantationofapatentIMAunder
patient.
circumstances that suggest an increased risk of colonic
ischemia.
Levelofrecommendation 1(Strong)
Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate)
Qualityofevidence A(High)
We suggest that patients with ruptured AAA who
We recommend preserving blood flow to at least one require transfer for repair be referred to a facility with
hypogastric artery inthe course of OSR. anestablishedruptureprotocolandsuitableendovascu-
lar resources.
Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
Levelofrecommendation GoodPracticeStatement
Qualityofevidence Ungraded
We suggest concomitant surgical treatment of other
visceral arterial disease at the time of OSR in symptom-
Ifitisanatomicallyfeasible,werecommendEVARover
atic patients who are not candidates for catheter-based
open repairfor treatment ofa ruptured AAA.
intervention.
Levelofrecommendation 2(Weak) Levelofrecommendation 1(Strong)
Qualityofevidence B(Moderate) Qualityofevidence C(Low)
Journal of Vascular Surgery Chaikofetal 9
Volume67,Number1
Choiceofanesthetictechniqueandagent. Werecom- Levelofrecommendation 1(Strong)
mend general endotracheal anesthesia for patients un-
Qualityofevidence B(Moderate)
dergoing open aneurysm repair.
Levelofrecommendation 1(Strong)
We recommend postoperative troponin measurement
Qualityofevidence A(High)
for all patients with electrocardiographic changes or
chestpain after aneurysm repair.
Antibiotic prophylaxis. We recommend intravenous Levelsofrecommendation 1(Strong)
administration of a first-generation cephalosporin or, in Qualityofevidence A(High)
the event of penicillin allergy, vancomycin within 30
minutes before OSR or EVAR. Prophylactic antibiotics
should becontinued for nomorethan24 hours.
Maintenance of body temperature. We recommend
Levelofrecommendation 1(Strong) maintaining core body temperature at or above 36!C
Qualityofevidence A(High) duringaneurysm repair.
Levelsofrecommendation 1(Strong)
We recommend that any potential sources of dental
Qualityofevidence A(High)
sepsis be eliminated at least 2 weeks before implanta-
tionof an aorticprosthesis.
Levelofrecommendation GoodPracticeStatement Role of the ICU. We recommend postoperative man-
Qualityofevidence Ungraded agement in an ICU for the patient with significant car-
diac, pulmonary, or renal disease as well as for those
requiring postoperative mechanical ventilation or who
Intraoperative fluid resuscitation and blood conserva- developed a significant arrhythmia or hemodynamic
tion. Werecommend usingcell salvage oran ultrafiltra- instability duringoperative treatment.
tiondeviceif large bloodloss isanticipated.
Levelofrecommendation 1(Strong)
Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
Qualityofevidence B(Moderate)
If the intraoperative hemoglobin level is <10 g/dL and
Nasogastric decompression and perioperative nutri-
blood loss is ongoing, we recommend transfusion of
tion. Werecommendoptimizationofpreoperativenutri-
packed blood cells along with fresh frozen plasma and
tional status before elective open aneurysm repair if
platelets inaratioof 1:1:1.
repairwill not beunduly delayed.
Levelofrecommendation 1(Strong)
Qualityofevidence B(Moderate) Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
Cardiovascular monitoring. We suggest using pulmo-
naryarterycathetersonlyifthelikelihoodofamajorhe-
modynamicdisturbance is high. We recommend using nasogastric decompression
intraoperatively for all patients undergoing open aneu-
Levelofrecommendation 1(Strong)
rysm repair but postoperatively only for those patients
Qualityofevidence B(Moderate)
withnausea andabdominal distention.
Levelofrecommendation 1(Strong)
We recommend central venous access and arterial line
Qualityofevidence A(High)
monitoringinallpatientsundergoingopenaneurysmrepair.
Levelofrecommendation 1(Strong)
We recommend parenteral nutrition if a patient is un-
Qualityofevidence B(Moderate)
able to tolerate enteral support 7 days after aneurysm
repair.
WerecommendpostoperativeST-segmentmonitoringfor
Levelofrecommendation 1(Strong)
allpatientsundergoingopenaneurysmrepairandforthose
Qualityofevidence A(High)
patientsundergoingEVARwhoareathighcardiacrisk.
10 Chaikofetal Journal of Vascular Surgery
January2018
Prophylaxis for deep venous thrombosis. We recom- We suggest notreatment of typeIV endoleaks.
mend thromboprophylaxis that includes intermittent
Levelofrecommendation 2(Weak)
pneumaticcompressionandearlyambulationforallpa-
Qualityofevidence C(Low)
tients undergoing OSRor EVAR.
Levelofrecommendation 1(Strong)
We recommend open repair if endovascular interven-
Qualityofevidence A(High)
tion fails to treat a type I or type III endoleak with
ongoinganeurysm enlargement.
Wesuggestthromboprophylaxiswithunfractionatedor
Levelofrecommendation 1(Strong)
low-molecular-weight heparin for patients undergoing
Qualityofevidence B(Moderate)
aneurysm repair at moderate to high risk for venous
thromboembolism and low risk forbleeding.
We suggest open repair if endovascular intervention
Levelofrecommendation 2(Weak)
fails to treat a type II endoleak with ongoing aneurysm
Qualityofevidence C(Low)
enlargement.
