! SOCIETY FOR VASCULAR SURGERY DOCUMENT The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm Elliot L. Chaikof, MD, PhD,a Ronald L. Dalman,MD,b Mark K.Eskandari, MD,c BenjaminM. Jackson, MD,d W. Anthony Lee,MD,eM. Ashraf Mansour, MD,fTara M. Mastracci, MD,gMatthewMell, MD,b M. Hassan Murad, MD,MPH,hLouis L. Nguyen,MD, MBA, MPH,iGustavo S.Oderich, MD,j Madhukar S. Patel,MD, MBA,ScM,a,k MarcL. Schermerhorn, MD, MPH,aandBenjamin W.Starnes, MD,l Boston,Mass;PaloAlto,Calif;Chicago,Ill;Philadelphia,Pa;BocaRaton,Fla;GrandRapids,Mich;London,UnitedKingdom; Rochester,Minn;andSeattle,Wash ABSTRACT Background: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operativerisk,andneedtointervene.Carefulattentiontothechoiceofoperativestrategyalongwithoptimaltreatment ofmedicalcomorbiditiesiscriticaltoachievingexcellentoutcomes.Moreover,appropriatepostoperativesurveillanceis necessarytominimizesubsequentaneurysm-relateddeathormorbidity. Methods:ThecommitteemadespecificpracticerecommendationsusingtheGradingofRecommendationsAssessment, Development,andEvaluationsystem.Threesystematicreviewswereconductedtosupportthisguideline.Twofocusedon evaluatingthebestmodalitiesandoptimalfrequencyforsurveillanceafterendovascularaneurysmrepair(EVAR).Athird focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included(1)generalapproachtothepatient,(2)treatmentofthepatientwithanAAA,(3)anestheticconsiderationsand perioperativemanagement,(4)postoperativeandlong-termmanagement,and(5)costandeconomicconsiderations. Results: Alongwithprovidingguidanceregardingthemanagementofpatientsthroughoutthecontinuumofcare,we haverevisedanumberofpriorrecommendationsandaddressedanumberofnewareasofsignificance.Newguidelinesare providedforthesurveillanceofpatientswithanAAA,includingrecommendedsurveillanceimagingat12-monthintervalsfor patientswithanAAAof4.0to4.9cmindiameter.Werecommendendovascularrepairasthepreferredmethodoftreatment forrupturedaneurysms.IncorporatingknowledgegainedthroughtheVascularQualityInitiativeandotherregionalquality collaboratives,wesuggestthattheVascularQualityInitiativemortalityriskscorebeusedformutualdecision-makingwith patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortalityandconversionratetoopensurgicalrepairof2%orlessandthatperformatleast10EVARcaseseachyear.Wealso suggestthatelectiveopenaneurysmrepairbelimitedtohospitalswithadocumentedmortalityof5%orlessandthat performatleast10openaorticoperationsofanytypeeachyear.Toencouragethedevelopmentofeffectivesystemsofcare thatwouldleadtoimprovedoutcomesforthosepatientsundergoingemergentrepair,wesuggestadoor-to-intervention timeof<90minutes,basedonaframeworkof30-30-30minutes,forthemanagementofthepatientwitharuptured aneurysm.WerecommendtreatmentoftypeIandIIIendoleaksaswellasoftypeIIendoleakswithaneurysmexpansionbut recommendcontinuedsurveillanceoftypeIIendoleaksnotassociatedwithaneurysmexpansion.Whereasantibioticpro- phylaxisisrecommendedforpatientswithanaorticprosthesisbeforeanydentalprocedureinvolvingthemanipulationof thegingivalorperiapicalregionofteethorperforationoftheoralmucosa,antibioticprophylaxisisnotrecommendedbefore respiratorytractprocedures,gastrointestinalorgenitourinaryprocedures,anddermatologicormusculoskeletalprocedures unlessthepotentialforinfectionexistsorthepatientisimmunocompromised.Increasedutilizationofcolorduplexultra- soundissuggestedforpostoperativesurveillanceafterEVARintheabsenceofendoleakoraneurysmexpansion. From the Department of Surgery, Beth Israel Deaconess Medical Center, W.L.Gore,andGEHealthcare.M.L.S.hasbeenaconsultantforCookMedical, Bostona; the Department of Surgery, Stanford University, Palo Altob; the Abbott,Philips,hasreceivedfinancialsupportfromAbbott,Endologix,Cook DepartmentofSurgery,NorthwesternUniversity,Chicagoc;theDepartment Medical,andPhilips,andhasbeenamemberoftheScientificAdvisoryCom- of Surgery, University of Pennsylvania, Philadelphiad; the Christine E. Lynn mitteeMembershipforEndologix.W.B.S.isastockholderinAORTICACorpo- Heart&VascularInstitute,BocaRatonRegionalHospital,BocaRatone;the ration.Allotherauthorshavenothingtodisclose. DepartmentofSurgery,SpectrumHealthMedicalGroup,GrandRapidsf;The Additionalmaterialforthisarticlemaybefoundonlineatwww.jvascsurg.org. Royal Free Hospital, Londong; the Evidence-based Practice Centerh and