5. Which of the following is the treatment of choice for our patient’s high blood pressure?
The recommended agents for blood pressure control in this patient population are betablockers, such as propranolol. In a small study of patients with infrarenal aortic aneurysms, beta-blockers reduced the mean expansion rate from 0.68 cm/year to 0.36 cm/year, although larger trials have not yet confirmed this benefit.35,36 The 2005 ACC/AHA guidelines recommend beta-blockers for patients who are being managed medically.25 Other antihypertensive drugs can be added to achieve optimal blood pressure control after the addition of a beta-blocker.
Open vs endovascular repair
If a patient has an abdominal aortic aneurysm larger than 5.5 cm or if the benefits of surgery are determined to outweigh the risks, a surgical plan should be developed. Patients should be evaluated for surgical risk factors, and this should guide the choice of surgical approach—ie, open repair or endovascular repair.
Compared with open repair, endovascular repair has been increasing in popularity. It has a lower rate of complications, including a significantly lower rate of perioperative death, even though patients who undergo endovascular repair are on average significantly older than those who undergo open repair.37–39
Endovascular repair is performed with open or percutaneous access of the common femoral artery. An endograft, which is packed into an introductory sheath, is introduced into the aorta and expands upon unsheathing. It is positioned to “land” in sealing zones of normal-caliber aorta, where it seals to exclude the aneurysm from circulatory flow (Figure 3).
This is different from the open approach in that it avoids the large incision and aortic cross-clamping necessary in open repair. In open repair, a large incision is made in the patient’s abdomen and the aorta is cross-clamped to stop blood flow. The aneurysm is then incised and a graft is sutured into place to protect the vessel wall from stress (Figure 4).
Our patient elected to undergo endovascular repair of his aneurysm with a bifurcated graft (Figure 3). He was able to walk the day after his procedure, and he was sent home that same day. According to the guidelines of the Society for Vascular Surgery,40 he will have surveillance CT angiography at 1 and 12 months to detect “endoleak” or aneurysm enlargement. If these are not seen, he will then undergo routine surveillance with abdominal duplex ultrasonography.