SVS Guidelines Bundle

Abdominal Aortic Aneurysm

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Diagnosis 4 ➤ The SVS suggests deferring elective aneurysm repair for 30 days after bare-metal stent placement or coronary artery bypass surgery if clinical circumstances permit. As an alternative, EVAR may be performed with uninterrupted continuation of dual antiplatelet therapy. (2-B) ➤ The SVS suggests deferring open aneurysm repair for ≥6 months after drug-eluting coronary stent placement or, alternatively, performing EVAR with continuation of dual antiplatelet therapy. (2-B) ➤ In patients with a drug-eluting coronary stent requiring open aneurysm repair, the SVS recommends discontinuation of P2Y12 platelet receptor inhibitor therapy 10 days preoperatively with continuation of aspirin. The P2Y12 inhibitor should be restarted as soon as possible after surgery. The relative risks and benefits of perioperative bleeding and stent thrombosis should be discussed with the patient. (1-B) ➤ The SVS suggests continuation of beta blocker therapy during the perioperative period if it is part of an established medical regimen. (2-B) ➤ If a decision was made to start beta blocker therapy (because of the presence of multiple risk factors, such as coronary artery disease, renal insufficiency, and diabetes), the SVS suggests initiation well in advance of surgery to allow sufficient time to assess safety and tolerability. (2-B) ➤ The SVS suggests preoperative pulmonary function studies, including room air arterial blood gas determinations, in patients with a history of symptomatic chronic obstructive pulmonary disease (COPD), long- standing tobacco use, or inability to climb one flight of stairs. (2-C) ➤ The SVS recommends smoking cessation for ≥2 weeks before aneurysm repair. (1-C) ➤ The SVS suggests administration of pulmonary bronchodilators for at least 2 weeks before aneurysm repair in patients with a history of COPD or abnormal results of pulmonary function testing. (2-C) ➤ The SVS suggests holding angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor antagonists on the morning of surgery and restarting these agents after the procedure once euvolemia has been achieved. (2-C) ➤ The SVS recommends preoperative hydration in non-dialysis– dependent patients with renal insufficiency before aneurysm repair. (1-A)

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