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Majority of Elective Small Aneurysm Repairs Still Fall Within Current SVS Guidelines
Thomas Heafner, M.D., Manju Kalra, M.B.B.S, Ying Huang, M.D., Thomas Bower, M.D., Gustavo Oderich, M.D., Randall DeMartino, M.D., Jill Johnstone, M.D., Fahad Shuja, M.B.B.S, Peter Gloviczki, M.D..
Mayo Clinic, Rochester, MN, USA.

Objectives: The size criteria for elective open repair (OR) of infrarenal abdominal aortic aneurysms (irAAA) were established at ≥5.5 cm by the SVS 18 years ago. Subsequent widespread adoption of endovascular repair (EVAR) with attendant lower early mortality sparked interest in lowering this threshold. Two randomized control trials (PIVOTAL and CAESAR, 2010) failed to demonstrate survival benefit of early EVAR in small aneurysms. However, National Registry data from Europe and the US revealed up to 40% of elective irAAA repairs are performed at < 5.5 cm, with reasons not identifiable. The aim of this study was to evaluate the degree of non-adherence to SVS guidelines in our practice and elucidate reasons for divergence. Methods: Data from consecutive patients undergoing elective repair (OR and EVAR) of irAAAs between 2012 and 2017 at our institution were retrospectively reviewed. Primary endpoint was to quantify the annual percentage of irAAAs repaired outside SVS guidelines (<5.5cm but >5.0cm; <5.0cm) and by type of repair. Secondary endpoint was operative mortality. Results: Of 2034 total irAAA repairs (778 OR, 1256 EVAR) during the study period 395 (19%) were repaired (60% (237/395) EVAR and 40% (158/395) OR) at a maximum diameter < 5.5 cm, 297 (75%) were < 5.0 cm. Mean age was lower in OR patients (68 vs 75 years; p < .001); 86% (340/395) of patients were male. The median annual incidence of < 5.5 cm irAAA repairs was 24; not significantly different prior to and after 2010. There was a trend of increasing EVAR and decreasing OR during the study period (Figure 1); p < .001. Rapid aneurysm sac expansion (31%) and associated iliac aneurysm (AIA) > 3.5 cm (26%) comprised commonest indications for repair; AIA (33%) for repair at < 5 cm and sac expansion (56%) for > 5cm. In hospital mortality was 0.25 % (1/395), secondary to bowel and lower extremity ischemia due to intra-operative embolization during EVAR. Conclusions: Although the number of elective EVARs for irAAAs less than 5.5 cm continues to rise, majority of these still fall within accepted SVS guideline size exceptions.

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