Correspondence:ElliotL.Chaikof,MD,PhD,DepartmentofSurgery,Harvard DepartmentofSurgery,jMayoClinic,Rochester;theDepartmentofSurgery, Medical School, Beth Israel Deaconess Medical Center, 110 Francis St, Ste BrighamandWomen’sHospital,Bostoni;theDepartmentofSurgery,Massa- 9F,Boston,MA02115(e-mail:[email protected]). chusettsGeneralHospital,Bostonk;andtheDepartmentofSurgery,University Independentpeer-reviewandoversighthasbeenprovidedbymembersofthe ofWashington,Seattle.l SVS Document OversightCommittee: Thomas L. Forbes,MD(Chair),Martin Authorconflictofinterest:M.K.E.hasreceivedhonorariumandfinancialsup- Bjorck,MD,RuthBush,MD,HansHenningEckstein,MD,KakraHughes,MD, portfromPrairieEducationandResearchCooperative(Bard),SilkRoadMed- GregMoneta,MD,EvaRzucidlo,MD. ical,Inc,andW.L.Gore&Associates.W.A.L.andT.M.M.havereceivedresearch 0741-5214 grants from Cook Medical. G.S.O. has received consulting fees and grants Copyright"2017bytheSocietyforVascularSurgery.PublishedbyElsevierInc. (all paid to Mayo Clinic with no personal income) from Cook Medical, https://doi.org/10.1016/j.jvs.2017.10.044 2 Journal of Vascular Surgery Chaikofetal 3 Volume67,Number1 Conclusions:ImportantnewrecommendationsareprovidedforthecareofpatientswithanAAA,includingsuggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areasofuncertaintyarehighlightedthatwouldbenefitfromfurtherinvestigationinadditiontoexistinglimitationsin diagnostictests,pharmacologicagents,intraoperativetools,anddevices.(JVascSurg2018;67:2-77.) TABLE OF CONTENTS Roleof elective EVAR inthehigh-risk SUMMARY OF GUIDELINES FOR THE CARE OF andunfit patient 34 PATIENTS WITH AN ABDOMINAL AORTIC OSR 35 ANEURYSM 4 Indications 35 DEFINITION OF THE PROBLEM 12 Surgicalapproach 35 Purpose of theseguidelines 12 Aortic clamping 35 Methodology andevidence 12 Grafttype andconfiguration 36 Literature search and evidencesummary 12 Maintenance of pelvic circulation 37 GENERAL APPROACH TO THE PATIENT 12 Managementof associated History andrisk factors forabdominal intra-abdominal vascular disease 37 aortic aneurysms 12 Managementof associated intra-abdominal Physical examination 17 nonvascular disease 38 Assessment of medical comorbidities 17 Perioperative outcomes of open AAArepair 38 Preoperative evaluation of cardiacrisk 17 Thepatient with aruptured aneurysm 39 Preoperative coronaryrevascularization 18 Preoperative management and Perioperative medical management considerations forpatient transfer 39 of coronary arterydisease 19 Systemsof care andtime goals Pulmonary disease 19 forintervention 39 Renalinsufficiency 20 Initialoperative management 41 Diabetes mellitus 21 Roleof EVAR 42 Hematologicdisorders 21 Managementof postoperative complications 42 BiomarkersandheritablerisksforanAAA 22 Abdominalcompartmentsyndrome 42 Biomarkers for thepresence and expansion Ischemic colitis 42 ofanaorticaneurysm 22 Multisystem organfailure 42 Geneticmarkers identifying risk Special considerations 42 ofaorticaneurysm 22 Inflammatoryaneurysm 42 Aneurysmimaging 22 Horseshoe kidney 43 Modalitiesfor aneurysmimaging 22 Aortocaval fistula 43 Prediction of aneurysm expansion ANESTHETIC CONSIDERATIONS AND and rupture risk 23 PERIOPERATIVE MANAGEMENT 43 Recommendations for aneurysm screening 24 Choice of anesthetictechnique and agent 43 Recommendations for aneurysm surveillance 25 Anesthetic considerations inthe patient Recommendations for imagingthe with aruptured aneurysm 44 symptomaticpatient 27 Antibiotic prophylaxis 44 TREATMENTOFTHEPATIENTWITHANAAA 27 Intraoperative fluidresuscitation and blood Thedecision to treat 27 conservation 44 Medical management duringthe period Cardiovascular monitoring 44 ofaneurysmsurveillance 29 Maintenance of bodytemperature 45 Timingforintervention 29 Roleof the ICU 45 Assessmentofoperativeriskandlifeexpectancy 30 Nasogastric decompression and EVAR 31 perioperative nutrition 46 Considerations for percutaneous repair 31 Prophylaxis fordeep venous thrombosis 46 Infrarenal fixation 31 Postoperative bloodtransfusion 46 Suprarenal fixation 31 Perioperative pain management 46 Management of theinternal iliacartery 32 POSTOPERATIVE AND LONG-TERM Management of associated vascular disease 33 MANAGEMENT 47 Perioperative outcomes of elective EVAR 33 Lateoutcomes 47 Incidence of30-day and in-hospital