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Managementofasymptomaticabdominalaorticaneurysm
Authors: RonaldLDalman,MD,MatthewMell,MD,FACS
SectionEditors: JosephLMills,Sr,MD,JohnFEidt,MD,EmileRMohlerIII,MD,DenisLClement,MD,PhD
DeputyEditor: KathrynACollins,MD,PhD,FACS

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Dec2016.|Thistopiclastupdated:Nov10,2016.
INTRODUCTIONAbdominalaorticaneurysm(AAA)isacommonandpotentiallylifethreateningcondition.
Withoutrepair,rupturedAAAisnearlyuniformlyfatal.Ofthe50percentofpatientswithrupturedAAAwho
reachthehospitalfortreatment,between30and50percentwilldieinthehospital[1,2].
Forasymptomaticpatients,electiverepairoftheaneurysmisthemosteffectivemanagementtoprevent
rupture.However,electiveaorticsurgeryisalsoassociatedwithrisks,andthus,electiveAAArepairisnot
recommendeduntiltheriskofruptureexceedstherisksassociatedwithrepair.Forasymptomaticpatients,
theriskofAAArupturegenerallyexceedstheriskassociatedwithelectiveAAArepairwhenaneurysm
diameterexceeds5.5cm[3,4].Otherfactorssuchasthepatient'sage,rateofaneurysmexpansion,andthe
presenceofcoexistentperipheralarterydiseaseorperipheralaneurysmarealsoimportanttoconsiderwhen
determiningwhentoproceedwithelectiveAAArepair.
ForpatientswithasymptomaticAAAwhodonothaveindicationsforelectiverepair,medicaltreatmentis
aimedatreducingcardiovascularriskintheeventthatAAArepairisneeded,andlimitingtherateofaortic
expansion.WhenelectiveAAArepairisindicated,thechoicebetweenopenandendovascularAAArepair
remainsdebated.AlthoughelectiveendovascularAAArepairisassociatedwithlowerratesofperioperative
(30day)morbidityandmortalitycomparedwithelectiveopenrepair(<2versusapproximately5percent),
longtermoutcomesaresimilar[5].
ThemanagementofthepatientwithasymptomaticAAAwillbereviewedhere.Theclinicalfeaturesand
issuesrelatedtodiagnosisandscreening,managementofsymptomatic(nonruptured)andrupturedAAA,
anddetailsofsurgicalandendovascularrepairarediscussedelsewhere.(See"Screeningforabdominal
aorticaneurysm"and"Epidemiology,riskfactors,pathogenesisandnaturalhistoryofabdominalaortic
aneurysm"and"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm"and"Managementof
symptomatic(nonruptured)andrupturedabdominalaorticaneurysm"and"Endovascularrepairofabdominal
aorticaneurysm"and"Opensurgicalrepairofabdominalaorticaneurysm"and"Surgicalandendovascular
repairofrupturedabdominalaorticaneurysm".)
ANEURYSMTERMINOLOGY
AneurysmdefinitionAnabdominalaortawithamaximaldiameter>3.0cmisconsideredaneurysmalin
mostadultpatients[3,4,6].Abdominalaorticaneurysm(AAA)mostoftenaffectsthesegmentofaorta
betweentherenalandinferiormesentericarteries(infrarenal)(figure1)approximately5percentinvolvethe
renal(pararenal)(image1)orvisceralarteries(suprarenal)[7].(See"Clinicalfeaturesanddiagnosisof
abdominalaorticaneurysm",sectionon'Aneurysmdefinitionandanatomy'.)
Forthepurposesofthisdiscussion:
Smallaneurysmshaveadiameter<4.0cm
Mediumaneurysmshaveadiameterbetween4.0and5.5cm
Largeaneurysmshaveadiameter5.5cm
Verylargeaneurysmshaveadiameter6.0cm
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Rapidexpansion,whichisthoughttoincreasetheriskforrupture,isdefinedasanincreaseinmaximalaortic
diameter5mmoverasixmonthperiodoftimeor>10mmoverayear,usingthesameradiographicmethod
ofmeasurement[4].(See"Epidemiology,riskfactors,pathogenesisandnaturalhistoryofabdominalaortic
aneurysm",sectionon'ExpansionandruptureofAAA'.)
ClinicalpresentationsMostAAAsdonotproduceanysymptoms.AnoccultAAAmaybediscoveredasa
resultofscreening,onroutinephysicalexamination,oronimagingstudiesobtainedtoevaluateanunrelated
condition.SymptomaticAAAreferstoanyofanumberofsymptoms(eg,abdominalpain,limbischemia)that
canbeattributedtotheaneurysm.SymptomsassociatedwithAAAmayormaynotbeduetoAAArupture.
TheclinicalfeaturesanddiagnosisofAAA,andthemanagementofsymptomatic(nonruptured)andruptured
AAAarediscussedindetailelsewhere.(See"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm"
and"Managementofsymptomatic(nonruptured)andrupturedabdominalaorticaneurysm",sectionon'Initial
management'.)
ANEURYSMREPAIRVERSUSCONSERVATIVEMANAGEMENTElectiveabdominalaorticaneurysm
(AAA)repairisthemosteffectivemanagementtopreventrupture.However,electiveaorticsurgeryis
associatedwithrisks,andthus,electiveAAArepairisnotrecommendeduntiltheriskofruptureexceedsthe
risksassociatedwithrepair(anestheticrisk,techniquerelatedrisks)[5].Forasymptomaticpatients,
randomizedtrialscomparingobservationwithopenorendovascularAAArepairhavefoundthattheriskof
AAArupturegenerallydoesnotexceedtheriskassociatedwithelectiveAAArepairuntilaneurysmdiameter
exceeds5.5cm[812].WeagreewithguidelinesfromtheSocietyforVascularSurgerythatrecommend
observationforasymptomaticAAA<5.5cmindiameterbaseduponthesetrials[5].(See'Aneurysmdiameter
andrupturerisk'below.)
ThetimingofAAArepairmaybeaffectedbyotherfactorssuchasthepresenceofcoexistentperipheral
arterydiseaseorperipheralaneurysm(eg,iliacaneurysm,femoralaneurysm)andotherfactorsthatincrease
theriskofrupture,includingadvancedageandrapidaneurysmexpansion.(See'Otherconsiderations'
below.)
AlthoughrepairmaynotbewarrantedinpatientswithAAAdiameter<5.5cm,thesepatientsremainatriskfor
aneurysmexpansion.Assuch,managementconsistsofongoingclinicalevaluationandAAAsurveillance,and
riskmodification.(See'Conservativemanagement'below.)
AneurysmdiameterandruptureriskAneurysmdiameteristhestrongestpredictorofaneurysmrupture,
withriskincreasingmarkedlyataneurysmdiametersgreaterthan5.5cm(figure2)[8,1320].Sinceitis
uncommonforAAAssmallerthan5cmtorupture,manyvascularsurgeonsadoptedthismeasurementasan
indicationforelectiverepair[21,22].Asanexample,inonesystematicreviewthatincluded21studiesof
patientswithAAAalsoreportingAAAoutcomes,37of2323(1.6percent)withsmallAAAwentontorupture
[23].
Largeraneurysmdiameterandfasterrateofaneurysmexpansioncorrelatetoanincreasedlikelihoodof
symptomsandcomplications.Ruptureisthemostfearedcomplication,andisassociatedwithhighmorbidity
andmortality.OtherrarecomplicationsofAAAincludeaneurysmthrombosisandthromboembolism,which
canleadtoacutelimbischemia.(See"Managementofsymptomatic(nonruptured)andrupturedabdominal
aorticaneurysm"and"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm",sectionon'Risk
factors'.)
RandomizedtrialsBaseduponobservationalstudiesofthenaturalhistoryofAAAshowingthatitwas
uncommonforasymptomaticAAAsmallerthan5cmtorupture,thiswasthetraditionalthresholdabovewhich
openaneurysmrepairwasperformed[22,24].Whetherthisrepresentedoptimalmanagementwasaddressed
inrandomizedtrialscomparinganeurysmrepairwithnonoperativemanagementplussurveillanceimagingfor
mediumsizedaneurysms(4.0to5.5cm),withtwotrialsusingopenAAArepair[8,9],andthreelatertrials
usingendovascularaneurysmrepair[1012,25,26].Independentmetaanalysesofthesetrialshavefoundno
advantagetoearlyrepair(openorendovascular)forAAAmeasuring4.0to5.5cm[27].
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ObservationversusopenrepairIntheUnitedKingdom(UK)SmallAneurysmand(US)Aneurysm
DetectionandManagement(ADAM)trials,whichwerepredominantlycomposedofmen,theriskofdeathdue
toruptureduringtheperiodofsurveillanceofmediumsized(4.0to4.4cm)AAAwaslowerthantheriskof
deathfromopenAAArepair[8,9].Alateranalysispooledresultsfrombothtrialsandfoundnodifferencesin
survivalbetweenimmediateopenrepairandsurveillance(2.6to8yearfollowup)foranydiameterinthe
rangeof4to5.5cm,formenorwomen,orforanyage[28].Asubsequentmetaanalysisin2007ofthese
trialsfoundnosignificantdifferencesinallcausemortalitybetweenthegroupsatfivetoeightyearsfollowup
[29].
Theimportantpointsofthesetrialsaresummarized:
UKSmallAneurysmtrialTheUKSmallAneurysmtrialrandomlyassigned1090patients(83percent
men)withasymptomaticAAAwithadiameterof4.0to5.5cmtoelectivesurgeryorobservationwith
ultrasoundsurveillanceeverysixmonths[8,30].Opensurgicalrepairwasperformediftheaneurysm
diameterexceeded5.5cm,expandedmorethan10mminayear,orbecametenderorsymptomatic.
Thetwogroupshadsimilarcardiovascularriskfactorsatbaseline.Afterameanfollowupofeightyears,
thefollowingfindingswerenoted:
Aninitialsurvivaladvantagewasapparentforpatientsintheobservationgroupbecauseofa30day
operativemortalityof5.4percent.However,ateightyearsfollowup,mortalitywassignificantlylower
forpatientswhounderwentelectivesurgery(43versus48percent).Equipoisebetweenthe
therapieswasachievedatapproximatelyfiveyears(figure3)(thepointatwhichtheareaunderthe
survivalcurveisequal).
Themeandurationofsurvivalwasthesameinthetwogroups(6.7versus6.5years)sinceearly
mortalitywasoffsetbyimprovedlatesurvivalinthegroupthatunderwentsurgery.Theauthors
ascribetheimprovedlatesurvivalinthesurgerygrouptobeneficialchangesinlifestyle,particularly
smokingcessation,whichwasmorefrequentinthisgroup.
Duringfollowupofthesurveillancegroup,themediananeurysmgrowthratewas3.3mmperyear
andthemeanriskofaneurysmrupturewas1.6percentperyearduringtheinitialfollowupperiod,
butincreasedto3.2percentperyearduringthelastthreeyearsoffollowup,asexpected,sincethe
aneurysmsundersurveillancewerelargerduringthislatertimeperiod.
TheriskofAAArupturewasfourtimeshigherinwomencomparedwithmen(hazardratio[HR]4.0,
95%CI2.07.9).Theincidenceoffatalrupturewasalsosignificantlygreaterforwomencompared
withmen(19versus14percent).(See'Femalegender'below.)
ADAMtrialTheAneurysmDetectionandManagement(ADAM)Trialrandomlyassigned1136patients
(over99percentmale),aged50to79yearswithAAAdiameterbetween4.0to5.4cmtoopenaneurysm
repairorsurveillance[9].Electivesurgerywasperformedwhentheaneurysmexpandedto>5.5cmor
becamesymptomatic.Operativemortalityinthistrialwas2.7percent.After4.9yearsoffollowup,there
werenodifferencesinmortality(25versus21.5percent)oraneurysmrelateddeath(3versus2.6
percent)betweenthesurgeryandsurveillancegroups.Inthesurveillancearm,62percentofthepatients
eventuallyrequiredsurgery.AAAruptureoccurredin1.9percent(0.6percentperyear).
ObservationversusendovascularrepairTheUKSmallAneurysmTrialandtheADAMtrialwere
performedpriortothewidespreaduseofendovascularaneurysmrepair(EVAR).TwotrialscomparingEVAR
toobservationforAAA<5.5cmsimilarlyfoundnosignificantlongtermdifferencesbetweenAAArepairand
nonoperativemanagement,andthesestudieslendfurthersupporttothe5.5cmthresholdestablishedfrom
earlierrandomizedtrials[10,11,25,26].InspiteofthelowerperioperativemortalityrateassociatedwithEVAR,
thereappearstobenoadvantagetoelectiveEVARrepairforsmallandmediumsizedaneurysms.
OtherconsiderationsAdecisionforelectiverepairofasymptomaticAAAreliesprimarilyondetermining
ruptureriskbaseduponaneurysmdiameter>5.5cm.However,thediameterthresholdforrepairisnot
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absolute.DecidingwhentoperformelectiveAAArepairshouldalsotakeintoaccountthenaturalhistoryof
AAAandfactorsthatincreasetheriskforaneurysmexpansionorrupturesuchasadvancedage,female
gender,andongoingsmoking,aswellasexpansionrates.TimingofAAArepairmayalsobeaffectedby
coexistentvasculardiseaseorotherperipheralarteryaneurysms.TheriskfactorsassociatedwithAAA
expansionandrupturearediscussedindetailelsewhere.(See"Epidemiology,riskfactors,pathogenesisand
naturalhistoryofabdominalaorticaneurysm",sectionon'ExpansionandruptureofAAA'.)
Somestudieshavealsoidentifieddisparitiesinruptureratesbaseduponinsurancestatus[31,32].Differences
aremultifactorial,butcanbeexplainedinpartbylowersurveillanceratesforpatientswithknownAAAfor
patientseligibleforMedicaidinsurance.Thisfindinghighlightstheneedforandvalueofsurveillanceforall
patientswithAAAthatdoesnotmeetcriteriaforoperativerepair,preferablyusingastandardizedprotocol.
(See'Aneurysmsurveillance'below.)
