Assessment of medical comorbidities. In patients with active cardiac conditions, including unstable angina, decompensated heart failure, severe valvular disease, and significant arrhythmia, we recommend cardiology consultation before endovascular aneurysm repair (EVAR) or open surgical repair (OSR). Level of recommendation: 1 (Strong), Quality of evidence: B (Moderate)
In patients with significant clinical risk factors, such as coronary artery disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic renal insufficiency, and unknown or poor functional capacity (metabolic equivalent [MET] < 4), who are to undergo OSR or EVAR, we suggest noninvasive stress testing. Level of recommendation: 2 (Weak), Quality of evidence: B (Moderate)
We recommend a preoperative resting 12-lead electrocardiogram (ECG) in all patients undergoing EVAR or OSR within 30 days of planned treatment. Level of recommendation: 1 (Strong), Quality of evidence: B (Moderate)
We recommend echocardiography before planned operative repair in patients with dyspnea of unknown origin or worsening dyspnea. Level of recommendation: 1 (Strong), Quality of evidence: A (High)
We suggest coronary revascularization before aneurysm repair in patients with acute ST-segment or non-STsegment elevation myocardial infarction (MI), unstable angina, or stable angina with left main coronary artery or three-vessel disease. Level of recommendation: 2 (Weak), Quality of evidence: B (Moderate)
We suggest coronary revascularization before aneurysm repair in patients with stable angina and two-vessel disease that includes the proximal left descending artery and either ischemia on noninvasive stress testing or reduced left ventricular function (ejection fraction < 50%). Level of recommendation: 2 (Weak), Quality of evidence: B (Moderate)
In patients who may need aneurysm repair in the subsequent 12 months and in whom percutaneous coronary intervention is indicated, we suggest a strategy of balloon angioplasty or bare-metal stent placement, followed by 4 to 6 weeks of dual antiplatelet therapy. Level of recommendation: 2 (Weak), Quality of evidence: B (Moderate)
We suggest 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. Level of recommendation: 2 (Weak), Quality of evidence: B (Moderate)
We suggest deferring open aneurysm repair for at least 6 months after drug-eluting coronary stent placement or, alternatively, performing EVAR with continuation of dual antiplatelet therapy. Level of recommendation 2 (Weak), Quality of evidence B (Moderate)
In patients with a drug-eluting coronary stent requiring open aneurysm repair, we recommend 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. Level of recommendation 1 (Strong), Quality of evidence B (Moderate)
We suggest continuation of beta blocker therapy during the perioperative period if it is part of an established medical regimen. Level of recommendation 2 (Weak), Quality of evidence B (Moderate)
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), we suggest initiation well in advance of surgery to allow sufficient time to assess safety and tolerability. Level of recommendation 2 (Weak), Quality of evidence B (Moderate)
We suggest 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. Level of recommendation 2 (Weak), Quality of evidence C (Low)
We recommend smoking cessation for at least 2 weeks before aneurysm repair. Level of recommendation 1 (Strong), Quality of evidence C (Low)
We suggest 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. Level of recommendation 2 (Weak), Quality of evidence C (Low)
We suggest 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. Level of recommendation 2 (Weak), Quality of evidence C (Low)
We recommend preoperative hydration in nondialysisdependent patients with renal insufficiency before aneurysm repair. Level of recommendation 1 (Strong), Quality of evidence A (High)
We recommend preprocedure and postprocedure hydration with normal saline or 5% dextrose/sodium bicarbonate for patients at increased risk of contrast-induced nephropathy (CIN) undergoing EVAR. Level of recommendation 1 (Strong) Quality of evidence A (High)
We recommend holding metformin at the time of administration of contrast material among patients with an estimated glomerular filtration rate (eGFR) of <60 mL/min or up to 48 hours before administration of contrast material if the eGFR is <45 mL/min. Level of recommendation 1 (Strong), Quality of evidence C (Low)
We recommend restarting metformin no sooner than 48 hours after administration of contrast material as long as renal function has remained stable (<25% increase in creatinine concentration above baseline). Level of recommendation 1 (Strong), Quality of evidence C (Low)
We recommend perioperative transfusion of packed red blood cells if the hemoglobin level is <7 g/dL. Level of recommendation 1 (Strong), Quality of evidence B (Moderate)
We suggest hematologic assessment if the preoperative platelet count is <150,000/mL. Level of recommendation 2 (Weak), Quality of evidence C (Low)