mortality 33 Endoleak 47 Perioperative morbidity 33 TypeI endoleak 47 Endoleak 34 TypeII endoleak 47 Accesssite complications 34 TypeIII endoleak 48 Acutelimb thrombosis 34 TypeIV endoleak 48 Postimplantation syndrome 34 Endotension 48 Ischemic colitis 34 Devicemigration 48 4 Chaikofetal Journal of Vascular Surgery January2018 Limb occlusion 48 We recommend echocardiography before planned Graft infection 49 operative repair in patients with dyspnea of unknown Prevention of an aorticgraft infection originor worsening dyspnea. Incisional hernia 50 Para-anastomotic aneurysm 51 Levelofrecommendation 1(Strong) Recommendation for postoperative surveillance 51 Qualityofevidence A(High) Surveillance imagingmodality 51 Surveillance outcomes 51 Summary 51 Wesuggestcoronaryrevascularizationbeforeaneurysm COST AND ECONOMIC CONSIDERATIONS repair in patients with acute ST-segment or non-ST- IN ANEURYSM REPAIR 51 segment elevation myocardial infarction (MI), unstable CARE OF THE PATIENT WITH AN AAA: AREAS angina, or stable angina with left main coronary artery IN NEED OF FURTHER RESEARCH 53 or three-vesseldisease. REFERENCES 53 APPENDIX: SEARCH STRATEGY Levelofrecommendation 2(Weak) Qualityofevidence B(Moderate) SUMMARY OF GUIDELINES FOR THE CARE OF PATIENTS WITH AN ABDOMINAL AORTIC Wesuggestcoronaryrevascularizationbeforeaneurysm ANEURYSM repair in patients with stable angina and two-vessel dis- Physical examination. In patients with a suspected or ease that includes the proximal left descending artery known abdominal aortic aneurysm (AAA), we recom- and either ischemia on noninvasive stress testing or mend performing physical examination that includes reduced left ventricular function (ejection fraction an assessmentof femoral and popliteal arteries. < 50%). Inpatientswithapoplitealorfemoralarteryaneurysm, werecommend evaluation foran AAA. Levelofrecommendation 2(Weak) Qualityofevidence B(Moderate) Levelofrecommendation 1(Strong) Qualityofevidence A(High) In patientswhomayneedaneurysm repairinthesub- sequent12monthsandinwhompercutaneouscoronary interventionisindicated,wesuggestastrategyofballoon Assessmentofmedicalcomorbidities. Inpatientswith angioplastyorbare-metalstentplacement,followedby4 active cardiac conditions, including unstable angina, to 6weeks of dualantiplatelet therapy. decompensated heart failure, severe valvular disease, and significant arrhythmia, we recommend cardiology Levelofrecommendation 2(Weak) consultation before endovascular aneurysm repair Qualityofevidence B(Moderate) (EVAR) oropen surgical repair(OSR). Levelofrecommendation 1(Strong) We suggest deferring elective aneurysm repair for 30 Qualityofevidence B(Moderate) daysafterbare-metalstentplacementorcoronaryartery bypass surgery if clinical circumstances permit. As an alternative,EVARmaybeperformedwithuninterrupted In patients with significant clinical risk factors, such as continuation of dualantiplatelet therapy. coronaryarterydisease,congestiveheartfailure,cerebro- vascular disease, diabetes mellitus, chronic renal insuffi- Levelofrecommendation 2(Weak) ciency, and unknown or poor functional capacity Qualityofevidence B(Moderate) (metabolic equivalent [MET] < 4), who are to undergo OSR orEVAR, wesuggest noninvasive stress testing. Wesuggestdeferringopenaneurysmrepairforatleast Levelofrecommendation 2(Weak) 6monthsafterdrug-elutingcoronarystentplacementor, alternatively,performingEVARwithcontinuationofdual Qualityofevidence B(Moderate) antiplatelet therapy. We recommenda preoperative resting 12-lead electro- Levelofrecommendation 2(Weak) cardiogram (ECG) in all patients undergoing EVAR or Qualityofevidence B(Moderate) OSR within 30daysof planned treatment. In patients with a drug-eluting coronary stent requiring Levelofrecommendation 1(Strong) open aneurysm repair, we recommend discontinuation Qualityofevidence B(Moderate) of P2Y platelet receptor inhibitor therapy 10 days 12 Journal of Vascular Surgery Chaikofetal 5 Volume67,Number1 preoperatively with continuation of aspirin. The P2Y in- We recommend preoperative hydration in nondialysis- 12 hibitor should be restarted as soon as possible after sur- dependentpatientswithrenalinsufficiencybeforeaneu- gery. The relative risks and benefits of perioperative rysmrepair. bleeding and stent