FemalegenderTherandomizedtrialsdiscussedabovewerecomprisedpredominatelyofmen.For
women,alowerthresholdof5cmmaybejustifiedforelectiverepairofasymptomaticAAAduetothehigher
rateofruptureinwomencomparedwithmenforAAAofthesamediameter[8,33].Inanobservationalstudy,
theaorticsizeindex(ASI=aneurysmdiameter[cm]/bodysurfacearea[m2])wasmorepredictiveofrupture
forwomenratherthanaorticdiameteralone[34].However,becausetheriskofdeathfromelectiverepairis
alsoincreasedinwomen,inpartrelatedtoalaterageatpresentation,itcanbearguedthatthethresholdfor
repairforwomenshouldbethesameasformen,at5.5cm[3537].Womenathighriskformortalitywith
AAArepairaremorelikelytodiefromearlyinterventionthanfromrupture.Supportforthisviewcomesfroma
followupstudythatcomparedsurvivaldifferencesbetweenthosewithAAA4.0to5.4cmundergoing
immediateopenrepairversussurveillanceamongparticipantsoftheUKSmallAneurysmTrialandtheADAM
trials(n=2226)[38].Survivalwassimilarforbothwomenandmenindependentoftreatment(openrepairor
surveillance).Survivalforwomenwasalsosimilarforrelativelylarger(5.0to5.4cm)versussmaller(<4.0to5
cm)aneurysms.
Conversely,womenatlowriskformortalitywithrepairappeartohavealoweroverallriskofAAArelated
deathfollowingrepairwhentheaneurysmreachesorexceeds5cm.Areasonablecompromisemaybeto
offerAAArepairtowomenwhoareatlowoperativeriskatthelowerthresholdof5.0cm,whileusingthe
typicalthresholdforwomenwhohaveahigheroperativerisk.
PatientageYoungerpatientswithAAAwithalonglifeexpectancywilllikelyrequirerepairatsome
pointintheirlives[8].Thelikelihoodofreceivingsurgeryatsomepointinthefutureformediumsized
aneurysms(4.0to5.5cm),is50percentatthreeyears,60to65percentatfiveyears,and70to75percent
ateightyears(figure4)[8,9,29,30,39].
Amongolderpatients,endovascularrepairisassociatedwithanearlysurvivaladvantagethatgradually
decreasesovertime.OverallfiveyearsurvivalfollowingAAArepairwas69percentinonesystematicreview,
withagecorrelatingwithworsesurvival[40].Apropensityscorematchedcohortstudyinvolving39,966
matchedpairsofUnitedStatesMedicarebeneficiaries(>65yearsofage)foundnosignificantlongterm
survivaladvantageforendovascularrepaireventhoughperioperative(30day)mortalitywassignificantly
lowerforendovascularcomparedwithopenrepair(1.6versus5.2percent)[41].Thesurvivaladvantagefor
EVARlastedonlythroughthefirstthreeyearsoffollowup.
AlthoughsmallcaseserieshavedocumentedacceptableoutcomesforEVARincarefullyselected
octogenariansandnonagenarians[4246],continuedobservationmaybewarrantedforAAAthatexceeds5.5
cminolderpatients,particularlyamongthosewhoarefrailforwhomalongtermbenefitisunlikely[47].
Thosewithmedicalcomorbiditiesoftendiefromassociatedillnesses.(See'Counselingthehighriskpatient'
below.)
RapidexpansionEarlierrepairmaybenefitpatientswithwelldocumentedrapidaneurysmexpansion
(>5mminsixmonthsor10mmperyear)onserialimagingstudiesperformedbythesamemodality[8].
SomedatasuggestthatrapidlyexpandingAAAsaremorelikelytohavesymptomsandhaveahigherriskof
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rupture.Rapidexpansionmayrepresentinstabilityoftheaorticwallandmaybeasignofimpendingaortic
rupture.(See"Clinicalfeaturesanddiagnosisofabdominalaorticaneurysm",sectionon'Riskfactors'.)
CoexistentaneurysmorPADRepairofAAAwithadiameterthathasnotexceededthethresholdof
5.5cmmaybereasonableinpatientswithotherassociatedarterialdiseasessuchasaneurysmaldiseaseof
theiliac,femoral,orpoplitealarteries,orsymptomaticcoexistentaortoiliacocclusivearterialdisease.Itis
importanttonotethataneurysmexpansiontendstobelessrapidinpatientswithperipheralarterydiseaseor
diabetesmellitus[9,48].(See"Poplitealarteryaneurysm"and"Iliacarteryaneurysm".)
Repairofsuprarenaland/orthoracoabdominalaneurysmsinvolvesmoreextensivesurgeryandgreater
operativerisk.Forthisreason,andconsideringthatthenormaldiameteroftheproximalaortaislarger,repair
ofsuchaneurysmsistypicallynotundertakenuntiltheaorticdiameterhasexceeded5.5to6.0cm.(See
"Managementofthoracicaorticaneurysminadults".)
VerylargeaneurysmMostpatientswithasymptomaticAAAcanbemanagedonanoutpatientbasis.
However,onoccasion,apatientwillpresentclinicallywithaverylarge(6.0cmindiameter)asymptomatic
AAAthatmaywarrantadmissionandinpatientevaluation.
Althoughtherearenodatatoassistwithclinicalmanagementofverylarge,asymptomaticAAAorany
uniformlyacceptedstandardsofcare,wesuggestimmediatereferraltoavascularsurgeonbecauseofthe
highriskforrupture.Wesuggestearlierratherthanlateraneurysmrepaironceappropriatepreoperative
studies,medicalriskassessment,andassessmentofaortoiliacanatomyarecompleted.Thereisno
advantagetoanexcessivedelay.Forpatientsfoundtohaveaverylarge,asymptomaticAAAinapractice
settingthatdoesnothavevascularexpertise,wesuggestreferraltoavascularcenterinatimelymanner.
Verylarge,asymptomaticAAAhasanestimatedruptureriskovera12monthperiodof10to20percentfor
thosebetween6and7cm,20to40percentforthose7to8cmand30to50percentforthoselargerthan8
cm.Theruptureriskoveraperiodofweeksormonthsduringtheinterveningperiodfromthetimeofinitial
diagnosisanddefinitivetreatmentisnotknown.Rupturecanoccurduringthisinterval.Becauseofthe
potentialforrupture,somevascularsurgeonsroutinelyadmitpatientswithverylarge,asymptomaticAAAfor
preoperativeevaluation,butthevalidityofthispracticehasnotbeensubstantiated.
Thepatientandhisorherfamilyshouldunderstandtheriskofrupturepriortodefinitiverepairandshouldbe
counseledregardingpotentialsymptomsthatcanbeassociatedwithAAAandencouragedtocommunicate
thedevelopmentofsymptomstothesurgeonandprimarycarephysician.
MEDICALRISKASSESSMENTTheprimarygoalofelectiveAAArepairistopreventruptureand
minimizeaneurysmrelatedmorbidityandmortality.Theassessmentofriskforelectiveaneurysmrepair
versustherisksofobservationshouldincludethepatient'sexpectedsurvivalfromothermedicalconditions.
Repairmaynotbewarrantediftheexpectedmortalityratefromanotherconditionishigherthantheexpected
aneurysmrelatedmortality.
Patientswithcoexistentcoronaryarterydiseaseandcigarettesmokerswithsignificantchronicobstructive
pulmonarydiseasearemorelikelytoexperienceseriousperioperativecomplications(eg,coronaryischemia,
arrhythmias,pneumonia)[49,50].TheriskforperioperativemorbidityandmortalityrelatedtoelectiveAAA
repairisalsoincreasedinolderpatients,femalepatients,andthosewithrenaldysfunction.
PatientsdiagnosedwithAAAhaveanincreasedriskforcardiovasculardisease,andallpatientswithAAA
shouldundergocardiovascularriskassessment[23,51].Thisincreaseinriskwasillustratedinaprospective
studythatidentifiedAAAin8.8percentofpatientsscreenedAAAwas<3.5cmindiameterin88percentof
thepatients[51].Duringa4.5yearfollowupperiod,patientswithAAAhadahigheroverallmortalitythan
thosewithoutAAA(adjustedrisk[RR]1.3,95%CI1.041.67)andanincreasedriskofincidental
cardiovasculardisease(adjustedrisk1.57,95%CI1.182.07).Inasystematicreviewthatincluded21studies
ofpatientswithsmallAAA(<5.5cm)alsoreportingcardiovascularoutcomes(althoughtherewaswide
variabilityindefinitionsused),theprevalenceofischemicheartdiseaseamongthosewithsmallAAAwas45
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percent,27percentformyocardialinfarction,and14percentforstroke[23].(See"Evaluationofcardiacrisk
priortononcardiacsurgery"and"Managementofcardiacriskfornoncardiacsurgery".)
TheprevalenceofsmokinginrandomizedtrialsamongpatientsundergoingAAArepairis24to40percent
[8,5254].Currentsmokersandpatientswithasignificantsmokinghistoryorpulmonarydiseaseshouldbe
evaluatedbaseduponstandardguidelinesforassessingperioperativerisk.Patientswithseverepulmonary
diseasewhoarenotcandidatesforgeneralanesthesiamaybeconsideredforendovascularaneurysmrepair
iftherearenoothercontraindicationsforendovascularrepair.Smokingcessationpriortoelectivesurgeryis
discussedindetailelsewhere.(See"Evaluationofpreoperativepulmonaryrisk"and"Strategiestoreduce
postoperativepulmonarycomplicationsinadults",sectionon'Smokingcessation'.)
RenalfailureisuncommonafterAAArepair.Onestudyidentifiedsixriskfactorsassociatedwithrenalfailure
(definedasarequirementofpostoperativerenalreplacementtherapy)followingopenAAArepair[55].These
includedpreoperativecreatinine>1.7mg/dL,age>75years,symptomaticAAA,AAArupture,treated
hypertension,andpulmonarydisease.Preoperativerenaldysfunctionwasthestrongestpredictorof
postoperativerenalfailure.InastudythatevaluateddatafromtheUKEVARtrials,theredidnotappeartobe
anysignificantlongtermdifferenceinrenalfunctioncomparingendovascularwithopenAAArepair[56].
CONSERVATIVEMANAGEMENTOnlyasmallproportionofpatientsdiagnosedwithabdominalaortic
aneurysm(AAA)meetthecriteriaforinterventionatthetimeoftheinitialdiagnosis.Basedupontheresultof
randomizedtrials,patientswithAAA<5.5cmindiametershouldbemanagedconservatively.However,the
naturalhistoryofAAAisoneofprogressiveexpansionnecessitatingperiodicclinicalevaluationand
surveillanceofaneurysmdiametertoidentifyAAAthatexceedsthethresholdforrepairorisrapidly
expanding[57].
MedicaltherapiesforAAAfocusonthemanagementofmodifiableriskfactorsforAAAandcardiovascular
diseasewiththegoalsofreducingtheneedforinterventionduetoaneurysmexpansionorrupture,reducing
morbidityandmortalityassociatedwithrepair,andreducingcardiovascularmorbidityandmortality[58,59].
AlthoughmanypharmacologictherapiesaimedatlimitingAAAexpansionandpreventingrupturehavebeen
investigated,nopharmacologictherapyhasbeenprovensuccessfulatachievingthesegoals,andassuch,
wesuggestnotimplementinganyofthepharmacologictherapiesdiscussedbelowforthesolepurposeof
treatingAAA.However,amongthefactorsassociatedwithAAAexpansionandrupture,smokingisthemost
importantmodifiableriskfactorandwerecommendsmokingcessationforallpatientswithAAA.Although
reducedaneurysmexpansionandruptureriskhavenotbeenclearlydemonstratedamongthosewhohave
stoppedsmoking,smokingcessationhasotherbenefits.Inaddition,becauseAAAisregardedasacoronary
riskequivalent,weagreewithmajorsocietyguidelinesthatrecommendaspirin(ASA)andstatintherapyfor
patientswithAAAtoreducetheriskofafuturecardiovascularevent,unlesscontraindicated[4,5].Other
medicalconditionsshouldbetreatedasappropriate(eg,hypertension).
CardiovascularriskreductionCurrentmultidisciplinaryguidelinesregardAAAasacoronaryheart
diseaseequivalentandrecommendmedicaltherapy(antiplatelettherapy,statintherapy,antihypertensive
therapy)toreducecardiovascularrisk,unlesscontraindicated[4].Thereisnoevidencetosuggestthataspirin
therapycontributesinanywaytoinitiatingAAAexpansionorrupture.Thesetherapiesalsodonotappearto
significantlyreduceratesofAAAexpansion[60].(See'Therapiestolimitaorticexpansion'belowand
"Preventionofcardiovasculardiseaseeventsinthosewithestablisheddiseaseorathighrisk".)
Inastudythatincludedover12,000patientswithadiagnosisofAAA,thepercentageuseofmedicationsto
managecardiovascularriskincreasedfrom2000to2012(from26to77percentforstatins,56to74percent
forantiplateletagents,and75to84percentforantihypertensivedrugs)[61].OnKaplanMeieranalysis,five
yearsurvivalimprovedforpatientsreceivingversusnotreceivingeachtherapy(68versus42percentfor
statins,64versus40percentforantiplateletagents,and62versus39percentforantihypertensiveagents).
ManagingcardiovascularriskisalsoimportantforimprovingoveralloutcomesassociatedwithAAArepair
(opensurgicalorendovascularrepair)giventhatapproximatelyonehalfofpatientswithsmallAAAwhoare
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beingconservativelymanagedwilleventuallyundergoAAArepair[4,62].Asystematicreviewofstatinusein
patientswithAAAfoundasignificantlydecreasedriskofallcausemortalityatfiveyearsfollowingAAArepair
forthoseonstatinscomparedwithnostatintherapy(oddsratio[OR]0.57,95%CI0.420.79)[60].
