Medical treatment of small abdominal aortic aneurysm

Abstract

Conventional open repair or endovascular aneurysm repair is indicated for infrarenal abdominal aortic aneurysm (AAA) when the diameter of the latter is ≥ 5.5 cm. This therapeutic strategy is based on results of randomized trials of open repair versus ultrasound surveillance of small AAA (<5.5 cm). Studies of screening for AAA have shown that >90% of aneurysms detected are small aneurysms (<5.5 cm). Despite the low annual risk of rupture of these aneurysms, patients with small AAA are left with a potentially life-threatening disease for which no immediate treatment is available. Hence, medical treatment directed at limiting the expansion of small AAA has emerged as an alternative therapeutic strategy. Randomized trials of doxycycline, roxithromycin, and propranolol in patients with small AAA have been published. The results of the doxycycline and roxithromycin trials suggest that both medications can limit AAA expansion, especially during the first year of treatment. Propranolol did not limit AAA expansion, and the trials were stopped because of its serious side effects. In other studies, statins and indomethacin have also been shown to limit AAA expansion. However, these studies were observational with relatively small numbers of patients. Thus, large randomized controlled trials with long follow-up are needed to objectively assess the efficacy of medications that have shown potential in limiting AAA expansion. In addition, recent evidence of regression of AAA in experimental animal models is likely to change our concepts of the molecular pathogenesis of AAA, and could make medical treatment of small AAA a possibility.