thrombosis shouldbe discussed with thepatient. Levelofrecommendation 1(Strong) Levelofrecommendation 1(Strong) Qualityofevidence A(High) Qualityofevidence B(Moderate) We recommend preprocedure and postprocedure hy- drationwithnormalsalineor5%dextrose/sodiumbicar- We suggest continuation of beta blocker therapy dur- bonateforpatientsatincreasedriskofcontrast-induced ingtheperioperativeperiodifitispartofanestablished nephropathy (CIN)undergoing EVAR. medicalregimen. Levelofrecommendation 1(Strong) Levelofrecommendation 2(Weak) Qualityofevidence A(High) Qualityofevidence B(Moderate) We recommend holding metformin at the time of If a decision was made to start beta blocker therapy administration of contrast material among patients (because of the presence of multiple risk factors, such as coronary artery disease, renal insufficiency, and dia- with an estimated glomerular filtration rate (eGFR) of <60 mL/min or up to 48 hours before administration betes), we suggest initiation well in advance of surgery to allow sufficient timeto assess safety andtolerability. of contrast material if the eGFRis <45 mL/min. Levelofrecommendation 1(Strong) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Qualityofevidence B(Moderate) We recommend restarting metformin no sooner than We suggest preoperative pulmonary function studies, 48 hours after administration of contrast material as including room air arterial blood gas determinations, in long as renal function has remained stable (<25% patients with a history of symptomatic chronic obstruc- increase increatinine concentration above baseline). tive pulmonary disease (COPD), long-standing tobacco use, orinability to climboneflightof stairs. Levelofrecommendation 1(Strong) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Qualityofevidence C(Low) We recommend perioperative transfusion of packed Werecommendsmokingcessationforatleast2weeks redblood cellsif the hemoglobin levelis <7g/dL. before aneurysmrepair. Levelofrecommendation 1(Strong) Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) Qualityofevidence C(Low) We suggest hematologic assessment if the preopera- We suggest administration of pulmonary bronchodila- tiveplatelet countis <150,000/mL. tors for at least 2 weeks before aneurysm repair in pa- tients with a history of COPD or abnormal results of Levelofrecommendation 2(Weak) pulmonary function testing. Qualityofevidence C(Low) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Aneurysmimaging. Werecommendusingultrasound, when feasible, as the preferred imaging modality for We suggest holding angiotensin-converting enzyme aneurysm screeningand surveillance. (ACE) inhibitors and angiotensin receptor antagonists Levelofrecommendation 1(Strong) on the morning of surgery and restarting these agents Qualityofevidence A(High) after the procedureonce euvolemia has been achieved. Levelofrecommendation 2(Weak) We suggest that the maximum aneurysm diameter Qualityofevidence C(Low) derived from computed tomography (CT) imaging 6 Chaikofetal Journal of Vascular Surgery January2018 shouldbebasedonanouterwalltoouterwallmeasure- WerecommendaCTscantoevaluatepatientsthought ment perpendicular to the pathof the aorta. tohaveAAApresentingwithrecent-onsetabdominalor back pain, particularly in the presence of a pulsatile Levelofrecommendation GoodPracticeStatement epigastricmass orsignificant risk factors for AAA. Qualityofevidence Ungraded Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) We recommend a one-time ultrasound screening for AAAsinmenorwomen65to75yearsofagewithahis- tory of tobaccouse. The decision to treat. Wesuggestreferraltoavascular Levelofrecommendation 1(Strong) surgeonatthetimeofinitialdiagnosisofanaorticaneurysm. Qualityofevidence A(High) Levelofrecommendation GoodPracticeStatement Qualityofevidence Ungraded We suggest ultrasound screening for AAA in first- degree relatives of patients who present with an AAA. We recommend repair for the patient who presents Screening should be performed in first-degree relatives with an AAA and abdominal or back pain that is likely whoarebetween65and75yearsofageorinthoseolder to beattributed to theaneurysm. than75years andingood health. Levelofrecommendation 1(Strong) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Qualityofevidence