Perioperative(30day)mortalitywasnotsignificantlydifferent.Otherstudieshavesimilarlyfoundabenefitfor
statintherapyforpatientswithAAA[6375].
Patientswithhypertensionshouldbeevaluatedandtreatedtorecommendedbloodpressuregoals.No
specificantihypertensivetherapyhas,thusfar,beenshowntoalterthenaturalhistoryofAAA.Whenever
possible,patientsshouldavoidbloodpressurespikes.(See"Overviewofhypertensioninadults"and"Whatis
goalbloodpressureinthetreatmentofhypertension?"and'UncertainbenefitforlimitingAAAexpansion'
belowand'Exercise'below.)
TherapiestolimitaorticexpansionThelikelihoodthatananeurysmwillexpandorruptureisinfluenced
byanumberoffactors,includinganeurysmdiameter,rateofexpansion,gender,ongoingsmoking,recent
surgery,andothermedicalfactors[76,77].Theseriskfactorsarediscussedelsewhere.(See"Epidemiology,
riskfactors,pathogenesisandnaturalhistoryofabdominalaorticaneurysm",sectionon'Expansionand
ruptureofAAA'.)
AnumberofdrugtargetsthatmayinhibitAAAformationorprogressionhavebeenidentifiedinanimalmodels
andinvitrostudies.Thesestudieshavegeneratedmuchinterestforthetreatmentofpatientswithsmall
aneurysmshowever,todate,thereisnoprovenevidencethatanyofthesetargetsunequivocallyprevents
aorticexpansionandrupture[7882].Amulticenterstudythatidentified5362patientswithAAAfoundno
significantassociationbetweenAAAprogressionandusageofstatins,betablockers,angiotensinconverting
enzymeinhibitors,orangiotensinIIreceptorblockers[83].
Potentiallybeneficialtherapies
SmokingcessationCigarettesmokingistheriskfactormoststronglyassociatedwithaneurysm
formation,aneurysmexpansion,andaneurysmrupture,andisthemostimportantmodifiableriskfactorin
patientswithAAA[48,59,77,8486].Weagreewiththemultidisciplinaryguidelinessuggestingthatindividuals
diagnosedwithAAAandthosewhohaveafamilyhistoryofAAAbeadvisedtostopsmokingandoffered
cessationinterventions[4,5,87].Smokingcessationhasmanyotherbenefits.Themanagementofsmoking
cessationisdiscussedindetailelsewhere.(See"Benefitsandrisksofsmokingcessation"and"Overviewof
smokingcessationmanagementinadults".)
Smokingcessationispresumedtoprovideabenefitbyreducingtheharmfuleffectsofsmokinginmediating
connectivetissuedegradation,althoughthishasnotbeenproven[88].Withsmokingcessation,theriskof
developingAAAslowlydeclinesovertime[77,85],buttheeffectofsmokingcessationonAAAthatisalready
formedisunknown.TherearenocontrolledtrialsofsmokingcessationinpatientswithAAA,anditisunlikely
thatanysuchstudieswilleverbeperformed.However,formersmokersundergoingAAArepairhavelower
ratesofaneurysmrelatedmortalityandallcausemortalitycomparedwithcurrentsmokers,suggestingthe
importanceofsmokingcessation[89,90].SmokingcessationforatleasttwomonthspriortoAAArepairwas
foundinoneprospectivestudytosignificantlyreducetheincidenceofpostoperativerespiratorycomplications
(57versus15percent)[91].
ExerciseItiswidelyacceptedthathigherlevelsofphysicalactivityareassociatedwithalowerriskof
cardiovascularmorbidityanddeath.WeagreethatpatientswithAAAshouldparticipateinanexercise
programforsecondarypreventionofcardiovasculardisease.Patientsshouldbecounseledthatmoderate
physicalactivitysuchasrunning,biking,swimming,hiking,orsexualactivityandactivitiessuchasgardening,
golfing,andhorsebackridingdonotprecipitateAAArupture[92].However,heavylifting,especiallywhile
holdingthebreath,andotheractivitiesthatleadtoValsalva,transientlyinducesignificantincreasesinblood
pressureandshouldbeavoided.
Moderatephysicaltherapymayalsolimitaneurysmexpansion[93].Inexperimentalaneurysms,increased
aorticbloodflowappearstoinhibitAAAexpansion[94].MagneticresonanceimaginginpatientswithAAA
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whohaveexercisedhasdemonstratedincreasedabdominalaorticbloodflow[95],andthus,exercisemay
havethepotentialtolimitAAAexpansioninhumansaswell.Althoughtheexactmechanismsremaintobe
determined,exercisereducesthelevelsofsystemicmarkersofinflammationrelevanttoAAAs.Onetrialthat
randomlyassigned140patientswithAAA<5.5cmfoundnosignificanteffectofanexerciseprogramonAAA
expansionratesoveranaverageof23months[96,97].Thereweremarkedimprovementsinexercise
capacityinthetraininggroup,andtherewasamodestinverseassociationbetweenthechangeinexercise
capacityandchangeinAAAdiameter.(See"Exerciseandfitnessinthepreventionofcardiovasculardisease"
and"Thebenefitsandrisksofexercise".)
UncertainbenefitforlimitingAAAexpansion
BetablockertherapyBetablockershavearoleinmanagingpatientswithcardiovasculardisease,
buttheyhavenotbeenclearlyshowntoreduceaneurysmexpansionrates[98].(See"Managementof
cardiacriskfornoncardiacsurgery",sectionon'Betablockers'.)
AnumberofearlyanimalstudiesandretrospectivereviewssuggestedthatbetablockersmayinhibitAAA
expansion[98101].Onestudyevaluated121patientswithaninfrarenalaorticaneurysmwhoweremonitored
byserialultrasoundexamination38ofthepatientsweretreatedwithabetablocker[99].Themean
expansionratewassignificantlylowerinthepatientsreceivingabetablocker(0.36versus0.68cmperyear).
However,twolargetrialsfoundnosignificantdifferencesinAAAexpansionratesinpatientsreceivingbeta
blockerscomparedwiththosewhodidnot[98,102].Thelackofbenefitmayhavebeenrelatedtopoor
complianceduetothesideeffectsofbetablockadethatmeasurablydiminishedqualityoflife.Althoughthese
studiesdidnotshowabenefitforpropranololinlimitingAAAexpansion,theydonotexcludethepossibility
thatabettertoleratedselectivebetaadrenergicblockercouldbebeneficial.
ARBsandACEinhibitorsAlthoughanimalstudieshavesuggestedtheutilityofangiotensin
receptorblockersorangiotensinconvertingenzyme(ACE)inhibitorsindecreasingtherateofaneurysm
expansion[103,104],theclinicaluseoftheseagentshasnotclearlydemonstratedthesamebenefits.Infusion
ofangiotensinIIintorodentspromotesAAAformation,whichisthoughttobeduetoaorticinflammationand
proteolysisandnotduetothesecondaryincreaseinbloodpressure[105107].Angiotensintype1receptor
blockade(ARB)usually[108113],butnotalways[109],inhibitsaneurysmdevelopmentinvariousanimal
modelssuchasAAAsinducedbyangiotensinII,AAAsinducedbychemicalagents,andAAAsinmice
geneticallypredisposedtoaneurysm.ACEinhibitorsarenotreliableforinhibitingexperimentalAAA
development[108,109,114].
AnumberofclinicalstudieshaveassociatedreducedratesofAAAexpansionorrupturewiththeuseofACE
inhibitorsandARBs[115117].Twotrialsareongoing[118120].Astudyof15,326patientswhopresented
withAAA(intactorruptured)evaluatedtheprehospitaluseofACEinhibitors[115].PatientstakingACE
inhibitorsweresignificantlylesslikelytopresentwithrupturedaneurysmcomparedwiththosewhowerenot
onACEinhibitors(OR0.82,95%CI0.740.90).Bycontrast,areportfromtheUnitedKingdomSmallAAA
studyfoundanincreasedriskofAAAexpansionforpatientsonACEinhibitors[117].
OtherantihypertensivesagentsDiureticsandcalciumchannelblockershavealsobeenstudiedfor
theireffectsonAAAexpansion.Althoughatrendtowardlowerexpansionrateshasbeenobservedfor
calciumchannelblockers,significantdifferenceshavenotbeenseen[48].Diureticsappeartohavenoimpact
onexpansionrates.
StatintherapyThepathogenesisofAAAinvolvesdiminishedintegrityofthearterialwalldrivenby
localinflammation,analteredbalanceinarterialwallrepair,anddegradationbyenzymessuchasmatrix
metalloproteinases(MMPs)[121].StatinsreducetheexpressionofMMPsinaconcentrationdependent
manner,independentoftheircholesterolloweringeffects[122,123].
AnimalstudiessuggestthatstatinsmaylimitAAAexpansion[124129].However,theinfluenceofstatinsfor
inhibitingatherosclerosismayberelativelygreater[128].Norandomizedtrialshavespecificallyassessedthe
effectofstatinsonAAAexpansionorrupture.Anumberofobservationalstudieshaveexaminedtheeffectof
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statintherapyontheexpansionofsmallAAAs[64,75,116,117,119,130134].Earlystudiesreportedreduced
ratesofAAAexpansioninpatientstreatedwithstatins[64,75,119,132134]however,mostlargerstudies
havenotconfirmedarelationship[116,117,131,135,136].IntheTrmsostudy,statintherapywasassociated
withanincreasedriskofdevelopingAAA(OR3.8,95%CI1.459.81)[84].However,inapopulationbased
casecontrolstudythatincluded7168patients,adecreasedriskforAAArupturewasfoundforcurrentstatin
userscomparedwithneverusers(OR0.70,95%CI0.610.95),ariskdifferencethatpersistedafter
adjustmentforconfoundingfactors[130].However,multiplemetaanalysesfoundnoevidencethatstatins
impactAAAexpansionratebutdidobserveasurvivalbenefitforthoseonstatins[60,137].Thus,although
thereisinsufficientevidencetorecommendtheinitiationofstatintherapysolelyforthetreatmentofAAAs
[58],statintherapyshouldbeconsideredforpatientswithAAAtoreduceoverallcardiovascularrisk.
AntibiotictherapyAntibiotictherapyhasalsobeenevaluatedforitspotentialeffectonAAA
expansion.Itwasinitiallypostulatedthataneurysmprogressionmaybeenhancedbysecondarymicrobial
infectionwithintheaorticwall.SerologicevidenceofChlamydiapneumoniaeinfectionwasassociatedwithan
increasedrateofAAAexpansion[138],andtwosmalltrialssuggestedthatroxithromycinmaydecreaseAAA
expansionrates[139,140].Althoughinfectionisknowntopotentiallyleadtotheformationofaneurysms,clear
evidencesupportingaroleforinfectionintheformationandprogressionofthemajorityofAAAs(noninfected)
remainstobeestablished[92].[139]
Inthelate1980s,itwasrecognizedthatthecommonlyusedtetracyclineantibioticsinhibitedmatrix
metalloproteinases(MMPs)invitro[141],andinaneurysmtissue[142,143].MMPsarepostulatedtoplaya
roleinaneurysmformation.Inatleast14separatestudiesinanimalmodels,doxycyclinehasbeenfoundto
inhibitaneurysmdevelopmentandprogression[79,144].Intwoanimalstudies,rapamycinsimilarlyinhibited
experimentallyinducedAAA[145,146].
Inhumans,doxycyclinedecreasesinflammatorymarkersinAAA[147,148],buthasnotbeenfoundto
definitivelyreducetherateofAAAexpansion[149151].ThePHarmaceuticalAneurysmStabilizationTrial
(PHAST)didnotfindareductioningrowthofsmallAAA(3.5to5.0cm)following18monthsofdoxycycline
(100mgdaily)comparedwithplacebo,ratheraneurysmexpansionwasgreaterinthedoxycyclinegroup(4.1
mmversus3.3mm),butthiswasnotconsideredtobeclinicallyrelevant[149].Doxycyclinetreatmentdidnot
influencetheneedfor,ortimingofelectiveAAArepair.Thestudywaslimitedbythehighnumberofpatients
lostfromthestudyduetononadherence,adversetreatmenteffects,orelectiveAAArepair.Nevertheless,
theseresultsmayindicatethatmethodsforgeneratinganeurysmsinanimalsmaybeaninadequatemodelfor
humandisease.AnothertrialisunderwayusingahigherdoseofDoxycycline[150].
AntiplatelettherapyAntiplatelettherapymayinfluencetheformationofthrombuswithinAAAand
reduceprogressioninpatientswithsmallAAA,butadefinitiveassociationbetweenplateletinhibitionand
aneurysmprogressionhasnotbeenidentified[116].
Antiplatelettherapy(aspirin)ispostulatedtodecreasethrombusformation,reduceaorticwallinflammation
andstabilizetheaorticwall[152].ThevolumeofthrombuswithinAAAscorrelatestomaximumAAAdiameter
[153],andcirculatingconcentrationsofthrombindegradationproducts(Ddimer)arestronglyassociatedwith
thepresenceofAAAandprogressioninpatientswithsmallAAAs[154,155].Thrombusfromhuman
infrarenalAAAsalsocontainsinflammatorycells[156,157].Inanimalmodels,plateletinhibitionhasbeen
foundtolimitAAAformation[157,158].Althoughanumberofclinicalstudieshavebeenperformed,
antiplatelettherapyhasnotbeenevaluatedinrandomizedtrials[64,75,116,117,119,131134,152].Inone
study,ASAwasassociatedwithdecreasedratesofprogressionofsmallAAA[152].However,largerstudies
havefoundnosignificantassociationbetweenantiplatelettherapyandAAAexpansion[116,117,131].
AntiinflammatoryagentsAcharacteristichistologicalfeatureofhumanAAAisadense
inflammatoryinfiltratewithavarietyofcellsincludingmacrophages,neutrophilsandlymphocytestypically
present[159,160].

