A 67-year-old man presents to your office after community ultrasound screening revealed an aortic aneurysm measuring 3.0x3.5 cm Physical examination confirms a palpable, pulsatile, nontender abdominal mass just above the umbilicus. The patient's medical conditions include hypertension, hyperlipidemia, and tobacco use. What is the best recommendation for the patient to consider?
Abdominal aortic aneurysms (AAAs) occur in 1% to 2% of men older than 50 years and to a lesser extent in women. Smoking and hypertension are major risk factors for the development of AAA. Abdominal aneurysms are commonly asymptomatic, but acute rupture may occur without warning. Some will expand and become painful, with pain as a harbinger of rupture. The risk of rupture increases with the size of the aneurysm The 5-year risk of rupture is 1% to 2% if the aneurysm is less than 5 cm, but 20% to 40% if the size is greater than 5 cm Other studies indicate that, in patients with AAAs less than 5.5 cm, there is no difference in mortality rate between those followed with ultrasound and those who undergo elective aneurysmal repair. Therefore, operative repair is typically recommended in asymptomatic individuals when the AAA diameter is greater than 5.5 cm; other indications for surgery are rapid expansion or onset of symptoms. With careful preoperative evaluation and postoperative care, the surgical mortality rate should be less than 1% to 2%. Renal artery involvement increases the complexity of surgical repair but does not increase the risk of rupture. Endovascular stent grafts for infrarenal AAAs are successful and have largely replaced open surgical repair in many centers.
Watchful waiting is the best course until the first onset of abdominal pain
Surgery is indicated now except for the excess operative risk represented by the patient's hypertension and tobacco use
Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being aneurysmal size greater than 5.5 cm
Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being involvement of a renal artery
C.V.S.