The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines
2009; Elsevier BV; Volume: 50; Issue: 4 Linguagem: Inglês
10.1016/j.jvs.2009.07.002
ISSN1097-6809
AutoresElliot L. Chaikof, David C. Brewster, Ronald L. Dalman, Michel S. Makaroun, Karl A. Illig, Gregorio A. Sicard, Carlos H. Timaran, Gilbert R. Upchurch, Frank J. Veith,
Tópico(s)Vascular Procedures and Complications
ResumoThe Clinical Practice Council of the Society for Vascular Surgery charged a writing committee with the task of updating practice guidelines, initally published in 2003, for surgeons and physicians who are involved in the preoperative, operative, and postoperative care of patients with abdominal aortic aneurysms (AAA).1Brewster D.C. Cronenwett J.L. Hallett Jr, J.W. Johnston K.W. Krupski W.C. Matsumura J.S. Guidelines for the treatment of abdominal aortic aneurysms Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery.J Vasc Surg. 2003; 37: 1106-1117Abstract Full Text Full Text PDF PubMed Scopus (301) Google Scholar This document provides recommendations for evaluating the patient, including risk of aneurysm rupture and associated medical co-morbidities, guidelines for selecting surgical or endovascular intervention, intraoperative strategies, perioperative care, long-term follow-up, and treatment of late complications. Decision making related to the care of patients with AAA is complex. Aneurysms present with varying risks of rupture and patient specific factors influence anticipated life expectancy, operative risk, and the need to intervene. Careful attention to the choice of operative strategy, as influenced by anatomic features of the AAA, along with optimal treatment of medical co-morbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative patient surveillance and timely intervention in the case of a late complication is necessary to minimize subsequent aneurysm-related death or morbidity. All of these clinical decisions are determined in an environment where cost-effectiveness will ultimately dictate the ability to provide optimal care to the largest possible segment of the population. Currently available clinical data sets have been reviewed in formulating these recommendations. However, an important goal of this document is to clearly identify those areas where further clinical research is necessary. A comprehensive review of the available clinical evidence in the literature was conducted in order to generate a concise set of recommendations. The strength of any given recommendation and the quality of evidence was scored based on the GRADE system (Table I).2Guyatt G. Gutterman D. Baumann M.H. Addrizzo-Harris D. Hylek E.M. Phillips B. et al.Grading strength of recommendations and quality of evidence in clinical guidelines.Chest. 2006; 129: 174-181Crossref PubMed Scopus (441) Google Scholar When the benefits of an intervention outweighed its risks, or, alternatively, risks outweighed benefits, a strong recommendation was noted. However, if benefits and risks were less certain, either because of low quality evidence or because high quality evidence suggests benefits and risks are closely balanced, a weak recommendation was recorded. The quality of evidence that formed the basis of these recommendations was scored as high, moderate, or low. Not all randomized controlled trials are alike and limitations may compromise the quality of their evidence. In addition, if there is a large magnitude of effect, the quality of evidence derived from observational studies may be high. Thus, quality of evidence was scored as high when additional research is considered very unlikely to change confidence in the estimate of effect; moderate when further research is likely to have an important impact in the estimate of effect; or low when further research is very likely to change the estimate of the effect.Table ICriteria for strength of a recommendation and grading quality of evidenceStrength of a recommendation Strong Benefits > Risks Risks > Benefits Weak Benefits ∼ Risks Quality of evidence precludes accurate assessment of risks