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Elastases(proteases)secretedfromthesecellsdegradethenormalarterialwallarchitecture,and,
particularly,theelasticlamellae.Aorticthrombusalsocontainsneutrophils,andhighconcentrationsof
proinflammatorycytokinesandproteolyticenzymes[156,157].Inhibitionoftheseinflammatorycells
suppressesthedevelopmentofAAAinrodentmodels[161].Anumberofproteaseinhibitorshavebeen
developedasantineoplasticagents,butmosthavesideeffectsthatwouldlimittheiruseinpatientswithAAA
[162].
Mastcells,whichcontainchymaseandotherproinflammatorycytokines,maycontributetoAAAformation
[163].MicethataredeficientinthiscelltypeareprotectedfromexperimentalAAA[164,165].Thesefindings
haveraisedinterestintheuseofmastcellstabilizingagentsinpatientswithsmallAAAs.However,atrialthat
randomized326patientstopemirolastorplacebofoundnosignificantdifferencesinsmallAAA(3.0to4.9
cm)expansionrates(mean2.42mm)overa12monthperiod[166].
SafetyofantiplatelettherapyandAAAItiscurrentlyunknownwhetherASAalonehasasubstantial
effectwithrespecttohemorrhageinassociationwithAAArupture.Theoretically,thrombusformationwouldbe
impededhowever,theretroperitonealstructuresprobablyplayagreaterroleinlimitingtheinitialexpansionof
hematomafollowingAAArupture.Ingeneral,wefeelthatthebeneficialeffectsofASAinreducing
cardiovascularmorbidityandmortalityoutweighthetheoreticrisksofincreasedbleedingwithAAArupture.
CounselingthehighriskpatientAsymptomaticpatientswithAAArepair>5.5cmwhohavemedical
comorbiditiesthatincreasetheirriskforrepair(opensurgicalorendovascular)abovetheexpectedlevelmay
bebestmanagedconservatively,reservingrepaironlyifsymptomsdevelop(includingrupture).(See
"Managementofsymptomatic(nonruptured)andrupturedabdominalaorticaneurysm".)
InadatabasereviewbytheVascularStudyGroupofNewEngland,among1653patientsundergoing
endovascularaneurysmrepair,19percentweredeemedunfittoundergoopenaneurysmrepair[167].
Patientswhowereunfitforopenrepairwereolder,andmorelikelytohavecardiacdiseaseorchronic
obstructivepulmonarydisease.Bycontrast,comparedwiththosedeemedfitforopenAAArepair,patients
deemedunfithadsignificantlyhigherratesofcardiac(7.8versus3.1percent)andpulmonary(3.6versus1.6
percent)complications.Survivalforthosedeemedunfitwassignificantlyworsethanthosedeemedfit(one
yearsurvival93versus96percentthreeyearsurvival73versus89percent,andfiveyearsurvival61versus
80percent).Evenadjustingforage,designationasunfitwasasignificantpredictorofworsefiveyearsurvival
(hazardratio1.6,95%CI1.22.2).InareviewofoutcomesinmenwithscreendetectedlargeAAAdeemed
notfitforrepair,deathoccurredin14/34atamedianof34.9monthsafterdiagnosis,9fromrupturedAAA
[168].Longtermoutcomesforpatientsdeemedunfitforopensurgeryshouldalsobeconsideredwhen
consideringendovascularrepair.(See'Openversusendovascularaneurysmrepair'below.)
Expectedruptureratesforuntreatedpatientsvarydependingonthepopulationstudied,aneurysmdiameter,
andotherriskfactorsforrupture(eg,smoking,chronicobstructivepulmonarydisease,unmanagedmedical
conditions).ThebiologyofAAAmayalsobechanging.Theriskofruptureanddeathhasbeendeclining,in
parallelwithreductionsinpercapitasmoking[169].(See"Epidemiology,riskfactors,pathogenesisand
naturalhistoryofabdominalaorticaneurysm",sectionon'ExpansionandruptureofAAA'.)
Onestudyevaluated198menwithcontraindicationstorepairorrefusal[170].Theoneyearincidenceof
rupture(anddeath)was9.4percentforAAA5.5to5.9cmindiameter,10.2percentforAAA6.0to6.9
cm,and37.5percentforAAA>7.0cm.
Inanotherstudyof72patientswhoweredeemedunfitforAAArepair,mediansurvivalforAAA5.1to
6.0cmwas44monthsand11percentdiedofruptureforAAA6.1and7.0cm,mediansurvivalwas26
monthsand20percentdiedofruptureandforAAA>7cm,survivalwassixmonthsand43percent
ruptured[171].
Inalaterstudythatincluded1514patientswithuntreatedAAA,cumulativeannualrupturerateswere3.5
percentforAAAs5.5to6.0cm,4.1percentforAAAs6.1to7.0cm,and6.3percentforAAAs>7.0cm
[172].
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Longtermsurvivalinhighriskpatientsmaybeunaffectedbyrepair.TheEVAR2(Endovascularrepairof
aorticaneurysminpatientsphysicallyineligibleforopenrepair)trialrandomlyassigned404patientswithAAA
>5.5cmandwhowereaged60yearsoroldertoendovascularaneurysmrepairornointervention[12].The
endovasculargrouphadalowerriskofaneurysmrelatedmortality(adjustedhazardratio0.53,95%CI0.32
0.89)buttherewerenosignificantdifferencesinallcausemortalityHR0.99(95%CI0.781.27)ateightyears
followup.
Decisionmakinginhighriskpatientsisdifficult,butshouldincludeacandiddiscussionwiththepatientandhis
orherfamilymembers.Thisdiscussionshouldincludecounselingthepatienttocreateanadvanceddirective
detailingthepatient'swishesintheeventofrupture.Familymembersshouldbemadeawareofthesewishes,
giventhatthepatientmaynotbeabletoreporthisorherwishesatthetimeofaneurysmrupture.
FollowupPatientswithsmallandmediumsizedAAAandhighriskpatientswhoarebeingmanaged
conservativelyshouldundergoperiodicclinicalevaluationtoevaluateforanysymptomsthatmightberelated
totheaneurysm,andtomonitorbloodpressureandthesuccessofriskreductionstrategies.Amongpatients
identifiedwithsmallAAA(3.6cm),inonestudy,followupwasoverallpoorat65percent[173].Therateof
followupisevenpoorerforthoseidentifiedincidentallyonimagingstudiesperformedforanotherreason
[174].
Forpatientswhoelectnorepairorwhoarenotcandidatesforanytypeofrepair,ongoingevaluationand
surveillanceisnotneeded.(See'Counselingthehighriskpatient'above.)
AneurysmsurveillancePatientswithsmallaneurysmsunderobservationshouldundergoperiodic
imagingtoassessforaorticexpansion,buttheoptimalsurveillanceschedulehasnotbeenclearlydefined
[8,9,30,175,176].Weobtainanannualultrasoundstudyforaneurysms<4.5cmandannualormorefrequent
intervals(eg,everysixmonths)forlargeraneurysmsdependinguponthecharacteristicsoftheaneurysm(eg,
expansionrate).PatientswithknownAAAwhopresentwithrupturehavebeennotedtobemorelikelyto
havegapsintheirsurveillance[173,177].
IntheUnitedKingdomsmallaneurysmstudy,ascheduleforsurveillanceintervalswasdeterminedthat
minimizedthelikelihoodofaneurysmgrowthtogreaterthan5.5cmbetweenscreeningvisits[48].Asmightbe
expected,therecommendedintervalsforsurveillancewereshorterforlargeraneurysmsandlongerfor
smalleraneurysms.Surveillancewasevery3monthsforAAA5.0to5.4cm,every12monthsforAAA4.5to
4.9cm,every24monthsforAAA4.0to4.4cmandevery36monthsforAAA3.5to3.8cm.Inthisstudy,less
frequentsurveillancewasfelttobesafe,andthesuggestedsurveillancescheduleresultedina<1percent
chanceofananeurysmsurpassing5.5cmindiameterbetweenscreeningvisits[178].Theseintervalsare
consistentwiththoseusedintheMulticentreAneurysmScreeningStudy(MASS)[179].Basedlargelyupon
thesestudies,multidisciplinaryguidelinesforthediagnosisandmanagementofperipheralarterydisease
recommendsurveillanceevery6to12monthsusingultrasoundorCTforaneurysms4.0to5.4cmin
diameter,butalessfrequentinterval(everytwotothreeyears)foraneurysms3.0to4.0cmindiameter,and
everyfiveyearsforaorticdiameterbetween2.6to2.9cm[4,5,175].RecommendationsforAAAsurveillance
schedulevarywidelyaroundtheglobe[175].
Morefrequentfollowupandsurveillance(annualultrasoundforAAA<4.5cmormorefrequentforlarger
aneurysm)maybeprudentgiventhelowcostofultrasoundandforthefollowingreasons.
Whentheaneurysmsurveillanceintervalisextendedbeyondayear,theinherentinaccuraciesassociated
withaorticmeasurementsusingultrasoundandCTbecomemorerelevant.Multiplestudiesobtainedover
morefrequentintervalshelpresolveconflictsandaremorelikelytocapturerapidaorticexpansion.
Thereisapotentialforpatientstobelosttofollowupwhenextendedsurveillanceintervalsareused.
GapsinsurveillanceofAAAareassociatedwithAAArupture.Thus,ifalongersurveillanceintervalis
chosen,itisimportanttohavearemindersysteminplace.Inadatabasereviewofnearly10,000patients
withknownAAAwhounderwentrepairofanintactorrupturedaneurysm,gapsinsurveillancewere
definedasnoimagingwithinoneyearpriortosurgeryornoimagingformorethantwoyearsafterthe
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initialimage[177].PatientswithrupturedAAAweresignificantlymorelikelytohavegapsinsurveillance
comparedwiththosereceivingrepairforintactAAA(47.4versus11.8percent).Inamultivariateanalysis,
gapsinsurveillanceremainedthelargestpredictorofruptureafteradjustingformedicalcomorbidities
(OR5.82,95%CI,4.647.31).
SignificantanxietyisoftenassociatedwithadiagnosisofAAAandmanypatientsfindreassurancewitha
fixedsurveillanceinterval[180].Althoughformanypatients,theseanxietiesmaybereducedwithproper
education.
Annualclinicalexaminationandriskreductionassessmentcanbeperformedconcurrently[181,182].
ThereisinterestinusingAAAsacvolumeforsurveillance[183185].AAAsacvolumehasbeennotedin
researchstudiestochangewhenAAAdiameterhasnothowever,thesignificanceofthisobservationis
unknown.MorefrequentCTscanning,whichisrequiredforthismeasurement,isexpensiveandwouldsubject
thepatienttoadditionalradiationexposure.Thus,wedonotusesuchmeasurementsforroutineAAA
surveillance.
AAAREPAIRElectiveabdominalaorticaneurysm(AAA)repairisthemosteffectivemanagementto
preventrupture.Twomethodsofaneurysmrepairarecurrentlyavailable:opensurgeryandendovascular
aneurysmrepair(EVAR).ThemortalityofelectiveAAArepairis3to5percentforopenAAArepair,butlower
at0.5to2percentforEVAR[186188].Whenchoosingthetypeofrepair,itisimportanttotakeintoaccount
thepatient'sexpectedsurvival(shorttermandlongterm),whichdependsuponthepatient'sageandmedical
comorbidities.(See'Medicalriskassessment'above.)
OpenAAArepairOpenaneurysmrepairinvolvesreplacementofthediseasedaorticsegmentwitha
tubeorbifurcatedprostheticgraft(figure5)throughamidlineabdominalorretroperitonealincision[189].
WithtechnicalrefinementsforopenAAArepair,complicationssuchasacuterenalfailure,distal
embolization,woundinfection,colonicischemia,falseaneurysmformation,aortoduodenalfistula,graft
infection,andperioperativebleedinghavebecomelesscommonfollowingroutineelectivesurgerybut
remainsignificantissuesfollowingemergentopenAAArepair.
EVAREVARinvolvestheplacementofmodulargraftcomponentsdeliveredviatheiliacorfemoral
arteriestolinetheaorta(figure5)andexcludetheaneurysmsacfromthecirculation.EVARrequires
fulfillmentofspecificanatomiccriteria.Upto70percentofpatientsareEVARcandidates.This
percentageisexpectedtoincreasewiththeapprovalofspecializedendograftdesignsthatwillallowthe
treatmentofmorechallengingaorticaneurysmanatomy.AlthoughEVARisassociatedwithlower
perioperativemortality,lateAAArupturehasbeenreported.
SummaryofindicationsforelectiveAAArepairRepairofasymptomaticAAAisgenerallyindicated
underthecircumstanceslistedbelow.Theseindicationsarediscussedinmoredetailabove.Repairof
symptomatic(nonruptured)andrupturedAAAarediscussedseparately.(See'Aneurysmrepairversus
conservativemanagement'aboveand"Managementofsymptomatic(nonruptured)andrupturedabdominal
aorticaneurysm".)
AsymptomaticAAA5.5cm
RapidlyexpandingAAA
AAAassociatedwithperipheralarterialaneurysm(eg,iliac,popliteal)orperipheralarterydisease(eg,
iliacocclusivedisease)
OpenversusendovascularaneurysmrepairRandomizedtrialscomparingopenAAArepairwithEVAR
havefoundsignificantlyimprovedshortterm(30day)morbidityandmortalityforEVAR,butnosignificant
differencesinlongtermoutcomes[53,190197].Apooledanalysisofthesetrialsidentifieda69percent
reductionintheriskforperioperativemortalityforendovascularcomparedwithopenrepair(oddsratio[OR]
33,95%CI0.170.64)[198].EVARappearstobeassociatedwiththeneedformoresecondaryprocedures,
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andanongoingfutureriskofaorticrupture.However,thereappearstobenosignificantdifferencesinoverall
complicationrateswhenallcomplicationsforeachprocedureareincluded[199].Theimportantpointsof
theserandomizedtrialsaresummarizedbelow.
DREAMtrialTheDutchRandomizedEndovascularAneurysmManagement(DREAM)trialrandomly
assigned351patientstoopenrepairorEVAR[52].AllpatientshadAAA>5cminmaximaldiameterand
weresuitablecandidatesforeithertechnique.
Theperioperative(30day)mortalityratewaslowerforEVARcomparedwithopenAAArepair(1.2versus4.6
percent),thoughthisresultwasnotsignificant.Attwoyearspostrandomization,thecumulativeratesof
aneurysmrelateddeathremainedlessforEVAR(2.1versus5.7percent)comparedwithopenrepair,a
differencethatwasentirelyduetotheinitialperioperativeoutcomes[191].However,therewerenosignificant
differencesinoverallsurvival(89.7percentforEVARand89.6percentforopenrepair).Theperioperative
survivaladvantageseenwithEVARwasnotsustainedafterthefirstpostoperativeyear,duetoanincreasein
nonaneurysmrelatedmortalityintheEVARgroup.Theseresultsweremaintainedatsixyearswithsurvival
ratesforEVARat68.9percentandopenrepairat69.9percent[192].
TherateofmoderateandseveresystemiccomplicationswassignificantlylowerforEVAR(11.7versus26.4
percent)comparedwithopenrepair.Ratesofmoderateandseverevascularorgraftrelatedcomplications
weresignificantlygreaterforEVAR(16.4versus8.6percent)comparedwithopenrepair.Theneedfor
secondaryvascularinterventionwassignificantlyhigherforEVAR(29.6versus18.1percent)comparedwith
openrepair.
EVAR1trialTheendovascularaneurysmrepairversusopenrepairinpatientswithAAA(EVAR1)trial
randomlyassigned1252patientstoAAArepairwithEVAR(n=626)oropenAAArepair(n=626)[193].
Perioperative(30day)mortalitywassignificantlylessforEVAR(1.8versus4.3percent).Nosignificant
differenceswereseeninoverallmortality,andgraftrelatedcomplicationsoccurredmorefrequentlywith
EVAR.NewcomplicationsrelatedtoEVARcontinuedtooccurouttoeightyearsoffollowup[53].Theearly
benefitofEVARwaslostbeginningapproximatelyeightyearsafterrandomizationduetolatefatalsecondary
aneurysmruptures.Overameanof12.7yearsoffollowup,theoverallmortalityratewassimilar(9.3versus
8.9deathsper100personyearsfortheEVARandopengroups,respectively)[200].However,aneurysm
relatedmortalitywassignificantlyincreasedforEVARaftereightyears(7versus1percent)andwasmainly
attributabletosecondaryaneurysmsacrupture.Whethernewergenerationstentgraftswouldhavethese
samelongtermaneurysmrelatedrisksisunknownoveronethirdofthestentgraftdevicesreceivedbythe
enrolleesinthisstudyarenolongerused[193].Anotherfindingoflongertermfollowupwasthatthenumber
ofcancerdeathswas50of179intheEVARgroupand31of154intheopengroup(aftereightyears,
adjustedhazardratio1.87,95%CI1.19to2.96).Nootherstudyhasobservedanincreasedcancerriskwith
theuseofaorticstentgrafts.IntheEVARgroup,37of50ofthesecancerdeathsweredescribedas"other"
(ie,notlungcancer).Ifthesewereabdominalcancers,theirincreaseddetectioncouldberelatedtomore
frequentsurveillance.Baseduponestimatedcancerrisks[201,202],itisunlikelythesecanbeattributedto
imagingrelatedradiationexposure.
ReinterventionratesweresignificantlyhigherforEVARcomparedwithopenrepair.Acriticismofthistrialwas
thatallcomplicationsrelatedtoopenrepair,suchasincisionalhernia,werenotincludedinthestudy.The
shorttermbenefitofEVARwaslostduetolatefatalaneurysmruptures.Theauthorsconcludedthat
treatmentbyEVARsignificantlyreducedtheoperativemortalitycomparedwithopenrepair,buttherewereno
longtermadvantagesofonetypeofrepairforaneurysmrelatedoroverallmortality.
OVERtrialTheOpenVersusEndovascularRepair(OVER)trialisanongoingmulticentertrialatthe
VeteransAffairsMedicalCentersthatrandomlyassigned881veterans49withAAA>5.0cm,anassociated
iliacaneurysmwithmaximaldiameter3.0cm,oradiameterof4.5cmwithrapidenlargement(definedas
0.5cmgrowthinsixmonthsor1.0cminoneyear)toopenAAArepairorEVAR[54].Patientswere
candidatesforeithertypeofrepair.
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Overallmortalitywasnotsignificantlydifferentbetweenthegroupsat(7.0percentEVAR,9.8percentopen
repair)overnineyearsoffollowup[195].Sixaneurysmruptureswereconfirmedintheendovascularrepair
groupcomparedwithnoneintheopenrepairgroup(meanfollowup5.2years)however,thedifferencewas
notstatisticallysignificant.
EVARwasassociatedwithsignificantlyshorterproceduretimes(2.9versus3.7hours),ashorterdurationof
mechanicalventilation(3.6versus5.0hours),shorterintensivecareunitstay(1versus4days),shorterlength
ofhospitallength(3versus7days),andlowertransfusionrequirements(0versus1unit).
Inthistrial,incisionalherniawasincludedasanopenrepairrelatedcomplication.Asaresult,theratesof
secondaryinterventionwerefoundtobesimilarbetweenthegroups(13.7percentEVAR,12.5percentopen
AAArepair)withthemajorityofsecondaryproceduresintheEVARgroupduetoendovascularrevisions
comparedwithrepairofincisionalherniaintheopenAAAgroup.Aseparatedatabasereviewalsofound
similarcomplicationratesbetweenopenandendovascularrepairwhenallcomplicationswereincluded[199].
ACEtrialTheAneurysmedel'aorteabdominale:ChirurgieversusEndoprothese(ACE)trialrandomly
assigned316patientswithAAA>5cmtoEVARoropensurgery[194].Aswiththestudiesabove,therewere
nosignificantdifferencesinthecumulativesurvivalormajoradverseeventsrates(95.9versus93.2percentat
oneyearfollowup,and85.1versus82.4percent,respectively,atthreeyearsfollowup).Inhospitalmortality
wasalsonotsignificantlydifferent(0.6versus1.3percent).Theneedforreinterventionwashigherinthe
EVARgroup(16versus2.4percent),comparedwithopenAAArepair,althoughincisionalherniarepairwas
notconsidered.
ChoiceofAAArepairapproachWhenithasbeendeterminedthatapatientshouldundergoelective
AAArepair,weagreewithguidelinesfrommajormedicalandsurgicalsocietiesthatemphasizean
individualizedapproachwhenchoosingthetypeofAAArepair,takingintoaccounttheanatomicfactors,
patientage,gender,riskforAAArupture,andriskforperioperativemorbidityandmortality[4,92,203205]:
Endovascularrepairmaybepreferredinpatientswithfavorableanatomy(asdefinedbythe"Instructions
forUse[IFU]"ofagivendevice)whoareatahighlevelofperioperativerisk.
Endovascularrepairmaybeappropriateinpatientswithfavorableanatomybutwhodonothaveahigh
surgicalrisk.
Opensurgicalrepairmaybepreferredforyoungerpatientswhohavealoworaverageperioperativerisk.
Basedupontherandomizedtrialspresentedabove,themainbenefitsofEVARappeartobethegreatestin
theshortterm,andthus,EVARisthemostappropriatechoiceforpatientswithalimitedlifeexpectancyand
thosewithahighlevelofperioperativerisk.However,whetheryoungerpatientswhoarenotathighriskfor
opensurgeryshouldundergoopensurgicalrepairversusEVARremainscontroversial[206209].Surveillance
ofendovascularstentgraftsoveranextendedperiodoftimeexposesthepatienttogreaterlevelsof
cumulativeradiationhowever,ultrasoundsurveillanceisbecomingmorecommon.AlthoughEVARdoesnot
eliminatetheriskoffutureaorticrupture,thisisalsotrueforopenAAArepair,whichcanhavelate
complicationssuchasanastomoticpseudoaneurysm(proximal,distal)anddevelopment/progressionofiliacor
suprarenalaneurysms.(See"Endovascularrepairofabdominalaorticaneurysm",sectionon'Endograft
surveillance'and"Complicationsofendovascularabdominalaorticrepair".)
IntheUnitedStates,morethan80percentofAAAsoverallarerepairedusinganendovascularapproach.For
patientswithanatomythatissuitableforendovascularrepair(ie,asdefinedbytheIFUofagivendevice),the
authorsspeculatethatthisrateisnearly100percent,giventhatmostofthelimitationstoEVARhavefallen
awaywithnewergenerationdevices,aswellasabetterunderstandingofthemodesoffailurefollowing
endovascularrepair.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
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gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easyto
readmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore
detailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowant
indepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremail
thesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsby
searchingon"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patienteducation:Abdominalaorticaneurysm(TheBasics)")
BeyondtheBasicstopics(see"Patienteducation:Abdominalaorticaneurysm(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Abdominalaorticaneurysm(AAA)isacommonandpotentiallylifethreateningcondition.Approximately
7000deathsperyearareattributedtorupturedAAAintheUnitedStates.Withoutrepair,rupturedAAA
isnearlyuniformlyfatal.Forasymptomaticpatients,electiverepairoftheaneurysmisthemosteffective
managementtopreventrupture.(See'Introduction'above.)
FormostpatientswithasymptomaticinfrarenalAAA<5.5cm,werecommendconservativemanagement
(watchfulwaiting)ratherthanelectiveAAArepair(Grade1A).Theriskofaneurysmrupturedoesnot
exceedtheriskofrepairuntiltheaneurysmdiameterreaches5.5cm.Forgoodrisksurgicalcandidates
(openorendovascularrepair)withAAA>5.5cm,werecommendelectiveAAArepair(Grade1A).
SituationsforwhichelectiverepairofasymptomaticAAA<5.5cmmayalsobeappropriateinclude(see
'Aneurysmrepairversusconservativemanagement'above):
Rapidlyexpanding(>0.5cminsixmonthsor>1cmperyear)infrarenalAAAinwelldocumented
serialstudies.Rapidexpansionmayrepresentinstabilityoftheaorticwall,andsomestudiessuggest
thatrapidlyexpandingAAAshaveahigherriskofrupture.
Patientswithassociatedarterialdiseasesuchascoexistingiliac,femoral,orpoplitealartery
aneurysms,orsymptomaticperipheralarterydisease.
ForthesamediameterAAA,theriskforAAAruptureishigherforwomenthanformen.Elective
repairofasymptomaticAAA>5cmmaybeappropriatehowever,theriskofdeathfromelective
repairisalsoincreasedinwomen.Alowerthresholdforrepairisbestreservedforwomenwhohave
alowriskforperioperativemorbidityandmortality.
ForpatientswithAAA>5.5cmwhohaveashortlifeexpectancy(<2years)duetoadvanced
comorbidities,particularlycardiopulmonarydiseaseormalignancy,wesuggestnorepairover
endovascularaneurysmrepair(Grade2B).Forthesepatientsandotherswhoelectnottoundergo
repair,ongoingAAAsurveillanceisnotneeded.Thepatientshouldbeencouragedtocreatean
advanceddirectivedetailingtheirwishesfornorepairofanykindintheeventofrupture.Familymembers
shouldbemadeawareofthesewishes,giventhatthepatientmaynotbeabletoreporthisorherwishes
atthetimeofaneurysmrupture.(See'Counselingthehighriskpatient'aboveand'Followup'above.)
Conservativemanagementconsistsofperiodicclinicalevaluationandsurveillanceofaneurysmdiameter
toidentifyAAAthatexceedsthethresholdforrepairorisrapidlyexpanding.Medicaltherapiesfor
patientswithAAAfocusonthemanagementofmodifiableriskfactorsforAAAandcardiovascular
diseasewiththegoalsofreducingtheneedforinterventionduetoaneurysmexpansionorrupture,
reducingmorbidityandmortalityassociatedwithAAArepair,andreducingcardiovascularmorbidityand
mortality.(See'Conservativemanagement'above.)

