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Selective management of abdominal aortic aneurysms in a prospective measurement program
P M Brown1, R Pattenden, C Vernooy
1Division of Vascular Surgery, Kingston General Hospital, Ontario, Canada.
Purpose:
The purpose of this study was to clarify the treatment of patients with small abdominal aortic aneurysms (AAAs) less than 5 cm in diameter and those believed to be unfit for operation with AAAs 5 cm diameter or greater.
Methods:
Four hundred ninety two patients with AAAs less than 5 cm when first seen were entered in a prospective measurement program by ultrasonography or computed tomography scan (exclusively after 1998) every 6 months. A decision regarding operative fitness was made when the AAA was 5 cm. Patients then underwent operation if fit or continued follow-up if their AAA was larger than 5 cm but they were unfit. A further group of 91 patients with aneurysms 5 cm or greater when first seen but unfit for repair were entered in the prospective measurement program.
Results:
In the group with AAAs less then 5 cm at entry, operation was performed in 201 patients as a result of increase in AAA size to 5 cm or greater (157), AAA expansion of more than 0.5 cm in 6 months (24), or for other reasons (20). Of those with AAAs smaller than 5 cm at entry, 291 have not undergone operation at a mean follow-up of 42 months. Expansion was significantly related to aneurysm size at entry and was highest in the 4.5 to 4.9 cm group at 0.7 cm/year. In the group of patients deemed unfit for operation with 5 cm AAAs [as a graduate of the less than 5 cm group at entry (85 patients) or first seen with AAA greater than 5 cm (91 patients)], 10 ruptures have occurred. Of these patients with ruptured AAAs, six had AAAs between 5.0 and 5.6 cm.
Conclusions:
Because of the risk of rupture demonstrated in our series in AAAs 5 cm or slightly greater and the progressive increase in expansion to a mean of 0.7 cm/year in those AAAs between 4.5 and 4.9 cm at entry, recommendation for elective operation in patients with AAAs between 4.5 and 4.9 cm at entry, recommendation for elective operation in patients with AAAs between 4.5 and 5.0 cm should be strongly considered in a fit patient.