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Update of the Society for Vascular Surgery abdominal aortic aneurysm guidelines

      The Society for Vascular Surgery (SVS) clinical practice guidelines for the care of patients with an abdominal aortic aneurysm (AAA), published in this issue of the Journal of Vascular Surgery, represent an update and, in many areas, a complete revision of AAA guidelines which were initially published in 2003 and updated in 2009. This comprehensive document includes 111 evidence-based recommendations on: screening; evaluation; medical, open surgical, and endovascular treatment; anesthetic considerations; and perioperative, early, and long-term postoperative management of patients with abdominal aortic aneurysms. The update also includes a chapter on cost and economic considerations. The 14-member AAA Guideline Committee was chaired by Dr Elliot Chaikof from Harvard Medical School, Beth Israel Deaconess Medical Center, who also lead the efforts of the previous update of the SVS aortic aneurysm guidelines.
      This document includes 29 guidelines that were rated 1A, which stands for a strong recommendation and a high-quality of evidence. The most important of these recommendations are a one-time ultrasound screening for AAA in men or women 65 to 75 years of age with a history of tobacco use, elective repair for patients at low or acceptable surgical risk with a fusiform AAA that is ≥5.5 cm, and immediate repair for patients who present with a ruptured aneurysm. Additional 1A recommendations include preservation of flow to at least one internal iliac artery during open or endovascular repair (EVAR), recommending FDA approved branched endograft devices in anatomically suitable patients to maintain perfusion to at least one internal iliac artery, staging bilateral internal iliac artery occlusion by at least one to two weeks, if required for EVAR, and recommending straight tube grafts for open surgical repair of AAA in the absence of significant disease of the iliac arteries.
      Along with providing guidance of these patients during the continuum of care, the writing group also offers several recommendations (Strong) and suggestions (Weak) that are novel compared to the previous versions. The new guidelines suggest surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter (Level of recommendation: 2 = Weak; Quality of evidence: C = Low). The document also incorporates the vast knowledge that has been gained through the Vascular Quality Initiative (VQI), suggesting that the VQI mortality risk score be used preoperatively to assist in making informed decisions about proceeding with aneurysm repair (Level of recommendation: 2 [Weak], Quality of evidence: C [Low]). An additional suggestion is that elective EVAR be performed at centers with a volume of at least 10 EVAR cases per year, with a documented perioperative mortality and conversion rate to open surgical repair of 2% or less (Level of recommendation: 2 = Weak; Quality of evidence: C = Low) and that elective open repair be performed at centers with an annual case volume of aortic operations of at least 10 per year, with a perioperative mortality rate of 5% or less (Level of recommendation: 2 = Weak; Quality of evidence: C = Low). This represents the first SVS clinical practice guideline document that specifically addresses the case volume-outcome relationship.
      When AAA rupture occurs, EVAR is recommended as the preferred method of treatment, if anatomically feasible (Level of recommendation: 1 = Strong; Quality of evidence: C = Low), with a goal of “door to intervention time” of less than 90 minutes (Level of recommendation: Good Practice Statement; Quality of evidence: Ungraded).
      The AAA guideline document is based on a thorough review of the literature by an expert panel, is supported by three systematic reviews and meta-analyses prepared by the Evidence-Based Practice Center of Mayo Clinic in Rochester, Minnesota, and was subjected to a robust peer review by members of the SVS Document Oversight Committee. The manuscript was also posted on the SVS website for member and public reviews and comments prior to approval by the SVS Executive Committee. To comply with requirements of the Agency for Healthcare and Research Quality's National Guideline Clearinghouse on evidence-based clinical practice guidelines, a detailed conflict of interest disclosure of all authors is attached.
      The updated AAA comprehensive guidelines, which list 780 references, should be thoroughly studied by vascular specialists, trainees, third-party payers, and all physicians and health care professionals who participate in the care of patients with AAAs.