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ForpatientswithAAAwhosmoke,werecommendsmokingcessation(Grade1A).Smokingis
stronglyassociatedwithAAAexpansionandrupture,andisthemostimportantmodifiableriskfactor.
Eventhoughreducedaneurysmexpansionandruptureriskhavenotbeenclearlydemonstrated
amongthosewhohavestoppedsmoking,smokingcessationhasotherclearbenefits.(See"Benefits
andrisksofsmokingcessation".)
PatientswithAAAareconsideredtohaveacoronaryequivalent.Statinsandaspirinareconsidered
appropriatetherapiestodecreasetheriskoffuturecardiovascularevents,asdiscussedelsewhere.
(See"Preventionofcardiovasculardiseaseeventsinthosewithestablisheddiseaseorathighrisk".)
AlthoughmanypharmacologictherapiesaimedatlimitingAAAexpansionandpreventingrupture
havebeentried,notherapyhasbeenprovensuccessfulatachievingthesegoals,andassuch,we
suggestnotimplementinganyofthepharmacologictherapiesdiscussedaboveforthesolepurpose
oftreatingAAA(Grade2C).
TheoptimalsurveillancescheduleforpatientswhoarenotundergoingAAArepairhasnotbeenclearly
defined.BasedlargelyuponthesurveillanceintervalsidentifiedintheUnitedKingdomSmallAneurysm
Trial,theSocietyofVascularSurgery(SVS)guidelinesforthediagnosisandmanagementofperipheral
arterydiseaserecommendsurveillanceevery6to12monthsusingultrasoundorcomputedtomography
(CT)formediumsizedaneurysms(4.0to5.4cmindiameter)butlessfrequentintervals(everytwoto
threeyears)forsmalleraneurysms.Wefrequentlyperformsurveillanceonsmallaneurysmsannuallyto
minimizeimagingvariabilityandalleviatepatientanxieties.Annualclinicalexaminationandriskreduction
assessmentcanalsobeperformedconcurrentlywithAAAsurveillance.(See'Aneurysmsurveillance'
above.)
Theprimarygoalsofaneurysmrepairaretopreventrupturewhileminimizingmorbidityandmortality
associatedwithrepair.Twomethodsofaneurysmrepairarecurrentlyavailable:traditionalopensurgery
andendovascularaneurysmrepair(EVAR).Inrandomizedtrials,EVARisassociatedwithlower
perioperativemorbidityandmortalitycomparedwithopenAAArepair,butdoesnotcompletelyeliminate
thefutureriskofAAArupture,whereasopenrepairisassociatedwithhigherperioperativemorbidityand
mortalitythanEVAR,butprovidesamoredefinitiverepair.PerioperativemortalityforelectiveopenAAA
repairis3to5percent,andforEVARis0.5to2percent.Longtermmortalityratesarenotsignificantly
different.(See'Openversusendovascularaneurysmrepair'above.)
Weagreewithguidelinesfrommajormedicalandsurgicalsocietiesthatemphasizeanindividualized
approachwhenchoosingtheapproachtoAAArepair,takingintoaccountaorticanatomy,patientage,
lifeexpectancy,andriskfactorsforperioperativemorbidityandmortality.Forpatientswithfavorable
anatomyforendovascularrepair(asdefinedbythe"InstructionsforUse"ofagivendevice)andahigh
levelofperioperativerisk,werecommendendovascularrepair,ratherthanopensurgicalrepair(Grade
1B).Endovascularrepairmayalsobeappropriateforpatientswithfavorableanatomy,butwhodonot
haveahighsurgicalrisk.Youngpatients(<60years)whohavealoworaverageperioperativeriskand
anexpectedlifespan>10yearsmayelectopensurgicalrepairratherthanendovascularrepairtolimit
lifelongexposuretoradiationthatmightresultfromstentgraftsurveillanceafterendovascularrepair.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.BownMJ,SuttonAJ,BellPR,SayersRD.Ametaanalysisof50yearsofrupturedabdominalaortic
aneurysmrepair.BrJSurg200289:714.
2.HoornwegLL,StormVerslootMN,UbbinkDT,etal.Metaanalysisonmortalityofrupturedabdominal
aorticaneurysms.EurJVascEndovascSurg200835:558.
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

