Vascular Medicine

Current Diagnostic and Treatment Algorithm for Aortic Aneurysm

Abdominal aortic aneurysm (AAA) is a common and potentially life-threatening condition, which is characterized by abnormal enlargementof the aorta and high risk of rupture. An arterial aneurysm is defined as a focal enlargementof a blood vessel with respect to the original artery. An abdominal aortic aneurysm is defined as an aortic diameter at least one and one-half times the normal diameter at the level of the renal arteries, which is approximately 2.0 cm (1). Thus, generally, a segment of abdominal aorta with a diameter of greater than 3.0 cm is considered an aortic aneurysm. Approximately 80% of aortic aneurysms occur between the renal arteries and the aortic bifurcation (1).

The risk of abdominal aortic aneurysms (AAAs) increases dramatically in the presence of the following factors: age older than 60 years, smoking, hypertension and Caucasian ethnicity. The likelihood that an aneurysm will rupture is influenced by the aneurysm size, expansion rate, continued smoking and persistent hypertension. The majority of AAAs are asymptomatic and are detected as an incidental finding on ultrasonography, abdominal computerizedd tomography (CT) or magnetic resonance imaging (MRI) performed for other purposes.

The treatment of abdominal aortic aneurysm has undergone dramatic improvements over the last decades, especially after the introduction of endovascular aneurysm repair using stent grafts. This resulted in decrease in both morbidity and mortality rates. Investigations such as CT scanning and angiography allow easy confirmation of the diagnosis of aortic aneurysms and permit a better assessment of the extent prior to surgical intervention. Germany is one of the leading countries in the clinical application of new sophisticated repair techniques of AAA and their improvement. Therefore, many overseas patients come to Germany for the diagnostic and evaluation of the indication for treatment. You can also get a second opinion from our experienced specialists without coming to Germany.    

Diagnostic Approach to AbdominalAortic Aneurysms

Both for getting a second opinion and organizing treatment in Germany, we need detailed information about the patient. The diagnostic for overseas patients is usually not complete when they contact us for a second opinion and subsequent treatment recommendations. The system employed by German Health Advisors, however, allows for the completion of this stage while the patient is in his homeland. It is not necessary to come to Germany for diagnostic procedures. You will be informed if there are any obstacles in the diagnostic processes. For the diagnosis of AAA, please bear in mind the following:

  • Detailed information about family history, comorbidities, risk factors, physical examination, blood count and differential, liver and renal function tests (see the request form for German Health Advisors) is needed. This will usually be carried out by our local colleagues and documented in the form of a doctor’s letter.
  • Abdominal Ultrasound is commonly used and is a highly accurate way to measure the size of an aneurysm.
  • Abdominal and pelvic (CT)  is highly accurate in determining the size and extent of an aneurysm. 
  • MRI may be an alternative to CT scans for those who need frequent monitoring, to reduce their exposure to radiation.
  • CT or MR Angiography (CTA or MRA) can be used to assess the extent of an aneurysm. 
  • If you want a second opinion or you want to come to Germany for the treatment, please obtain your digital radiology images from the facility and send the DICOM filesusing German Health Advisors’secure data transfer system.

Treatment of Abdominal Aortic Aneurysms

Management options for patients with an asymptomatic AAA include observation with follow-up, medical therapy, surgery and endovascular stenting. Below, we list the main current treatment options and indications: 

  • Surgical intervention is recommended for all symptomatic aneurysms and asymptomatic aneurysms greater than 5.5 cm in diameter. Options for surgical treatment include open surgery and endovascular techniques (EVAR, TEVAR, FEVAR). 
  • Although the standard treatment of abdominal aortic aneurysm has shifted from open surgery to endovascular repair, open surgery has remained the standard of care for complex aneurysms involving the visceral arteries and in patients unsuitable for endovascular aneurysm repair.
  • Regular surveillance through imaging studies should be conducted in asymptomatic aneurysms 3 cm to 5.5 cm in size. 
  • Medical management with beta-blockers, cessation of smoking and management of risk factors, such as dyslipidemia and hypertension, may be helpful in patients with small- to medium-sized aneurysms that are not treated surgically.

Follow-Up after the Treatment 

Lifelong postprocedural imaging surveillance is necessary after open and endovascular abdominal aortic aneurysm repair (EVAR) to assess for typical complications of endograft placement, as well as device failure and continued aneurysm growth. Refinement of the surveillance CT technique and development of ultrasound and MRI protocols are important to limit radiation exposure.

  • CTA is only recommended at one-month and one-year follow-up, and if there is an abnormality detected on ultrasound thereafter 
  • Non-contrast imaging of the whole aorta is recommended every five years 5 however CTA might be considered if there is no contraindication to contrast

Patients, who received their treatments in Germany, usually do not need to return to Germany for the follow-up visits. German Health Advisors will provide you with follow-up care through its Telemedicine platform.

References: 

  1. Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). ACC/AHA 2005
  2. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms, European Journal of Vascular and Endovascular Surgery (2018),https://doi.org/10.1016/j.ejvs.2018.09.020