Levelofrecommendation 2(Weak)
Postoperative blood transfusion. In the absence of Qualityofevidence C(Low)
ongoing blood loss, we suggest a threshold for blood
transfusion during or after aneurysm repair at a hemo-
We suggest treatment for ongoing aneurysm expan-
globin concentration of 7g/dLor below.
sion, eveninthe absenceof a visible endoleak.
Levelofrecommendation 2(Weak)
Qualityofevidence C(Low) Levelofrecommendation 2(Weak)
Qualityofevidence C(Low)
Perioperative pain management. We recommend We recommend that follow-up of patients after aneu-
multimodality treatment, including epidural analgesia, rysmrepairincludeathoroughlowerextremitypulseex-
for postoperative pain control after OSRof an AAA. amination or ankle-brachial index (ABI).
Levelofrecommendation 1(Strong)
Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
Qualityofevidence B(Moderate)
Late outcomes. We recommend treatment of type I Werecommendapromptevaluationforpossiblegraft
endoleaks. limb occlusion if patients develop new-onset lower ex-
tremity claudication, ischemia, or reduction in ABI after
Levelofrecommendation 1(Strong)
aneurysm repair.
Qualityofevidence B(Moderate)
Levelofrecommendation 1(Strong)
We suggest treatment of type II endoleaks associated Qualityofevidence A(High)
with aneurysm expansion.
Levelofrecommendation 2(Weak) We recommend antibiotic prophylaxis to prevent
Qualityofevidence C(Low) graft infection before any dental procedure involving
the manipulation of the gingival or periapical region
of teeth or perforation of the oral mucosa, including
We recommend surveillance of type II endoleaks not
scaling and root canal procedures, for any patient
associated withaneurysm expansion.
with an aortic prosthesis, whether placed by OSR or
Levelofrecommendation 1(Strong) EVAR.
Qualityofevidence B(Moderate)
Levelofrecommendation 1(Strong)
Qualityofevidence B(Moderate)
Werecommend treatment of typeIII endoleaks.
Levelofrecommendation 1(Strong)
We suggest antibiotic prophylaxis before respiratory
Qualityofevidence B(Moderate)
tract procedures, gastrointestinal or genitourinary
Journal of Vascular Surgery Chaikofetal 11
Volume67,Number1
procedures, and dermatologic or musculoskeletal pro-
Levelofrecommendation 1(Strong)
cedures for any patient with an aortic prosthesis if the
Qualityofevidence B(Moderate)
potential for infection exists or the patient is immuno-
compromised.
Recommendation for postoperative surveillance. We
Levelofrecommendation 2(Weak) recommend baseline imaging in the first month after
Qualityofevidence C(Low)
EVAR with contrast-enhanced CT and color duplex ul-
trasound imaging. In the absence of an endoleak or sac
Afteraneurysmrepair,werecommendpromptevalua- enlargement, imaging shouldbe repeated in12 months
tionforpossiblegraftinfectionifapatientpresentswith using contrast-enhanced CT or color duplex ultrasound
generalizedsepsis, groindrainage, pseudoaneurysm for- imaging.
mation, orill-definedpain.
Levelofrecommendation 1(Strong)
Qualityofevidence B(Moderate)
Levelofrecommendation 1(Strong)
Qualityofevidence A(High)
IfatypeIIendoleakisobserved1monthafterEVAR,we
We recommend prompt evaluation for possible aor- suggest postoperative surveillance with contrast-
toentericfistulainapatientpresentingwithgastrointes- enhanced CT and color duplex ultrasound imaging at 6
tinalbleeding after aneurysm repair. months.
Levelofrecommendation 1(Strong) Levelofrecommendation 2(Weak)
Qualityofevidence A(High) Qualityofevidence B(Moderate)
Inpatientspresentingwithaninfectedgraftinthepres-
If neither endoleaknor AAAenlargement is observed1
ence of extensive contamination with gross purulence,
year after EVAR, we suggest color duplex ultrasound
werecommendextra-anatomicreconstructionfollowed
whenfeasible,orCTimagingifultrasoundisnotpossible,
by excision of all graft material along with aortic stump
forannual surveillance.
closure covered byanomental flap.
Levelofrecommendation 2(Weak)
Levelofrecommendation 1(Strong)
Qualityofevidence C(Low)
Qualityofevidence B(Moderate)
IfatypeIIendoleakisassociatedwithananeurysmsac
Inpatientspresentingwithaninfectedgraftwithmin-
thatisshrinkingorstableinsize,wesuggestcolorduplex
imal contamination, we suggest in situ reconstruction
ultrasound for continued surveillance at 6-month inter-
with cryopreservedallograft.
valsfor 24 monthsandthen annually thereafter.
Levelofrecommendation 2(Weak) Levelofrecommendation 2(Weak)
Qualityofevidence B(Moderate) Qualityofevidence C(Low)
Inastablepatientpresentingwithaninfectedgraft,we
Ifanewendoleakisdetected,wesuggestevaluationfor
suggest in situ reconstruction with femoral vein after
atypeI or typeIII endoleak.
graftexcision anddébridement.
Levelofrecommendation 2(Weak)
Levelofrecommendation 2(Weak) Qualityofevidence C(Low)
Qualityofevidence B(Moderate)
We suggest noncontrast-enhanced CT imaging of the
Inunstablepatientswithinfectedgraft,werecommend
entireaortaat5-yearintervalsafteropenrepairorEVAR.
in situ reconstruction with a silver- or antibiotic-
impregnated graft, cryopreserved allograft, or polytetra- Levelofrecommendation 2(Weak)
fluoroethylene(PTFE)graft. Qualityofevidence C(Low)