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Clinical Crossroads
November 11, 2009

A 66-Year-Old Man With an Abdominal Aortic Aneurysm: Review of Screening and Treatment

Author Affiliations

Author Affiliations: Dr Schermerhorn is Chief, Section of Endovascular Surgery, and Director of Clinical Research, Division of Vascular Surgery, Beth Israel Deaconess Medical Center, and Assistant Professor of Surgery, Harvard Medical School, Boston, Massachusetts.

JAMA. 2009;302(18):2015-2022. doi:10.1001/jama.2009.1502
Abstract

Ruptured abdominal aortic aneurysm (AAA) is a common cause of death. Abdominal aortic aneurysms tend to be asymptomatic until the time of rupture, which has a mortality rate of greater than 80%. Therefore, elective repair prior to rupture is preferred if life expectancy is reasonable and the risk of rupture outweighs the risk of repair. Mr F, a 66-year-old man with a 5.2-cm AAA, illustrates the issues surrounding monitoring and treating AAA. Risk factors for AAA include older age, male sex, smoking history, and a family history of AAA. Screening for AAA with ultrasound has been shown to prevent rupture, prevent AAA-related death, and be cost-effective. Risk factors for rupture include larger diameter, female sex, and smoking history. Endovascular repair has lower operative mortality and complications and has replaced standard open surgery in more than half of patients. However, long-term survival is similar after endovascular and open surgical repair. Those at risk of AAA who would benefit from repair should undergo screening.

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    1 Comment for this article
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    A View Through the Smoke
    Javier Ena, MD, MPH | Hospital Marina Baixa. Alicante. Spain
    A major risk factor for the development of abdominal aortic aneurysm is smoking, and more than 90% of patients with such aneurysms have been smokers. After the cessation of smoking, the risk of developing an aneurysm declines each year, to approximately one thirtieth of the original risk [1]. The risk of rupture is low for aneurysms 5.5 cm or less in diameter, but above this threshold the risk increases markedly. After an aneurysm ruptures, only approximately 25% of patients reach the hospital alive, and only 10% reach the operating room alive [2]. Although blood pressure and lipids are currently well controlled, smoking is a significant risk factor for anerysm growth. I would send him to a smoking clinic and meanwhile check every 6 mo. the aneurysm size. If and when aneurysm size increases, an evaluation from a vascular surgeon will determine the feasibility of performing endovascular repair rather than open repair. An evaluation of pulmonary-function testing for chronic lung disease is also required [3]. Javier Ena, MD, MPH Dept. of Internal Medicine Hosp. Marina Baixa Alicante, Spain
    No conflicts of interest reported.
    1. Wilmink TBM, Quick CRG, Day NE. The association between cigarette smoking and abdominal aortic aneurysms. J Vasc Surg 1999;30:1099-1105.
    2. Brown LC, Powell JT, UK Small Aneurysm Trial Participants. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. Ann Surg 1999;230:289-297.
    3. Brown LC, Greenhalgh RM, Howell S, Powell JT, Thompson SG. Patient fitness and survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials. Br J Surg 2007;94:709-716.
    CONFLICT OF INTEREST: None Reported
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