C(Low) Werecommendelectiverepairforthepatientatlowor We suggest a one-time ultrasound screening for AAAs acceptable surgical risk with a fusiform AAA that is inmenorwomenolderthan75yearswithahistoryofto- $5.5 cm. bacco use and in otherwise good health who have not previously received ascreening ultrasound examination. Levelofrecommendation 1(Strong) Qualityofevidence A(High) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Wesuggestelectiverepairforthepatientwhopresents with asaccular aneurysm. Ifinitialultrasoundscreeningidentifiedanaorticdiameter Levelofrecommendation 2(Weak) >2.5cmbut<3cm,wesuggestrescreeningafter10years. Qualityofevidence C(Low) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) WesuggestrepairinwomenwithAAAbetween5.0cm and5.4 cmin maximumdiameter. We suggest surveillance imaging at 3-year intervals for Levelofrecommendation 2(Weak) patients with anAAA between 3.0 and3.9cm. Qualityofevidence B(Moderate) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Inpatientswithasmallaneurysm(4.0-5.4cm)whowill require chemotherapy, radiation therapy, or solid organ transplantation, we suggest a shared decision-making We suggest surveillance imaging at 12-month intervals approach todecide about treatment options. for patients with anAAA of 4.0to 4.9 cmindiameter. Levelofrecommendation 2(Weak) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Qualityofevidence C(Low) We suggest surveillance imaging at 6-month intervals Medical management during the period of AAA sur- for patients with an AAA between 5.0 and 5.4 cm in veillance. We recommendsmoking cessation toreduce diameter. the risk of AAAgrowth and rupture. Levelofrecommendation 2(Weak) Levelofrecommendation 1(Strong) Qualityofevidence C(Low) Qualityofevidence B(Moderate) Journal of Vascular Surgery Chaikofetal 7 Volume67,Number1 Wesuggestnot administeringstatins, doxycycline,rox- Werecommendstagingbilateralinternaliliacarteryoc- ithromycin, ACE inhibitors, or angiotensin receptor clusion byatleast 1to 2weeks if required forEVAR. blockers for the sole purpose of reducing the risk of Levelofrecommendation 1(Strong) AAA expansion andrupture. Qualityofevidence A(High) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) We suggest renal artery or superior mesenteric artery (SMA) angioplasty and stenting for selected patients Wesuggestnotadministeringbetablockertherapyfor withsymptomatic diseasebefore EVARorOSR. the sole purpose of reducing the risk of AAA expansion Levelofrecommendation 2(Weak) and rupture. Qualityofevidence C(Low) Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) We suggest prophylactic treatment of an asymptom- atic, high-grade stenosis of the SMA in the presence of ameanderingmesentericarterybasedoffofalargeinfe- Timing for intervention. We recommend immediate riormesentericartery(IMA),whichwillbesacrificeddur- repair for patients who present with a ruptured aneu- ingthe course of treatment. rysm. Levelofrecommendation 2(Weak) Levelofrecommendation 1(Strong) Qualityofevidence C(Low) Qualityofevidence A(High) We suggest preservation of accessory renal arteries at Should repair of a symptomatic AAA be delayed to the time of EVAR or OSR if the artery is 3 mm or larger optimizecoexistingmedicalconditions,werecommend indiameterorsuppliesmorethanone-thirdoftherenal that the patient be monitored in an intensive care unit parenchyma. (ICU) settingwith bloodproducts available. Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Levelofrecommendation 1(Strong) Qualityofevidence C(Low) Perioperative outcomes of elective EVAR. We suggest that elective EVAR be performed at centers with a vol- Assessment of operative risk and life expectancy. We ume of at least 10 EVAR cases each year and a docu- suggest informing patients contemplating open repair mented perioperative mortality and conversion rate to orEVARoftheirVascularQualityInitiative(VQI)perioper- OSRof 2% orless. ative mortality risk score. Levelofrecommendation 2(Weak) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Qualityofevidence C(Low) Role of elective EVAR in the high-risk and unfit EVAR. We recommend preservation of flow to at least patient. Wesuggestinforminghigh-riskpatientsoftheir oneinternal iliacartery. VQI perioperative mortality risk score for