Important new recommendations are provided for the care of patients with an AAA, including suggestions 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. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices.

As compared with open repair, endovascular repair of abdominal aortic aneurysm is associated with lower short-term rates of death and complications. The survival advantage is more durable among older patients. Late reinterventions related to abdominal aortic aneurysm are more common after endovascular repair but are balanced by an increase in laparotomy-related reinterventions and hospitalizations after open surgery.

Aim: The “2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease” provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). Methods: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

BACKGROUND Randomized trials and observational studies have shown that perioperative morbidity and mortality are lower with endovascular repair of abdominal aortic aneurysm than with open repair, but the survival benefit is not sustained. In addition, concerns have been raised about the long-term risk of aneurysm rupture or the need for reintervention after endovascular repair. METHODS We assessed perioperative and long-term survival, reinterventions, and complications after endovascular repair as compared with open repair of abdominal aortic aneurysm in propensity-score–matched cohorts of Medicare beneficiaries who underwent repair during the period from 2001 through 2008 and were followed through 2009. RESULTS We identified 39,966 matched pairs of patients who had undergone either open repair or endovascular repair. The overall perioperative mortality was 1.6% with endovascular repair versus 5.2% with open repair (P<0.001). From 2001 through 2008, perioperative mortality decreased by 0.8 percentage points among patients who underwent endovascular repair (P = 0.001) and by 0.6 percentage points among patients who underwent open repair (P = 0.01). The rate of conversion from endovascular to open repair decreased from 2.2% in 2001 to 0.3% in 2008 (P<0.001). The rate of survival was significantly higher after endovascular repair than after open repair through the first 3 years of follow-up, after which time the rates of survival were similar. Through 8 years of follow-up, interventions related to the management of the aneurysm or its complications were more common after endovascular repair, whereas interventions for complications related to laparotomy were more common after open repair. Aneurysm rupture occurred in 5.4% of patients after endovascular repair versus 1.4% of patients after open repair through 8 years of follow-up (P<0.001). The rate of total reinterventions at 2 years after endovascular repair decreased over time (from 10.4% among patients who underwent procedures in 2001 to 9.1% among patients who underwent procedures in 2007). CONCLUSIONS Endovascular repair, as compared with open repair, of abdominal aortic aneurysm was associated with a substantial early survival advantage that gradually decreased over time. The rate of late rupture was significantly higher after endovascular repair than after open repair. The outcomes of endovascular repair have been improving over time. (Funded by the National Institutes of Health.)

Background Recent reports have suggested that angioplasty +/− stenting (PTA/S) may have lower perioperative mortality than open surgery for revascularization of acute and chronic mesenteric ischemia (AMI and CMI). It is unclear if there has been nationwide adoption of this methodology or whether there is in fact a mortality benefit. Methods We identified all patients undergoing mesenteric revascularization, either surgical (bypass, endarterectomy, or embolectomy) or PTA/S from the Nationwide Inpatient Sample from 1988–2006. A diagnosis by ICD-9 coding of AMI or CMI was required for inclusion. We evaluated trends in management over this time period and compared in-hospital mortality and complications between surgical bypass and PTA/S for the years 2000–2006. Results From 1988 to 2006 there were 6,342 PTA/S and 16,071 open surgical repairs overall. PTA/S increased steadily over time surpassing all surgery for CMI in 2002. PTA/S for AMI has also increased and surpassed bypass in 2002 but has not surpassed all surgical procedures for AMI even in 2006. Mortality was lower after PTA/S than bypass for both CMI (3.7% vs 13%, P<0.01) and AMI (16% vs 28%, P<0.01). Bowel resection was more common after bypass than PTA/S for CMI (7% vs 3%, P<0.01) and this subgroup showed an increased in-hospital mortality for both repair types (54% and 25%). Conclusion PTA/S in being utilized with increasing frequency for revascularization of both CMI and AMI. Based on lower in-hospital mortality for patients as they are currently being selected, PTA/S is appropriate therapy for selected patients with CMI. Longitudinal data are needed to determine the durability of this benefit. The greater proportion of patients undergoing bowel resection with bypass for AMI suggests a more advanced level of ischemia in this group making comparison with PTA/S difficult. However, PTA/S may be useful in selected patients with AMI and appropriate anatomy. Further data with greater detail regarding symptomatology and anatomy will clarify appropriate patient selection.