Dear Dr. SerVaas: I have had an aortic aneurysm for four-plus years. It is presently at the "five" level in size. In general, what is the surgical risk percentage for a 75-year-old male? Might one be better off not doing surgery and just going on as I have these past years? R. P. Judge Lancaster, California Dear Reader: We asked vascular specialists at Indiana University School of Medicine to comment on your important dilemma. Dr. Stephen Lalka, professor of surgery, division of vascular surgery, responds: "Treatment of abdominal aortic aneurysms (AAAs), as with any medical intervention, is a matter of weighing the risk of the procedure against the benefit. In a majority of cases, AAAs of five centimeters will continue to grow. Data from the recent United Kingdom Small Aneurysm trial and the U.S. Veterans Affairs Aneurysm Detection and Management trial, involving over 2,200 patients, for the first time definitively demonstrated that the expansion rate of aneurysms is 0.33 cm per year with an annual rupture risk of 0.6 to one percent per year. "Both of these studies found that survival was not improved by elective surgery performed for AAAs less than 5.5 cm, compared to continued close surveillance with abdominal CT scans performed every six months. Within four years, 80 percent of the patients who were randomized to continued surveillance versus early surgery went on to require surgery due to expansion to the 5.5 cm threshold or because of the onset of aneurysm symptoms. "The mortality associated with the conventional open repair of AAAs is 3.0 to 6.0 percent in a typical 75-year-old patient. Endovascular repair is a treatment option in about 50 percent of AAA patients. The mortality rate of this procedure--in which a stent-graft is placed from inside the arteries through two small incisions made in the groin--is approximately 2 percent. Patients who have endovascular repair require follow-up for life with abdominal imaging. Open repair of an AAA does not require this continued surveillance. "In summary, if a 75-year-old patient is uncomfortable living with the knowledge that his aneurysm will likely grow to greater than 5.5 cm within four years, I would recommend being evaluated by a board-certified vascular surgeon who has extensive experience with endovascular and open abdominal aortic aneurysm repair. Although there is a small risk of dying from either the open or the endovascular repair, the risk of a 5 cm aneurysm rupturing in the next five years will likely exceed the risk of either type of surgery for people in reasonably good health. Rupture of an AAA is associated with an 80 percent mortality."
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