How I Treat: Asymptomatic Abdominal Aortic Aneurysm
Michael J. Bloch, MD | Renown Institute for Heart and Vascular Health (Reno, NV)
Introduction. A 65-year-old man who underwent an abdominal aortic aneurysm (AAA) presents for a follow-up visit.
History. The patient has a 40-pack-year history of smoking cigarettes and a known history of hypertension and dyslipidemia. There is no known history of diabetes or of previous heart or vascular disease. He has no abdominal pain, and he does not report any other symptoms. The patient underwent a screening ultrasound as part of his “welcome to Medicare” evaluation provided by another provider. This demonstrated a 5.3 cm abdominal aortic aneurysm. A follow-up computed tomography (CT) scan angiogram 3 months later showed a 5.6 cm fusiform infrarenal aortic aneurysm. Current medications include losartan 100 mg daily and amlodipine 5 mg daily.
Physical Examination. The patient’s blood pressure is 128/78 mmHg, and his heart rate is 78 beats per minute. He is afebrile and oxygen saturation of 98% on room air. There are no carotid bruits. His lungs are clear to auscultation with no wheezes, rhonchi, or crackles. On cardiac examination, there are normal heart sounds without murmurs, rubs, or gallops. The abdomen is soft and non-tender. There is a modest-sized pulsatile mass in the mid-epigastrium. There is no clubbing, cyanosis, or edema in the extremities. Dorsalis pedis and posterior tibial pulses are normal in both feet. There is no pronator drift, and all cranial nerves are intact.
The results of the blood work are notable for normal renal function and blood counts. His low-density lipoprotein cholesterol (LDL-C) is 132 mg/dl, high-density lipoprotein cholesterol (HDL-C) is 42 mg/dl, and triglycerides are 158 mg/dl. His blood glucose is 105 mg/dl.
Treatment and management. The patient is referred to a vascular surgeon who performs an endovascular aneurysm repair (EVAR) based on the Society for Vascular Surgery (SVS) and American Heart Association (AHA) recommendation to perform elective repair in men at low or acceptable surgical risk with a fusiform aneurysm that is at least 5.5 cm.1,2 The patient spends one night in the hospital and is discharged the next day after confirming that his blood pressure and renal function have not changed.
Outcome and follow-up. A CT angiogram performed 1 month after the procedure shows that the stent graft is intact and there is no evidence of an endoleak. His blood pressure remains < 130/80 mmHg at home. He continues with the same blood pressure medications. Since AAA is a form of atherosclerotic cardiovascular disease (ASCVD), he is started on a high-intensity statin with a goal LDL-C of < 70 g dl.3 Aspirin is started to reduce the high risk of heart attack and stroke associated with AAA. He is referred to a smoking cessation program. He will obtain a repeat abdominal ultrasound in 1 year and will need lifelong surveillance to make sure that he does not develop an endoleak or that the residual aneurysm sac does not increase in size.2