them to make aninformed decision toproceed with aneurysm repair. Levelofrecommendation 1(Strong) Qualityofevidence A(High) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) We recommend using Food and Drug Administration (FDA)-approved branch endograft devices in anatomi- OSR. We recommend a retroperitoneal approach for cally suitable patients to maintain perfusion to at least patients requiring OSR of an inflammatory aneurysm, a oneinternal iliacartery. horseshoekidney,oranaorticaneurysminthepresence of ahostile abdomen. Levelofrecommendation 1(Strong) Levelofrecommendation 1(Strong) Qualityofevidence A(High) Qualityofevidence C(Low) 8 Chaikofetal Journal of Vascular Surgery January2018 Wesuggestaretroperitonealexposureoratransperito- WesuggestconcomitantsurgicalrepairofanAAAand neal approach with a transverse abdominal incision for coexistent cholecystitis or an intra-abdominal tumor in patients with significant pulmonary disease requiring patients who are not candidates for EVAR or staged OSR. intervention. Levelofrecommendation 2(Weak) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Qualityofevidence C(Low) We recommend a thrombin inhibitor, such as bivaliru- din or argatroban, as an alternative to heparin for pa- Perioperative outcomes of open AAA repair. We sug- tients with a history of heparin-induced gest that elective OSR for AAA be performed at centers thrombocytopenia. with an annual volume of at least 10 open aortic opera- tions of any type and a documented perioperative mor- Levelofrecommendation 1(Strong) talityof 5% or less. Qualityofevidence B(Moderate) Levelofrecommendation 2(Weak) We recommend straight tube grafts for OSR of AAA in Qualityofevidence C(Low) the absenceof significant disease of theiliac arteries. Levelofrecommendation 1(Strong) The patient with a ruptured aneurysm. We suggest a Qualityofevidence A(High) door-to-intervention time of <90 minutes, based on a frameworkof30-30-30minutes,forthemanagementof We recommend performing the proximal aortic anas- the patient witha ruptured aneurysm. tomosis asclose to therenal arteries aspossible. Levelofrecommendation GoodPracticeStatement Levelofrecommendation 1(Strong) Qualityofevidence Ungraded Qualityofevidence A(High) An established protocol for the management of We recommend that all portions of an aortic graft be ruptured AAA isessential foroptimal outcomes. excluded from direct contact with the intestinal con- tents of the peritoneal cavity. Levelofrecommendation GoodPracticeStatement Qualityofevidence Ungraded Levelofrecommendation 1(Strong) Qualityofevidence A(High) We recommend implementing hypotensive hemosta- sis with restriction of fluid resuscitation in the conscious WerecommendreimplantationofapatentIMAunder patient. circumstances that suggest an increased risk of colonic ischemia. Levelofrecommendation 1(Strong) Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) Qualityofevidence A(High) We suggest that patients with ruptured AAA who We recommend preserving blood flow to at least one require transfer for repair be referred to a facility with hypogastric artery inthe course of OSR. anestablishedruptureprotocolandsuitableendovascu- lar resources. Levelofrecommendation 1(Strong) Qualityofevidence A(High) Levelofrecommendation GoodPracticeStatement Qualityofevidence Ungraded We suggest concomitant surgical treatment of other visceral arterial disease at the time of OSR in symptom- Ifitisanatomicallyfeasible,werecommendEVARover atic patients who are not candidates for catheter-based open repairfor treatment ofa ruptured AAA. intervention. Levelofrecommendation 2(Weak) Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) Qualityofevidence C(Low) Journal of Vascular Surgery Chaikofetal 9 Volume67,Number1 Choiceofanesthetictechniqueandagent. Werecom- Levelofrecommendation 1(Strong) mend general endotracheal anesthesia for patients un- Qualityofevidence B(Moderate) dergoing open aneurysm repair. Levelofrecommendation 1(Strong) We recommend postoperative troponin measurement Qualityofevidence A(High) for all patients with electrocardiographic changes or chestpain after aneurysm repair. Antibiotic prophylaxis. We recommend intravenous Levelsofrecommendation 1(Strong) administration of a first-generation cephalosporin