and benefitsGrading quality of evidence High Additional research is considered very unlikely to change confidence in the estimate of effect Moderate Further research is likely to have an important impact on in the estimate of effect Low Further research is very likely to change the estimate of the effectAdapted from Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, et al. Grading strength of recommendations and quality of evidence in clinical guidelines. Chest 2006;129:174-81. Open table in a new tab Adapted from Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, et al. Grading strength of recommendations and quality of evidence in clinical guidelines. Chest 2006;129:174-81. The medical history is helpful in determining the patient's risk of developing an AAA. Even in the absence of clinical symptoms, knowledge of the risk factors for developing an AAA may facilitate early diagnosis. The Aneurysm Detection and Management Veterans Affairs Cooperative Study Group (ADAM) trial found a number of factors to be associated with increased risk for AAA: advanced age, greater height, coronary artery disease (CAD), atherosclerosis, high cholesterol levels, hypertension, and, in particular, smoking.3Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Hye R.J. Makaroun M.S. et al.The aneurysm detection and management study screening program: validation cohort and final results Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.Arch Intern Med. 2000; 160: 1425-1430Crossref PubMed Google Scholar Indeed, aortic aneurysms occur almost exclusively in the elderly. In a 2001 study, the mean age of patients undergoing repair for AAA in the United States was 72 years.4Huber T.S. Wang J.G. Derrow A.E. Dame D.A. Ozaki C.K. Zelenock G.B. et al.Experience in the United States with intact abdominal aortic aneurysm repair.J Vasc Surg. 2001; 33 (discussion 310-1): 304-310Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 5Johnston K.W. Influence of sex on the results of abdominal aortic aneurysm repair Canadian Society for Vascular Surgery Aneurysm Study Group.J Vasc Surg. 1994; 20 (; discussion 923-6): 914-923Abstract Full Text Full Text PDF PubMed Google Scholar, 6Vardulaki K.A. Walker N.M. Day N.E. Duffy S.W. Ashton H.A. Scott R.A. Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm.Br J Surg. 2000; 87: 195-200Crossref PubMed Scopus (112) Google Scholar, 7Singh K. Bonaa K.H. Jacobsen B.K. Bjork L. Solberg S. Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study: The Tromso Study.Am J Epidemiol. 2001; 154: 236-244Crossref PubMed Scopus (227) Google Scholar, 8Steickmeier B. Epidemiology of arotic disease: Aneurysm, dissection, occlusion.Radiologe. 2001; 41: 624-632Crossref PubMed Scopus (16) Google Scholar Men outnumber women by a factor of 4 to 6 to 1.4Huber T.S. Wang J.G. Derrow A.E. Dame D.A. Ozaki C.K. Zelenock G.B. et al.Experience in the United States with intact abdominal aortic aneurysm repair.J Vasc Surg. 2001; 33 (discussion 310-1): 304-310Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 5Johnston K.W. Influence of sex on the results of abdominal aortic aneurysm repair Canadian Society for Vascular Surgery Aneurysm Study Group.J Vasc Surg. 1994; 20 (; discussion 923-6): 914-923Abstract Full Text Full Text PDF PubMed Google Scholar, 6Vardulaki K.A. Walker N.M. Day N.E. Duffy S.W. Ashton H.A. Scott R.A. Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm.Br J Surg. 2000; 87: 195-200Crossref PubMed Scopus (112) Google Scholar, 7Singh K. Bonaa K.H. Jacobsen B.K. Bjork L. Solberg S. Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study: The Tromso Study.Am J Epidemiol. 2001; 154: 236-244Crossref PubMed Scopus (227) Google Scholar, 8Steickmeier B. Epidemiology of arotic disease: Aneurysm, dissection, occlusion.Radiologe. 