16/34

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ManagementofasymptomaticabdominalaorticaneurysmUpToDate

3.JohnstonKW,RutherfordRB,TilsonMD,etal.Suggestedstandardsforreportingonarterial
aneurysms.SubcommitteeonReportingStandardsforArterialAneurysms,AdHocCommitteeon
ReportingStandards,SocietyforVascularSurgeryandNorthAmericanChapter,InternationalSociety
forCardiovascularSurgery.JVascSurg199113:452.
4.HirschAT,HaskalZJ,HertzerNR,etal.ACC/AHA2005PracticeGuidelinesforthemanagementof
patientswithperipheralarterialdisease(lowerextremity,renal,mesenteric,andabdominalaortic):a
collaborativereportfromtheAmericanAssociationforVascularSurgery/SocietyforVascularSurgery,
SocietyforCardiovascularAngiographyandInterventions,SocietyforVascularMedicineandBiology,
SocietyofInterventionalRadiology,andtheACC/AHATaskForceonPracticeGuidelines(Writing
CommitteetoDevelopGuidelinesfortheManagementofPatientsWithPeripheralArterialDisease):
endorsedbytheAmericanAssociationofCardiovascularandPulmonaryRehabilitationNationalHeart,
Lung,andBloodInstituteSocietyforVascularNursingTransAtlanticInterSocietyConsensusand
VascularDiseaseFoundation.Circulation2006113:e463.
5.ChaikofEL,BrewsterDC,DalmanRL,etal.SVSpracticeguidelinesforthecareofpatientswithan
abdominalaorticaneurysm:executivesummary.JVascSurg200950:880.
6.WanhainenA.Howtodefineanabdominalaorticaneurysminfluenceonepidemiologyandclinical
practice.ScandJSurg200897:105.
7.JongkindV,YeungKK,AkkersdijkGJ,etal.Juxtarenalaorticaneurysmrepair.JVascSurg2010
52:760.
8.Mortalityresultsforrandomisedcontrolledtrialofearlyelectivesurgeryorultrasonographicsurveillance
forsmallabdominalaorticaneurysms.TheUKSmallAneurysmTrialParticipants.Lancet1998
352:1649.
9.LederleFA,WilsonSE,JohnsonGR,etal.Immediaterepaircomparedwithsurveillanceofsmall
abdominalaorticaneurysms.NEnglJMed2002346:1437.
10.CaoP,DeRangoP,VerziniF,etal.Comparisonofsurveillanceversusaorticendograftingforsmall
aneurysmrepair(CAESAR):resultsfromarandomisedtrial.EurJVascEndovascSurg201141:13.
11.OurielK,ClairDG,KentKC,etal.Endovascularrepaircomparedwithsurveillanceforpatientswith
smallabdominalaorticaneurysms.JVascSurg201051:1081.
12.UnitedKingdomEVARTrialInvestigators,GreenhalghRM,BrownLC,etal.Endovascularrepairof
aorticaneurysminpatientsphysicallyineligibleforopenrepair.NEnglJMed2010362:1872.
13.SzilagyiDE,SmithRF,DeRussoFJ,etal.Contributionofabdominalaorticaneurysmectomyto
prolongationoflife.AnnSurg1966164:678.
14.FosterJH,BolasnyBL,GobbelWGJr,ScottHWJr.Comparativestudyofelectiveresectionand
expectanttreatmentofabdomianlaorticaneurysm.SurgGynecolObstet1969129:1.
15.ThompsonAR,CooperJA,AshtonHA,HafezH.Growthratesofsmallabdominalaorticaneurysms
correlatewithclinicalevents.BrJSurg201097:37.
16.SzilagyiDE,ElliottJP,SmithRF.Clinicalfateofthepatientwithasymptomaticabdominalaortic
aneurysmandunfitforsurgicaltreatment.ArchSurg1972104:600.
17.KatzDA,LittenbergB,CronenwettJL.Managementofsmallabdominalaorticaneurysms.Earlysurgery
vswatchfulwaiting.JAMA1992268:2678.
18.NevittMP,BallardDJ,HallettJWJr.Prognosisofabdominalaorticaneurysms.Apopulationbased
study.NEnglJMed1989321:1009.
19.PowellJT,GreenhalghRM.Clinicalpractice.Smallabdominalaorticaneurysms.NEnglJMed2003
348:1895.
20.BrewsterDC,CronenwettJL,HallettJWJr,etal.Guidelinesforthetreatmentofabdominalaortic
aneurysms.ReportofasubcommitteeoftheJointCounciloftheAmericanAssociationforVascular
SurgeryandSocietyforVascularSurgery.JVascSurg200337:1106.
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

17/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

21.MitchellMB,RutherfordRB,KrupskiWC.Infrarenalaorticaneurysms.In:VascularSurgery,4thed,
RutherfordRB(Ed),W.B.Saunders,Philadelphia1995.p.1032.
22.ErnstCB.Abdominalaorticaneurysm.NEnglJMed1993328:1167.
23.BathMF,GokaniVJ,SidloffDA,etal.Systematicreviewofcardiovasculardiseaseandcardiovascular
deathinpatientswithasmallabdominalaorticaneurysm.BrJSurg2015102:866.
24.Mitchell,MB,Rutherford,RB,Krupski,WC.Infrarenalaorticaneurysms.In:VascularSurgery,
Rutherford,RB(Eds),WBSaunders,Philadelphia1995.p.1032.
25.OurielK.ThePIVOTALstudy:arandomizedcomparisonofendovascularrepairversussurveillancein
patientswithsmallerabdominalaorticaneurysms.JVascSurg200949:266.
26.CaoP,CAESARTrialCollaborators.ComparisonofsurveillancevsAorticEndograftingforSmall
AneurysmRepair(CAESAR)trial:studydesignandprogress.EurJVascEndovascSurg200530:245.
27.FilardoG,PowellJT,MartinezMA,BallardDJ.Surgeryforsmallasymptomaticabdominalaortic
aneurysms.CochraneDatabaseSystRev2015:CD001835.
28.FilardoG,LederleFA,BallardDJ,etal.Effectofageonsurvivalbetweenopenrepairandsurveillance
forsmallabdominalaorticaneurysms.AmJCardiol2014114:1281.
29.LederleFA,KaneRL,MacDonaldR,WiltTJ.Systematicreview:repairofunrupturedabdominalaortic
aneurysm.AnnInternMed2007146:735.
30.UnitedKingdomSmallAneurysmTrialParticipants.Longtermoutcomesofimmediaterepaircompared
withsurveillanceofsmallabdominalaorticaneurysms.NEnglJMed2002346:1445.
31.MellMW,BakerLC.Payerstatus,preoperativesurveillance,andruptureofabdominalaorticaneurysms
intheUSMedicarepopulation.AnnVascSurg201428:1378.
32.OhrlanderT,MerloJ,OhlssonH,etal.Socioeconomicposition,comorbidity,andmortalityinaortic
aneurysms:a13yearprospectivecohortstudy.AnnVascSurg201226:312.
33.NaylorAR,ForbesTL.TransAtlanticdebate:Whetherevidencesupportsreducingthethreshold
diameterto5cmforelectiveinterventionsinwomenwithabdominalaorticaneurysms.EurJVasc
EndovascSurg201448:611.
34.LoRC,LuB,FokkemaMT,etal.Relativeimportanceofaneurysmdiameterandbodysizeforpredicting
abdominalaorticaneurysmruptureinmenandwomen.JVascSurg201459:1209.
35.DimickJB,StanleyJC,AxelrodDA,etal.Variationindeathrateafterabdominalaorticaneurysmectomy
intheUnitedStates:impactofhospitalvolume,gender,andage.AnnSurg2002235:579.
36.LederleFA.Shouldabdominalaorticaneurysmbemanageddifferentlyinwomen?ScandJSurg2008
97:125.
37.MehtaM,ByrneWJ,RobinsonH,etal.Womenderivelessbenefitfromelectiveendovascularaneurysm
repairthanmen.JVascSurg201255:906.
38.FilardoG,LederleFA,BallardDJ,etal.Immediateopenrepairvssurveillanceinpatientswithsmall
abdominalaorticaneurysms:survivaldifferencesbyaneurysmsize.MayoClinProc201388:910.
39.PowellJT,BrownLC,ForbesJF,etal.Final12yearfollowupofsurgeryversussurveillanceintheUK
SmallAneurysmTrial.BrJSurg200794:702.
40.BahiaSS,HoltPJ,JacksonD,etal.SystematicReviewandMetaanalysisofLongtermsurvivalAfter
ElectiveInfrarenalAbdominalAorticAneurysmRepair19692011:5YearSurvivalRemainsPoor
DespiteAdvancesinMedicalCareandTreatmentStrategies.EurJVascEndovascSurg201550:320.
41.SchermerhornML,BuckDB,O'MalleyAJ,etal.LongTermOutcomesofAbdominalAorticAneurysmin
theMedicarePopulation.NEnglJMed2015373:328.
42.LeeGK,UlleryBW,LeeJT.ElectiveEVARinnonagenariansissafeincarefullyselectedpatients.Ann
VascSurg201428:1402.
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

18/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

43.HertaultA,SobocinskiJ,KristmundssonT,etal.ResultsofFEVARinoctogenarians.AnnVascSurg
201428:1396.
44.TsilimparisN,PerezS,DayamaA,RicottaJJ2nd.Agestratifiedresultsfrom20,095aortoiliacaneurysm
repairs:shouldweapproachoctogenariansandnonagenariansdifferently?JAmCollSurg2012
215:690.
45.HughesK,AbdulrahmanH,PrendergastT,etal.Abdominalaorticaneurysmrepairinnonagenarians.
AnnVascSurg201529:183.
46.deBlicR,AlsacJM,JuliaP,etal.Electivetreatmentofabdominalaorticaneurysmisreasonablein
patients>85yearsofage.AnnVascSurg201428:209.
47.AryaS,KimSI,DuwayriY,etal.Frailtyincreasestheriskof30daymortality,morbidity,andfailureto
rescueafterelectiveabdominalaorticaneurysmrepairindependentofageandcomorbidities.JVasc
Surg201561:324.
48.BradyAR,ThompsonSG,FowkesFG,etal.Abdominalaorticaneurysmexpansion:riskfactorsand
timeintervalsforsurveillance.Circulation2004110:16.
49.DawsonJ,VigS,ChokeE,etal.Medicaloptimisationcanreducemorbidityandmortalityassociated
withelectiveaorticaneurysmrepair.EurJVascEndovascSurg200733:100.
50.FaggianoP,BonardelliS,DeFeoS,etal.Preoperativecardiacevaluationandperioperativecardiac
therapyinpatientsundergoingopensurgeryforabdominalaorticaneurysms:effectsoncardiovascular
outcome.AnnVascSurg201226:156.
51.NewmanAB,ArnoldAM,BurkeGL,etal.Cardiovasculardiseaseandmortalityinolderadultswithsmall
abdominalaorticaneurysmsdetectedbyultrasonography:thecardiovascularhealthstudy.AnnIntern
Med2001134:182.
52.PrinssenM,VerhoevenEL,ButhJ,etal.Arandomizedtrialcomparingconventionalandendovascular
repairofabdominalaorticaneurysms.NEnglJMed2004351:1607.
53.UnitedKingdomEVARTrialInvestigators,GreenhalghRM,BrownLC,etal.Endovascularversusopen
repairofabdominalaorticaneurysm.NEnglJMed2010362:1863.
54.LederleFA,FreischlagJA,KyriakidesTC,etal.Outcomesfollowingendovascularvsopenrepairof
abdominalaorticaneurysm:arandomizedtrial.JAMA2009302:1535.
55.GrantSW,GraysonAD,GrantMJ,etal.Whataretheriskfactorsforrenalfailurefollowingopen
electiveabdominalaorticaneurysmrepair?EurJVascEndovascSurg201243:182.
56.BrownLC,BrownEA,GreenhalghRM,etal.Renalfunctionandabdominalaorticaneurysm(AAA):the
impactofdifferentmanagementstrategiesonlongtermrenalfunctionintheUKEndoVascular
AneurysmRepair(EVAR)Trials.AnnSurg2010251:966.
57.IsselbacherEM.Thoracicandabdominalaorticaneurysms.Circulation2005111:816.
58.BaxterBT,TerrinMC,DalmanRL.Medicalmanagementofsmallabdominalaorticaneurysms.
Circulation2008117:1883.
59.LederleFA,JohnsonGR,WilsonSE,etal.Theaneurysmdetectionandmanagementstudyscreening
program:validationcohortandfinalresults.AneurysmDetectionandManagementVeteransAffairs
CooperativeStudyInvestigators.ArchInternMed2000160:1425.
60.TwineCP,WilliamsIM.Systematicreviewandmetaanalysisoftheeffectsofstatintherapyon
abdominalaorticaneurysms.BrJSurg201198:346.
61.BahiaSS,VidalDiezA,SeshasaiSR,etal.Cardiovascularriskpreventionandallcausemortalityin
primarycarepatientswithanabdominalaorticaneurysm.BrJSurg2016103:1626.
62.LindholtJS,SrensenJ,SgaardR,HennebergEW.Longtermbenefitandcosteffectivenessanalysis
ofscreeningforabdominalaorticaneurysmsfromarandomizedcontrolledtrial.BrJSurg201097:826.