or, in Qualityofevidence A(High) the event of penicillin allergy, vancomycin within 30 minutes before OSR or EVAR. Prophylactic antibiotics should becontinued for nomorethan24 hours. Maintenance of body temperature. We recommend Levelofrecommendation 1(Strong) maintaining core body temperature at or above 36!C Qualityofevidence A(High) duringaneurysm repair. Levelsofrecommendation 1(Strong) We recommend that any potential sources of dental Qualityofevidence A(High) sepsis be eliminated at least 2 weeks before implanta- tionof an aorticprosthesis. Levelofrecommendation GoodPracticeStatement Role of the ICU. We recommend postoperative man- Qualityofevidence Ungraded agement in an ICU for the patient with significant car- diac, pulmonary, or renal disease as well as for those requiring postoperative mechanical ventilation or who Intraoperative fluid resuscitation and blood conserva- developed a significant arrhythmia or hemodynamic tion. Werecommend usingcell salvage oran ultrafiltra- instability duringoperative treatment. tiondeviceif large bloodloss isanticipated. Levelofrecommendation 1(Strong) Levelofrecommendation 1(Strong) Qualityofevidence A(High) Qualityofevidence B(Moderate) If the intraoperative hemoglobin level is <10 g/dL and Nasogastric decompression and perioperative nutri- blood loss is ongoing, we recommend transfusion of tion. Werecommendoptimizationofpreoperativenutri- packed blood cells along with fresh frozen plasma and tional status before elective open aneurysm repair if platelets inaratioof 1:1:1. repairwill not beunduly delayed. Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) Levelofrecommendation 1(Strong) Qualityofevidence A(High) Cardiovascular monitoring. We suggest using pulmo- naryarterycathetersonlyifthelikelihoodofamajorhe- modynamicdisturbance is high. We recommend using nasogastric decompression intraoperatively for all patients undergoing open aneu- Levelofrecommendation 1(Strong) rysm repair but postoperatively only for those patients Qualityofevidence B(Moderate) withnausea andabdominal distention. Levelofrecommendation 1(Strong) We recommend central venous access and arterial line Qualityofevidence A(High) monitoringinallpatientsundergoingopenaneurysmrepair. Levelofrecommendation 1(Strong) We recommend parenteral nutrition if a patient is un- Qualityofevidence B(Moderate) able to tolerate enteral support 7 days after aneurysm repair. WerecommendpostoperativeST-segmentmonitoringfor Levelofrecommendation 1(Strong) allpatientsundergoingopenaneurysmrepairandforthose Qualityofevidence A(High) patientsundergoingEVARwhoareathighcardiacrisk. 10 Chaikofetal Journal of Vascular Surgery January2018 Prophylaxis for deep venous thrombosis. We recom- We suggest notreatment of typeIV endoleaks. mend thromboprophylaxis that includes intermittent Levelofrecommendation 2(Weak) pneumaticcompressionandearlyambulationforallpa- Qualityofevidence C(Low) tients undergoing OSRor EVAR. Levelofrecommendation 1(Strong) We recommend open repair if endovascular interven- Qualityofevidence A(High) tion fails to treat a type I or type III endoleak with ongoinganeurysm enlargement. Wesuggestthromboprophylaxiswithunfractionatedor Levelofrecommendation 1(Strong) low-molecular-weight heparin for patients undergoing Qualityofevidence B(Moderate) aneurysm repair at moderate to high risk for venous thromboembolism and low risk forbleeding. We suggest open repair if endovascular intervention Levelofrecommendation 2(Weak) fails to treat a type II endoleak with ongoing aneurysm Qualityofevidence C(Low) enlargement. Levelofrecommendation 2(Weak) Postoperative blood transfusion. In the absence of Qualityofevidence C(Low) ongoing blood loss, we suggest a threshold for blood transfusion during or after aneurysm repair at a hemo- We suggest treatment for ongoing aneurysm expan- globin concentration of 7g/dLor below. sion, eveninthe absenceof a visible endoleak. Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Perioperative pain management. We recommend We recommend that follow-up of patients after aneu- multimodality treatment, including epidural analgesia, rysmrepairincludeathoroughlowerextremitypulseex- for postoperative pain control after OSRof an AAA. amination or ankle-brachial index (ABI). Levelofrecommendation 1(Strong) Levelofrecommendation 1(Strong) Qualityofevidence A(High) Qualityofevidence B(Moderate) Late outcomes. We recommend treatment of type I Werecommendapromptevaluationforpossiblegraft endoleaks. limb occlusion if patients develop new-onset lower ex- tremity claudication, ischemia, or reduction in ABI after Levelofrecommendation 1(Strong) aneurysm repair. Qualityofevidence B(Moderate) Levelofrecommendation 1(Strong) We suggest treatment of type II endoleaks associated Qualityofevidence A(High) with aneurysm expansion. Levelofrecommendation 2(Weak) We recommend antibiotic prophylaxis to prevent Qualityofevidence C(Low) graft infection before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, including We recommend surveillance of type II endoleaks not scaling and root canal procedures, for any patient associated withaneurysm expansion. with an aortic prosthesis, whether placed by OSR or Levelofrecommendation 1(Strong) EVAR. Qualityofevidence B(Moderate) Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) Werecommend treatment of typeIII endoleaks. Levelofrecommendation 1(Strong) We suggest antibiotic prophylaxis before respiratory Qualityofevidence B(Moderate) tract procedures, gastrointestinal or genitourinary Journal of Vascular Surgery Chaikofetal 11 Volume67,Number1 procedures, and dermatologic or musculoskeletal pro- Levelofrecommendation 1(Strong) cedures for any patient with an aortic prosthesis if the Qualityofevidence B(Moderate) potential for infection exists or the patient is immuno- compromised. Recommendation for postoperative surveillance. We Levelofrecommendation 2(Weak) recommend baseline imaging in the first month after Qualityofevidence C(Low) EVAR with contrast-enhanced CT and color duplex ul- trasound imaging. In the absence of an endoleak or sac Afteraneurysmrepair,werecommendpromptevalua- enlargement, imaging shouldbe repeated in12 months tionforpossiblegraftinfectionifapatientpresentswith using contrast-enhanced CT or color duplex ultrasound generalizedsepsis, groindrainage, pseudoaneurysm for- imaging. mation, orill-definedpain. Levelofrecommendation 1(Strong) Qualityofevidence B(Moderate) Levelofrecommendation 1(Strong) Qualityofevidence A(High) IfatypeIIendoleakisobserved1monthafterEVAR,we We recommend prompt evaluation for possible aor- suggest postoperative surveillance with contrast- toentericfistulainapatientpresentingwithgastrointes- enhanced CT and color duplex ultrasound imaging at 6 tinalbleeding after aneurysm repair. months. Levelofrecommendation 1(Strong) Levelofrecommendation 2(Weak) Qualityofevidence A(High) Qualityofevidence B(Moderate) Inpatientspresentingwithaninfectedgraftinthepres- If neither endoleaknor AAAenlargement is observed1 ence of extensive contamination with gross purulence, year after EVAR, we suggest color duplex ultrasound werecommendextra-anatomicreconstructionfollowed whenfeasible,orCTimagingifultrasoundisnotpossible, by excision of all graft material along with aortic stump forannual surveillance. closure covered byanomental flap. Levelofrecommendation 2(Weak) Levelofrecommendation 1(Strong) Qualityofevidence C(Low) Qualityofevidence B(Moderate) IfatypeIIendoleakisassociatedwithananeurysmsac Inpatientspresentingwithaninfectedgraftwithmin- thatisshrinkingorstableinsize,wesuggestcolorduplex imal contamination, we suggest in situ reconstruction ultrasound for continued surveillance at 6-month inter- with cryopreservedallograft. valsfor 24 monthsandthen annually thereafter. Levelofrecommendation 2(Weak) Levelofrecommendation 2(Weak) Qualityofevidence B(Moderate) Qualityofevidence C(Low) Inastablepatientpresentingwithaninfectedgraft,we Ifanewendoleakisdetected,wesuggestevaluationfor suggest in situ reconstruction with femoral vein after atypeI or typeIII endoleak. graftexcision anddébridement. Levelofrecommendation 2(Weak) Levelofrecommendation 2(Weak) Qualityofevidence C(Low) Qualityofevidence B(Moderate) We suggest noncontrast-enhanced CT imaging of the Inunstablepatientswithinfectedgraft,werecommend entireaortaat5-yearintervalsafteropenrepairorEVAR. in situ reconstruction with a silver- or antibiotic- impregnated graft, cryopreserved allograft, or polytetra- Levelofrecommendation 2(Weak) fluoroethylene(PTFE)graft. Qualityofevidence C(Low)