2001; 41: 624-632Crossref PubMed Scopus (16) Google Scholar Family members are also at significant risk with 12% to 19% of those undergoing aneurysm repair having a first-degree relative with an AAA.9Darling 3rd, R.C. Brewster D.C. Darling R.C. LaMuraglia G.M. Moncure A.C. Cambria R.P. Abbott W.M. Are familial abdominal aortic aneurysms different?.J Vasc Surg. 1989; 10: 39-43PubMed Google Scholar, 10Johansen K. Koepsell T. Familial tendency for abdominal aortic aneurysms.JAMA. 1986; 256: 1934-1936Crossref PubMed Google Scholar, 11van Vlijmen-van Keulen C.J. Pals G. Rauwerda J.A. Familial abdominal aortic aneurysm: A systematic review of a genetic background.Eur J Vasc Endovasc Surg. 2002; 24: 105-116Abstract Full Text PDF PubMed Scopus (37) Google Scholar In a recent nationwide survey conducted in Sweden, the relative risk of developing AAA for first-degree relatives was approximately double that of persons without a family history of AAA.12Larsson E. Granath F. Swedenborg J. Hultgren R. A population-based case-control study of the familial risk of abdominal aortic aneurysm.J Vasc Surg. 2009; 49 (; discussion 51): 47-50Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Neither the gender of the index person nor the first-degree relative influenced the risk of AAA. An AAA is over seven times more likely to develop in a smoker than a nonsmoker, with the duration of smoking, rather than total number of cigarettes smoked, being the key variable (Table II).13Wilmink T.B. Quick C.R. Day N.E. The association between cigarette smoking and abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 1099-1105Abstract Full Text Full Text PDF PubMed Google Scholar The risk for developing an AAA is lower in women, African Americans, and diabetic patients.Table IIRisk factors for aneurysm development, expansion, and ruptureSymptomRisk factorsAAA development•Tobacco use•Hypercholesterolemia•Hypertension•Male gender•Family history (male predominance)AAA expansion•Advanced age•Severe cardiac disease•Previous stroke•Tobacco use•Cardiac or renal transplantAAA rupture•Female gender•↓FEV1•Larger initial AAA diameter•Higher mean blood pressure•Current tobacco use (length of time smoking ≫ amount)•Cardiac or renal transplant•Critical wall stress – wall strength relationshipAAA, Abdominal aortic aneurysm. Open table in a new tab AAA, Abdominal aortic aneurysm. Risk factors for rupture have also been identified. The United Kingdom Small Aneurysm trial (UKSAT) reported 103 aneurysm ruptures in 2,257 patients over a period of seven years, with an annual rupture rate of 2.2%.14Brown L.C. Powell J.T. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance UK Small Aneurysm Trial Participants.Ann Surg. 1999; 230 (; discussion 296-7): 289-296Crossref PubMed Scopus (277) Google Scholar Factors significantly and independently associated with an increased risk of rupture included female gender, large initial aneurysm diameter, low forced expiratory volume in one second (FEV1), current smoking history, and elevated mean blood pressure.14Brown L.C. Powell J.T. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance UK Small Aneurysm Trial Participants.Ann Surg. 1999; 230 (; discussion 296-7): 289-296Crossref PubMed Scopus (277) Google Scholar, 15Brown P.M. Zelt D.T. Sobolev B. The risk of rupture in untreated aneurysms: The impact of size, gender, and expansion rate.J Vasc Surg. 2003; 37: 280-284Abstract Full Text PDF PubMed Scopus (107) Google Scholar, 16Cronenwett J.L. Murphy T.F. Zelenock G.B. Whitehouse Jr, W.M. Lindenauer S.M. Graham L.M. et al.Acturial analysis of variables associated with rupture of small abdominal aortic aneurysms.Surgery. 1985; 98: 472-483PubMed Google Scholar Women are two to four times more likely to experience rupture than men.14Brown L.C. Powell J.T. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance UK Small Aneurysm Trial Participants.Ann Surg. 1999; 230 (; discussion 296-7): 289-296Crossref PubMed Scopus (277) Google Scholar, 15Brown P.M. Zelt D.T. Sobolev B. The risk of rupture in untreated aneurysms: The impact of size, gender, and expansion rate.J Vasc Surg. 2003; 37: 280-284Abstract Full Text PDF PubMed Scopus (107) Google Scholar, 16Cronenwett J.L. Murphy T.F. Zelenock G.B. Whitehouse Jr, W.M. Lindenauer S.M. Graham L.M. et al.Acturial analysis of variables associated with rupture of small abdominal aortic aneurysms.Surgery. 