https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

19/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

63.deBruinJL,BaasAF,HeymansMW,etal.Statintherapyisassociatedwithimprovedsurvivalafter
endovascularandopenaneurysmrepair.JVascSurg201459:39.
64.HeartProtectionStudyCollaborativeGroup.Randomizedtrialoftheeffectsofcholesterolloweringwith
simvastatinonperipheralvascularandothermajorvascularoutcomesin20,536peoplewithperipheral
arterialdiseaseandotherhighriskconditions.JVascSurg200745:645.
65.FeeneyJM,BurnsK,StaffI,etal.PrehospitalHMGCoAreductaseinhibitoruseandreducedmortality
inrupturedabdominalaorticaneurysm.JAmCollSurg2009209:41.
66.LeManachY,IbanezEstevesC,BertrandM,etal.Impactofpreoperativestatintherapyonadverse
postoperativeoutcomesinpatientsundergoingvascularsurgery.Anesthesiology2011114:98.
67.KertaiMD,BoersmaE,WesterhoutCM,etal.Associationbetweenlongtermstatinuseandmortality
aftersuccessfulabdominalaorticaneurysmsurgery.AmJMed2004116:96.
68.McNallyMM,AgleSC,ParkerFM,etal.Preoperativestatintherapyisassociatedwithimproved
outcomesandresourceutilizationinpatientsundergoingaorticaneurysmrepair.JVascSurg2010
51:1390.
69.DiehmN,BeckerG,KatzenB,etal.Statinsareassociatedwithdecreasedmortalityinabdominal,but
notinthoracicaorticaneurysmpatientsundergoingendovascularrepair:propensityscoreadjusted
analysis.Vasa200837:241.
70.SchoutenO,LeverTM,WeltenGM,etal.Longtermcardiacoutcomeinhighriskpatientsundergoing
electiveendovascularoropeninfrarenalabdominalaorticaneurysmrepair.EurJVascEndovascSurg
200836:646.
71.LeursLJ,VisserP,LaheijRJ,etal.Statinuseisassociatedwithreducedallcausemortalityafter
endovascularabdominalaorticaneurysmrepair.Vascular200614:1.
72.KurzencwygD,FilionKB,PiloteL,etal.Cardiacmedicaltherapyamongpatientsundergoingabdominal
aorticaneurysmrepair.AnnVascSurg200620:569.
73.KertaiMD,BoersmaE,WesterhoutCM,etal.Acombinationofstatinsandbetablockersis
independentlyassociatedwithareductionintheincidenceofperioperativemortalityandnonfatal
myocardialinfarctioninpatientsundergoingabdominalaorticaneurysmsurgery.EurJVascEndovasc
Surg200428:343.
74.TazakiJ,MorimotoT,SakataR,etal.Impactofstatintherapyonpatientswithcoronaryheartdisease
andaorticaneurysmordissection.JVascSurg201460:604.
75.SukhijaR,AronowWS,SandhuR,etal.Mortalityandsizeofabdominalaorticaneurysmatlongterm
followupofpatientsnottreatedsurgicallyandtreatedwithandwithoutstatins.AmJCardiol2006
97:279.
76.SweetingMJ,ThompsonSG,BrownLC,etal.Metaanalysisofindividualpatientdatatoexamine
factorsaffectinggrowthandruptureofsmallabdominalaorticaneurysms.BrJSurg201299:655.
77.KentKC,ZwolakRM,EgorovaNN,etal.Analysisofriskfactorsforabdominalaorticaneurysmina
cohortofmorethan3millionindividuals.JVascSurg201052:539.
78.BergqvistD.Pharmacologicalinterventionstoattenuatetheexpansionofabdominalaorticaneurysm
(AAA)asystematicreview.EurJVascEndovascSurg201141:663.
79.GolledgeJ,NormanPE.Currentstatusofmedicalmanagementforabdominalaorticaneurysm.
Atherosclerosis2011217:57.
80.RughaniG,RobertsonL,ClarkeM.Medicaltreatmentforsmallabdominalaorticaneurysms.Cochrane
DatabaseSystRev2012:CD009536.
81.AssarAN.Medicaltreatmentofsmallabdominalaorticaneurysm.JCardiovascSurg(Torino)2012
53:517.

https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

20/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

82.KokjeVB,HammingJF,LindemanJH.Editor'sChoicePharmaceuticalManagementofSmall
AbdominalAorticAneurysms:ASystematicReviewoftheClinicalEvidence.EurJVascEndovascSurg
201550:702.
83.LederleFA,NoorbaloochiS,NugentS,etal.Multicentrestudyofabdominalaorticaneurysm
measurementandenlargement.BrJSurg2015102:1480.
84.ForsdahlSH,SinghK,SolbergS,JacobsenBK.Riskfactorsforabdominalaorticaneurysms:a7year
prospectivestudy:theTromsStudy,19942001.Circulation2009119:2202.
85.WilminkTB,QuickCR,DayNE.Theassociationbetweencigarettesmokingandabdominalaortic
aneurysms.JVascSurg199930:1099.
86.LederleFA,NelsonDB,JosephAM.Smokers'relativeriskforaorticaneurysmcomparedwithother
smokingrelateddiseases:asystematicreview.JVascSurg200338:329.
87.2011WRITINGGROUPMEMBERS,2005WRITINGCOMMITTEEMEMBERS,ACCF/AHATASK
FORCEMEMBERS.2011ACCF/AHAFocusedUpdateoftheGuidelinefortheManagementofpatients
withperipheralarterydisease(Updatingthe2005Guideline):areportoftheAmericanCollegeof
CardiologyFoundation/AmericanHeartAssociationTaskForceonpracticeguidelines.Circulation2011
124:2020.
88.BuckleyC,WybleCW,BorhaniM,etal.Acceleratedenlargementofexperimentalabdominalaortic
aneurysmsinamousemodelofchroniccigarettesmokeexposure.JAmCollSurg2004199:896.
89.BrownLC,PowellJT.Riskfactorsforaneurysmruptureinpatientskeptunderultrasoundsurveillance.
UKSmallAneurysmTrialParticipants.AnnSurg1999230:289.
90.Smoking,lungfunctionandtheprognosisofabdominalaorticaneurysm.TheUKSmallAneurysmTrial
Participants.EurJVascEndovascSurg200019:636.
91.WarnerMA,OffordKP,WarnerME,etal.Roleofpreoperativecessationofsmokingandotherfactorsin
postoperativepulmonarycomplications:ablindedprospectivestudyofcoronaryarterybypasspatients.
MayoClinProc198964:609.
92.ChaikofEL,BrewsterDC,DalmanRL,etal.Thecareofpatientswithanabdominalaorticaneurysm:the
SocietyforVascularSurgerypracticeguidelines.JVascSurg200950:S2.
93.DalmanRL,TedescoMM,MyersJ,TaylorCA.AAAdisease:mechanism,stratification,andtreatment.
AnnNYAcadSci20061085:92.
94.NakahashiTK,HoshinaK,TsaoPS,etal.Flowloadinginducesmacrophageantioxidativegene
expressioninexperimentalaneurysms.ArteriosclerThrombVascBiol200222:2017.
95.TenfordeAS,ChengCP,SuhGY,etal.Quantifyinginvivohemodynamicresponsetoexercisein
patientswithintermittentclaudicationandabdominalaorticaneurysmsusingcinephasecontrastMRI.J
MagnResonImaging201031:425.
96.MyersJ,McElrathM,JaffeA,etal.Arandomizedtrialofexercisetraininginabdominalaorticaneurysm
disease.MedSciSportsExerc201446:2.
97.MyersJN,WhiteJJ,NarasimhanB,DalmanRL.Effectsofexercisetraininginpatientswithabdominal
aorticaneurysm:preliminaryresultsfromarandomizedtrial.JCardiopulmRehabilPrev201030:374.
98.PropanololAneurysmTrialInvestigators.Propranololforsmallabdominalaorticaneurysms:resultsofa
randomizedtrial.JVascSurg200235:72.
99.GadowskiGR,PilcherDB,RicciMA.Abdominalaorticaneurysmexpansionrate:effectofsizeandbeta
adrenergicblockade.JVascSurg199419:727.
100.BrophyCM,TilsonJE,TilsonMD.Propranololstimulatesthecrosslinkingofmatrixcomponentsinskin
fromtheaneurysmproneblotchymouse.JSurgRes198946:330.
101.LeachSD,TooleAL,SternH,etal.Effectofbetaadrenergicblockadeonthegrowthrateofabdominal
aorticaneurysms.ArchSurg1988123:606.
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

21/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

102.LindholtJS,HennebergEW,JuulS,FastingH.Impairedresultsofarandomiseddoubleblindedclinical
trialofpropranololversusplaceboontheexpansionrateofsmallabdominalaorticaneurysms.IntAngiol
199918:52.
103.YamamotoD,TakaiS,JinD,etal.Molecularmechanismofimidaprilforcardiovascularprotectionvia
inhibitionofMMP9.JMolCellCardiol200743:670.
104.RizzoniD,RodellaL,PorteriE,etal.Effectsoflosartanandenalaprilatdifferentdosesoncardiacand
renalinterstitialmatrixinspontaneouslyhypertensiverats.ClinExpHypertens200325:427.
105.SaraffK,BabamustaF,CassisLA,DaughertyA.Aorticdissectionprecedesformationofaneurysms
andatherosclerosisinangiotensinIIinfused,apolipoproteinEdeficientmice.ArteriosclerThrombVasc
Biol200323:1621.
106.DaughertyA,ManningMW,CassisLA.AngiotensinIIpromotesatheroscleroticlesionsandaneurysms
inapolipoproteinEdeficientmice.JClinInvest2000105:1605.
107.CassisLA,GupteM,ThayerS,etal.ANGIIinfusionpromotesabdominalaorticaneurysms
independentofincreasedbloodpressureinhypercholesterolemicmice.AmJPhysiolHeartCircPhysiol
2009296:H1660.
108.InoueN,MuramatsuM,JinD,etal.InvolvementofvascularangiotensinIIformingenzymesinthe
progressionofaorticabdominalaneurysmsinangiotensinIIinfusedApoEdeficientmice.JAtheroscler
Thromb200916:164.
109.LiaoS,MirallesM,KelleyBJ,etal.Suppressionofexperimentalabdominalaorticaneurysmsintherat
bytreatmentwithangiotensinconvertingenzymeinhibitors.JVascSurg200133:1057.
110.YangHH,KimJM,ChumE,etal.Effectivenessofcombinationoflosartanpotassiumanddoxycycline
versussingledrugtreatmentsinthesecondarypreventionofthoracicaorticaneurysminMarfan
syndrome.JThoracCardiovascSurg2010140:305.
111.KaschinaE,SchraderF,SommerfeldM,etal.Telmisartanpreventsaneurysmprogressionintheratby
inhibitingproteolysis,apoptosisandinflammation.JHypertens200826:2361.
112.FujiwaraY,ShirayaS,MiyakeT,etal.Inhibitionofexperimentalabdominalaorticaneurysminarat
modelbytheangiotensinreceptorblockervalsartan.IntJMolMed200822:703.
113.HabashiJP,JudgeDP,HolmTM,etal.Losartan,anAT1antagonist,preventsaorticaneurysmina
mousemodelofMarfansyndrome.Science2006312:117.
114.daCunhaV,ThamDM,MartinMcNultyB,etal.EnalaprilattenuatesangiotensinIIinduced
atherosclerosisandvascularinflammation.Atherosclerosis2005178:9.
115.HackamDG,ThiruchelvamD,RedelmeierDA.Angiotensinconvertingenzymeinhibitorsandaortic
rupture:apopulationbasedcasecontrolstudy.Lancet2006368:659.
116.ThompsonA,CooperJA,FabriciusM,etal.Ananalysisofdrugmodulationofabdominalaortic
aneurysmgrowththrough25yearsofsurveillance.JVascSurg201052:55.
117.SweetingMJ,ThompsonSG,BrownLC,etal.Useofangiotensinconvertingenzymeinhibitorsis
associatedwithincreasedgrowthrateofabdominalaorticaneurysms.JVascSurg201052:1.
118.https://clinicaltrials.gov/ct2/results?term=NCT01118520+&Search=Search(AccessedonSeptember29,
2016).
119.SchoutenO,vanLaanenJH,BoersmaE,etal.Statinsareassociatedwithareducedinfrarenal
abdominalaorticaneurysmgrowth.EurJVascEndovascSurg200632:21.
120.KiruG,BicknellC,FalaschettiE,etal.Anevaluationoftheeffectofanangiotensinconvertingenzyme
inhibitoronthegrowthrateofsmallabdominalaorticaneurysms:arandomisedplacebocontrolledtrial
(AARDVARK).HealthTechnolAssess201620:1.
121.WassefM,BaxterBT,ChisholmRL,etal.Pathogenesisofabdominalaorticaneurysms:a
multidisciplinaryresearchprogramsupportedbytheNationalHeart,Lung,andBloodInstitute.JVasc
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