1985; 98: 472-483PubMed Google Scholar, 17Norman P.E. Powell J.T. Abdominal aortic aneurysm: The prognosis in women is worse than in men.Circulation. 2007; 115: 2865-2869Crossref PubMed Scopus (45) Google Scholar Aneurysms in transplant patients also appear to have high expansion and rupture rates.18Englesbe M.J. Wu A.H. Clowes A.W. Zierler R.E. The prevalence and natural history of aortic aneurysms in heart and abdominal organ transplant patients.J Vasc Surg. 2003; 37: 27-31Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Prior surgical history is crucial to exclude certain disease processes, such as appendicitis or cholecystitis, that may mimic the presentation of a symptomatic aneurysm. In addition, the nature and extent of previous abdominal surgery may influence operative approach. When a pulsatile abdominal mass is discovered in a patient who has previously undergone open surgical repair (OSR) of an AAA, the presence of an anastomotic pseudoaneurysm,19Hallett Jr, J.W. Marshall D.M. Petterson T.M. Gray D.T. Bower T.C. Cherry Jr, K.J. et al.Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience.J Vasc Surg. 1997; 25 (; discussion 285-6): 277-284Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar iliac artery aneurysm,20Brunkwall J. Hauksson H. Bengtsson H. Bergqvist D. Takolander R. Bergentz S.E. Solitary aneurysms of the iliac arterial system: an estimate of their frequency of occurrence.J Vasc Surg. 1989; 10: 381-384PubMed Google Scholar or suprarenal aortic aneurysm should be considered. Likewise, complaints of abdominal or back pain in a patient with a prior history of endovascular aortic aneurym repair (EVAR) requires the treating physician to exclude an endoleak with attendant aneurysm expansion or rupture.21Bernhard V.M. Mitchell R.S. Matsumura J.S. Brewster D.C. Decker M. Lamparello P. et al.Ruptured abdominal aortic aneurysm after endovascular repair.J Vasc Surg. 2002; 35: 1155-1162Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar, 22Faries P.L. Cadot H. Agarwal G. Kent K.C. Hollier L.H. Marin M.L. Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion.J Vasc Surg. 2003; 37: 1155-1161Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 23Jones J.E. Atkins M.D. Brewster D.C. Chung T.K. Kwolek C.J. LaMuraglia G.M. et al.Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes.J Vasc Surg. 2007; 46: 1-8Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 24Pearce W.H. What's new in vascular surgery.J Am Coll Surg. 2003; 196: 253-266Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar An abdominal aortic aneurysm has been defined as “a pulsating tumor that presents itself in the left hypochondriac or epigastric regions.”25Gray H. Gray's Anatomy: Descriptive and Surgical.in: 15th ed. Chancellor Press, London1994: 526Google Scholar The abdominal aorta begins at the level of the diaphragm and the 12th thoracic vertebra and runs in the retroperitoneal space just anterior to and slightly to the left of the spine. At approximately the level of the umbilicus and the fourth lumbar vertebra, the aorta bifurcates into the right and left common iliac arteries. Unfortunately, only 30% to 40% of aneurysms are noted on physical examination with detection dependant on aneurysm size.26Kiev J. Eckhardt A. Kerstein M.D. Reliability and accuracy of physical examination in detection of abdominal aortic aneurysms.Vasc Endovasc Surg. 1997; 31: 143Crossref Google Scholar Aneurysms greater than 5 cm are detected in 76% of patients, whereas aneurysms between 3 cm and 3.9 cm are identified in only 29%. As would be anticipated, detection is limited by truncal obesity.27Fink H.A. Lederle F.A. Roth C.S. Bowles C.A. Nelson D.B. Haas M.A. The accuracy of physical examination to detect abdominal aortic aneurysm.Arch Intern Med. 2000; 160: 833-836Crossref PubMed Google Scholar, 28Lederle F.A. Walker J.M. Reinke D.B. Selective screening for abdominal aortic aneurysms with physical examination and ultrasound.Arch Intern Med. 1988; 148: 1753-1756Crossref PubMed Google Scholar Although most abdominal aneurysms are supraumbilical, in some patients, the aorta becomes more tortuous and elongated with age and an aneurysm may appear to be infraumbilical or to one side of the abdomen. The common iliac arteries may also become aneurysmal and palpable in one of the lower abdominal quadrants. It bears emphasis that palpation has not been reported to precipitate aortic rupture. An abdominal aneurysm may be present in up to 85% of patients with a femoral artery aneurysm and in up to 62% of those with a popliteal aneurysm.29Graham L.M. Zelenock G.B. Whitehouse Jr, W.M. Erlandson E.E. Dent T.L. Lindenauer S.M. Stanley J.C. Clinical significance of arteriosclerotic femoral artery aneurysms.Arch Surg. 1980; 115: 502-507Crossref PubMed Google Scholar, 30Whitehouse Jr, W.M. Wakefield T.W. Graham L.M. Kazmers A. Zelenock G.B. Cronenwett J.L. et al.Limb-threatening potential of arteriosclerotic popliteal artery aneurysms.Surgery. 1983; 93: 694-699PubMed Google Scholar In contrast, patients with an abdominal aneurysm have a 14% incidence of either a femoral or a popliteal artery aneurysm.31Diwan A. Sarkar R. Stanley J.C. Zelenock G.B. Wakefield T.W. Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms.J Vasc Surg. 2000; 31: 863-869Abstract Full Text Full Text PDF PubMed Google Scholar Tabled 1Physical examination should include an assessment of femoral and popliteal arteries in all patients with a suspected abdominal aortic aneurysm.Level of recommendation:StrongQuality of evidence:High Open table in a new tab Coronary artery disease (CAD) is the leading cause of early and late mortality after AAA repair.32Roger V.L. Ballard D.J. Hallett Jr, J.W. Osmundson P.J. Puetz P.A. Gersh B.J. Influence of coronary artery disease on morbidity and mortality after abdominal aortic aneurysmectomy: a population-based study, 1971-1987.J Am Coll Cardiol. 1989; 14: 1245-1252Abstract Full Text PDF PubMed Google Scholar Chronic kidney disease, chronic obstructive pulmonary disease (COPD), and diabetes mellitus may also influence morbidity and mortality. Accordingly, further evaluation is warranted and optimization of perioperative status beneficial when any of these conditions are present. Several studies have documented a lower incidence of perioperative cardiac complications with EVAR than OSR. In review of a statewide experience between 2000 and 2002, Anderson et al reported a 3.3% incidence of cardiac complications for EVAR as compared with 7.8% for OSR in 2002, which was similar to the events rates in 2001 and 2000.33Anderson P.L. Arons R.R. Moskowitz A.J. Gelijns A. Magnell C. Faries P.L. et al.A statewide experience with endovascular abdominal aortic aneurysm repair: rapid diffusion with excellent early results.J Vasc Surg. 2004; 39: 10-19Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar Likewise, Schermerhorn et al34Schermerhorn M.L. O'Malley A.J. Jhaveri A. Cotterill P. Pomposelli F. Landon B.E. Endovascular vs. open repair of abdominal aortic aneurysms in the medicare population.N Engl J Med. 2008; 358: 464-474Crossref PubMed Scopus (277) Google Scholar identified a significantly lower incidence of myocardial infarction (MI) among patients undergoing EVAR as compared with open repair in an analysis of propensity-score-matched cohorts of Medicare beneficiaries treated between 2001 and 2004 (7% vs 9.4%, P < .001). Similarly, in a small retrospective review of patients with three or more cardiac risk factors undergoing EVAR or OSR, the incidence of elevated troponin levels was significantly lower among those treated by EVAR (13% vs. 47%, P = .001).35Schouten O. Dunkelgrun M. Feringa H.H. Kok N.F. Vidakovic R. Bax J.J. Poldermans D. Myocardial damage in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.Eur J Vasc Endovasc Surg. 2007; 33: 544-549Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar However, not all studies have documented a reduction cardiac morbidity with EVAR. Notably, the incidence of cardiac complications was similar for both EVAR (5.3%) and OSR (5.7%) in the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial.36Prinssen M. Verhoeven E.L. Buth J. Cuypers P.W. van Sambeek M.R. Balm R. et al.; Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms.N Engl J Med. 2004; 351: 1607-1618Crossref PubMed Scopus (845) Google Scholar In summary, while elective open AAA repair can generally be considered to carry a higher risk for a perioperative cardiovascular event, EVAR should be considered a procedure that is associated with intermediate to high cardiac risk in the range of 3% to 7%. Regardless of the nature of repair, a substantial portion of patients with AAA have underlying CAD and postoperative MI carries with it a substantially increased risk of death, as well as a high risk for later cardiovascular events and death.37Mangano D.T. Browner W.S. Hollenberg M. Li J. Tateo I.M. Long-term cardiac prognosis following noncardiac surgery The Study of Perioperative Ischemia Research Group.JAMA. 1992; 268: 233-239Crossref PubMed Google Scholar, 38McFalls E.O. Ward H.B. Santilli S. Scheftel M. Chesler E. Doliszny K.M. The influence of perioperative myocardial infarction on long-term prognosis following elective vascular surgery.Chest. 1998; 113: 681-686Crossref PubMed Google Scholar Thus, it is critical to minimize the risk of cardiac morbidity during the course of OSR or EVAR for AAA. Guidelines, endorsed by the Society for Vascular Surgery, have been recently updated for preoperative cardiac evaluation of patients undergoing noncardiac vascular surgery.39Fleisher L.A. Beckman J.A. Brown K.A. Calkins H. Chaikof E. Fleischmann K.E. et al.ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary.Circulation. 2007; 116: 1971-1996Crossref PubMed Scopus (251) Google Scholar Past guidelines have proven safe and effective in reducing unnecessary resource utilization.40Bartels C. Bechtel J.F. Hossmann V. Horsch S. Cardiac risk stratification for high-risk vascular surgery.Circulation. 1997; 95: 2473-2475Crossref PubMed Google Scholar, 41Froehlich J.B. Karavite D. Russman P.L. Erdem N. Wise C. Zelenock G. et al.; American College of Cardiology; American Heart Association American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery.J Vasc Surg. 2002; 36: 758-763Abstract Full Text PDF PubMed Scopus (36) Google Scholar, 42Samain E. Farah E. Leseche G. Marty J. Guidelines for perioperative cardiac evaluation from the American College of Cardiology/American Heart Association task force are effective for stratifying cardiac risk before aortic surgery.J Vasc Surg. 2000; 31: 971-979Abstract Full Text Full Text PDF PubMed Google Scholar The first step, prior to planned aneurysm repair, is to determine whether an active cardiac condition exists, such as an unstable coronary syndrome (unstable or severe angina, recent MI <one month), decompensated heart failure (new onset, worsening, or New York Heart Association [NYHA] Class IV), significant arrhythmia (atrioventricular [AV] block, poorly controlled atrial fibrillation, new onset ventricular tachycardia), or severe valvular heart disease (symptomatic, aortic valve area < 1 cm2 or pressure gradient >40 mm Hg) (Table III). These conditions represent major clinical risks for postoperative MI or cardiovascular related death and mandate intensive management prior to aneurysm repair. In these cases, patients may be referred for coronary angiography to assess further therapeutic options. Depending on the results of the test and the risk of delaying repair, it may be appropriate to proceed to planned surgical or endovascular treatment with maximal medical therapy. CHF, Congestive heart failure; MET, metabolic equivalent unit; MI, myocardial infarction. Adapted from Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary. Circulation 2007;116:1971-96. In the absence of an active cardiac condition, further non-invasive testing is only indicated if it will change management. For an otherwise elective repair, both the patient's functional capacity and the presence of clinical risk factors will dictate the need for further testing. The functional capacity can be estimated from a patient's ability to perform various activities (Table IV). Asymptomatic patients capable of a moderate or high activity level (metabolic equivalent unit [MET] ≥ 4), such as climbing stairs or a short run, generally do not benefit from further testing. Those who cannot achieve these levels of activity or in whom activity level is unknown may benefit from non-invasive stress testing, if additional clinical risk factors exist. Lee et al43Lee T.H. Marcantonio E.R. Mangione C.M. Thomas E.J. Polanczyk C.A. Cook E.F. et al.Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.Circulation. 1999; 100: 1043-1049Crossref PubMed Google Scholar have derived and validated a Revised Cardiac Risk Index for stable patients, without an active cardiac condition. Five independent clinical risk factors were identified including heart disease (history of MI, positive treadmill test, use of nitroglycerin, angina, or electrocardiogram [ECG] with abnormal Q waves); congestive heart failure (history of heart failure, pulmonary edema, paroxysmal nocturnal dyspnea, peripheral edema, bilateral rales, S3, or chest radiograph with pulmonary vascular redistribution); cerebral vascular disease (history of transient ischemic attack or stroke); diabetes mellitus; and renal insufficiency (creatinine > 2 mg/dL). The presence of an increasing number of risk factors correlates with an increased risk of a postoperative event and patients who display three or more risk factors and have an unknown or low activity level (MET < 4) may benefit from stress testing, if it will change management. Otherwise, all patients should undergo a 12-lead ECG within one month of planned repair. Transthoracic echocardiography (TTE) may be of value in patients with dyspnea of unknown origin or worsening dyspnea and a history of heart failure, if TTE has not been performed within the past year. However, it should be noted that resting left ventricular function is not a consistent predictor of postoperative MI or death. MET, Metabolic equivalent unit (1 MET = 3.5 mL * kg−1 * min−1 oxygen uptake). Adapted from The Duke Activity Status Index (Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol 1989;64:651-4. and Nelson CL, Herndon JE, Mark DB, Pryor DB, Califf RM, Hlatky MA. Relation of clinical and angiographic factors to functional capacity as measured by the Duke Activity Status Index. Am J Cardiol 1991;68:973-5.). Routine coronary revascularization by coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) prior to elective vascular surgery in patients with stable cardiac symptoms does not appear to significantly alter the risk of postoperative MI or death or long-term outcome. In the Coronary Artery Revascularization Prophylaxis (CARP) trial, 510 patients with significant coronary artery stenosis scheduled for vascular operations were randomized to PTCA or CABG or no coronary revascularization before surgery.44McFalls E.O. Ward H.B. Moriz T.E. Goldman S. Krupski W.C. Litooy F. et al.Coronary artery revacularization before elective major vascular surgery.New Engl J Med. 2004; 351: 2795-2804Crossref PubMed Scopus (500) Google Scholar Patients with left main disease, severe aortic stenosis, or an ejection fraction of less than 0.20 were excluded. Both short-term risk and long-term outcome were not changed by coronary intervention. Similar findings have been reported by other randomized studies.45Poldermans D. Bax J.J. Schouten O. Neskovic A.N. Paelinck B. Rocci G. et al.; Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echo Study Group Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control?.J Am Coll Cardiol. 2006; 48: 964-969Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar, 46Poldermans D. Schouten O. Vidakovic R. Bax J.J. Thomson I.R. Hoeks S.E. et al.A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V Pilot Study.J Am Coll Cardiol. 2007; 49: 1763-1769Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar Patients with stable cardi
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