22/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

Surg200134:730.
122.NagashimaH,AokaY,SakomuraY,etal.A3hydroxy3methylglutarylcoenzymeAreductaseinhibitor,
cerivastatin,suppressesproductionofmatrixmetalloproteinase9inhumanabdominalaorticaneurysm
wall.JVascSurg200236:158.
123.EvansJ,PowellJT,SchwalbeE,etal.Simvastatinattenuatestheactivityofmatrixmetalloprotease9in
aneurysmalaortictissue.EurJVascEndovascSurg200734:302.
124.KalyanasundaramA,ElmoreJR,ManazerJR,etal.Simvastatinsuppressesexperimentalaortic
aneurysmexpansion.JVascSurg200643:117.
125.JonesA,DebR,TorsneyE,etal.Rosiglitazonereducesthedevelopmentandruptureofexperimental
aorticaneurysms.Circulation2009119:3125.
126.ZhangY,NaggarJC,WelzigCM,etal.SimvastatininhibitsangiotensinIIinducedabdominalaortic
aneurysmformationinapolipoproteinEknockoutmice:possibleroleofERK.ArteriosclerThrombVasc
Biol200929:1764.
127.SteinmetzEF,BuckleyC,ShamesML,etal.Treatmentwithsimvastatinsuppressesthedevelopmentof
experimentalabdominalaorticaneurysmsinnormalandhypercholesterolemicmice.AnnSurg2005
241:92.
128.GolledgeJ,CullenB,MoranC,RushC.Efficacyofsimvastatininreducingaorticdilatationinmouse
modelsofabdominalaorticaneurysm.CardiovascDrugsTher201024:373.
129.ShirayaS,MiyakeT,AokiM,etal.Inhibitionofdevelopmentofexperimentalaorticabdominalaneurysm
inratmodelbyatorvastatinthroughinhibitionofmacrophagemigration.Atherosclerosis2009202:34.
130.WemmelundH,HghA,HundborgHH,etal.Statinuseandruptureofabdominalaorticaneurysm.BrJ
Surg2014101:966.
131.FergusonCD,ClancyP,BourkeB,etal.Associationofstatinprescriptionwithsmallabdominalaortic
aneurysmprogression.AmHeartJ2010159:307.
132.KarlssonL,BergqvistD,LindbckJ,PrssonH.Expansionofsmalldiameterabdominalaortic
aneurysmsisnotreflectedbythereleaseofinflammatorymediatorsIL6,MMP9andCRPinplasma.
EurJVascEndovascSurg200937:420.
133.MosorinM,NiemelE,HeikkinenJ,etal.Theuseofstatinsandfateofsmallabdominalaortic
aneurysms.InteractCardiovascThoracSurg20087:578.
134.SchlsserFJ,TangelderMJ,VerhagenHJ,etal.Growthpredictorsandprognosisofsmallabdominal
aorticaneurysms.JVascSurg200847:1127.
135.DawsonJA,ChokeE,LoftusIM,etal.Arandomisedplacebocontrolleddoubleblindtrialtoevaluate
lipidloweringpharmacotherapyonproteolysisandinflammationinabdominalaorticaneurysms.EurJ
VascEndovascSurg201141:28.
136.RahmanMN,KhanJA,MazariFA,etal.Arandomizedplacebocontrolledtrialoftheeffectof
preoperativestatinuseonmatrixmetalloproteinasesandtissueinhibitorsofmatrixmetalloproteinasesin
areasoflowandpeakwallstressinpatientsundergoingelectiveopenrepairofabdominalaortic
aneurysm.AnnVascSurg201125:32.
137.TakagiH,MatsuiM,UmemotoT.Ametaanalysisofclinicalstudiesofstatinsforpreventionof
abdominalaorticaneurysmexpansion.JVascSurg201052:1675.
138.LindholtJS,AshtonHA,ScottRA.IndicatorsofinfectionwithChlamydiapneumoniaeareassociated
withexpansionofabdominalaorticaneurysms.JVascSurg200134:212.
139.VammenS,LindholtJS,OstergaardL,etal.Randomizeddoubleblindcontrolledtrialofroxithromycin
forpreventionofabdominalaorticaneurysmexpansion.BrJSurg200188:1066.
140.HghA,VammenS,OstergaardL,etal.Intermittentroxithromycinforpreventingprogressionofsmall
abdominalaorticaneurysms:longtermresultsofasmallclinicaltrial.VascEndovascularSurg2009
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

23/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

43:452.
141.LiuJ,XiongW,BacaRegenL,etal.Mechanismofinhibitionofmatrixmetalloproteinase2expression
bydoxycyclineinhumanaorticsmoothmusclecells.JVascSurg200338:1376.
142.CurciJA,MaoD,BohnerDG,etal.Preoperativetreatmentwithdoxycyclinereducesaorticwall
expressionandactivationofmatrixmetalloproteinasesinpatientswithabdominalaorticaneurysms.J
VascSurg200031:325.
143.BaxterBT,PearceWH,WaltkeEA,etal.Prolongedadministrationofdoxycyclineinpatientswithsmall
asymptomaticabdominalaorticaneurysms:reportofaprospective(PhaseII)multicenterstudy.JVasc
Surg200236:1.
144.PetrinecD,LiaoS,HolmesDR,etal.Doxycyclineinhibitionofaneurysmaldegenerationinanelastase
inducedratmodelofabdominalaorticaneurysm:preservationofaorticelastinassociatedwith
suppressedproductionof92kDgelatinase.JVascSurg199623:336.
145.LawrenceDM,SinghRS,FranklinDP,etal.Rapamycinsuppressesexperimentalaorticaneurysm
growth.JVascSurg200440:334.
146.RouerM,XuBH,XuanHJ,etal.Rapamycinlimitsthegrowthofestablishedexperimentalabdominal
aorticaneurysms.EurJVascEndovascSurg201447:493.
147.LindemanJH,AbdulHussienH,vanBockelJH,etal.Clinicaltrialofdoxycyclineformatrix
metalloproteinase9inhibitioninpatientswithanabdominalaneurysm:doxycyclineselectivelydepletes
aorticwallneutrophilsandcytotoxicTcells.Circulation2009119:2209.
148.WalshDB.Presidentialaddress:Timetolead!JVascSurg200949:519.
149.MeijerCA,StijnenT,WasserMN,etal.Doxycyclineforstabilizationofabdominalaorticaneurysms:a
randomizedtrial.AnnInternMed2013159:815.
150.MorrisDR,CunninghamMA,AhimastosAA,etal.TElmisartaninthemanagementofabDominalaortic
aneurYsm(TEDY):Thestudyprotocolforarandomizedcontrolledtrial.Trials201516:274.
151.MosorinM,JuvonenJ,BiancariF,etal.Useofdoxycyclinetodecreasethegrowthrateofabdominal
aorticaneurysms:arandomized,doubleblind,placebocontrolledpilotstudy.JVascSurg200134:606.
152.LindholtJS,SorensenHT,MichelJB,etal.Lowdoseaspirinmaypreventgrowthandlatersurgical
repairofmediumsizedabdominalaorticaneurysms.VascEndovascularSurg200842:329.
153.GolledgeJ,WolanskiP,ParrA,ButtnerP.Measurementanddeterminantsofinfrarenalaorticthrombus
volume.EurRadiol200818:1987.
154.GolledgeJ,MullerR,ClancyP,etal.EvaluationofthediagnosticandprognosticvalueofplasmaD
dimerforabdominalaorticaneurysm.EurHeartJ201132:354.
155.GolledgeJ,TsaoPS,DalmanRL,NormanPE.Circulatingmarkersofabdominalaorticaneurysm
presenceandprogression.Circulation2008118:2382.
156.HouardX,TouatZ,OllivierV,etal.Mediatorsofneutrophilrecruitmentinhumanabdominalaortic
aneurysms.CardiovascRes200982:532.
157.TouatZ,OllivierV,DaiJ,etal.Renewalofmuralthrombusreleasesplasmamarkersandisinvolvedin
aorticabdominalaneurysmevolution.AmJPathol2006168:1022.
158.DaiJ,LouedecL,PhilippeM,etal.EffectofblockingplateletactivationwithAZD6140ondevelopment
ofabdominalaorticaneurysminarataneurysmalmodel.JVascSurg200949:719.
159.KochAE,HainesGK,RizzoRJ,etal.Humanabdominalaorticaneurysms.Immunophenotypicanalysis
suggestinganimmunemediatedresponse.AmJPathol1990137:1199.
160.NewmanKM,JeanClaudeJ,LiH,etal.Cytokinesthatactivateproteolysisareincreasedinabdominal
aorticaneurysms.Circulation199490:II224.
161.PaganoMB,ZhouHF,EnnisTL,etal.Complementdependentneutrophilrecruitmentiscriticalforthe
developmentofelastaseinducedabdominalaorticaneurysm.Circulation2009119:1805.
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

24/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

162.LindemanJH,RabelinkTJ,vanBockelJH.Immunosuppressionandtheabdominalaorticaneurysm:
DoctorJekyllorMisterHyde?Circulation2011124:e463.
163.SunJ,ZhangJ,LindholtJS,etal.Criticalroleofmastcellchymaseinmouseabdominalaortic
aneurysmformation.Circulation2009120:973.
164.SunJ,SukhovaGK,YangM,etal.Mastcellsmodulatethepathogenesisofelastaseinduced
abdominalaorticaneurysmsinmice.JClinInvest2007117:3359.
165.MyrnpMI,TrosienJA,FontaineV,etal.Mastcellsassociatewithneovesselsinthemediaand
adventitiaofabdominalaorticaneurysms.JVascSurg200950:388.
166.SillesenH,EldrupN,HultgrenR,etal.Randomizedclinicaltrialofmastcellinhibitioninpatientswitha
mediumsizedabdominalaorticaneurysm.BrJSurg2015102:894.
167.DeMartinoRR,BrookeBS,RobinsonW,etal.Designationas"unfitforopenrepair"isassociatedwith
pooroutcomesafterendovascularaorticaneurysmrepair.CircCardiovascQualOutcomes20136:575.
168.LimJ,WolffJ,RoddCD,etal.OutcomeinMenwithaScreendetectedAbdominalAorticAneurysm
WhoarenotFitforIntervention.EurJVascEndovascSurg201550:732.
169.LederleFA.Theriseandfallofabdominalaorticaneurysm.Circulation2011124:1097.
170.LederleFA,JohnsonGR,WilsonSE,etal.Rupturerateoflargeabdominalaorticaneurysmsinpatients
refusingorunfitforelectiverepair.JAMA2002287:2968.
171.WesternCE,CarlisleJ,McCarthyRJ,CurrieIC.Palliationofabdominalaorticaneurysmsinthe
endovascularera.EurJVascEndovascSurg201345:37.
172.ParkinsonF,FergusonS,LewisP,etal.Ruptureratesofuntreatedlargeabdominalaorticaneurysmsin
patientsunfitforelectiverepair.JVascSurg201561:1606.
173.ChunKC,SchmidtAS,BainsS,etal.Surveillanceoutcomesofsmallabdominalaorticaneurysms
identifiedfromalargescreeningprogram.JVascSurg201663:55.
174.GregaDS,ShermanRG.Responsivenessofneurogenicheartstooctopamine.CompBiochemPhysiol
C197552:5.
175.RESCANCollaborators,BownMJ,SweetingMJ,etal.Surveillanceintervalsforsmallabdominalaortic
aneurysms:ametaanalysis.JAMA2013309:806.
176.BadgerSA,JonesC,McClementsJ,etal.Surveillancestrategiesaccordingtotherateofgrowthof
smallabdominalaorticaneurysms.VascMed201116:415.
177.MellMW,BakerLC,DalmanRL,HlatkyMA.Gapsinpreoperativesurveillanceandruptureofabdominal
aorticaneurysmsamongMedicarebeneficiaries.JVascSurg201459:583.
178.LederleFA,JohnsonGR,WilsonSE,etal.Relationshipofage,gender,race,andbodysizetoinfrarenal
aorticdiameter.TheAneurysmDetectionandManagement(ADAM)VeteransAffairsCooperativeStudy
Investigators.JVascSurg199726:595.
179.AshtonHA,BuxtonMJ,DayNE,etal.TheMulticentreAneurysmScreeningStudy(MASS)intothe
effectofabdominalaorticaneurysmscreeningonmortalityinmen:arandomisedcontrolledtrial.Lancet
2002360:1531.
180.MarteauTM.Screeningforaorticaneurysm:Detectionisnotasharmfulasitmightseem.BMJ2008
336:973.
181.KauffmannC,TangA,DugasA,etal.Clinicalvalidationofasoftwareforquantitativefollowupof
abdominalaorticaneurysmmaximaldiameterandgrowthbyCTangiography.EurJRadiol2011
77:502.
182.SarangarmD,KnepperJ,MarekJ,etal.Postendovascularaneurysmrepairpatientoutcomesand
followuparenotadverselyimpactedbylongtraveldistancetotertiaryvascularsurgerycenters.Ann
VascSurg201024:1075.
https://www.uptodate.com/contents/managementofasymptomaticabdominalaorticaneurysm/print?source=search_result&search=aneurisma&select

25/34

8/1/2017

ManagementofasymptomaticabdominalaorticaneurysmUpToDate

183.KitagawaA,MastracciTM,vonAllmenR,PowellJT.Theroleofdiameterversusvolumeasthebest
prognosticmeasurementofabdominalaorticaneurysms.JVascSurg201358:258.
184.RenapurkarRD,SetserRM,O'DonnellTP,etal.Aorticvolumeasanindicatorofdiseaseprogressionin
patientswithuntreatedinfrarenalabdominalaneurysm.EurJRadiol201281:e87.
185.KauffmannC,TangA,TherasseE,etal.Measurementsanddetectionofabdominalaorticaneurysm
growth:Accuracyandreproducibilityofasegmentationsoftware.EurJRadiol201281:1688.
186.BradyAR,FowkesFG,GreenhalghRM,etal.Riskfactorsforpostoperativedeathfollowingelective
surgicalrepairofabdominalaorticaneurysm:resultsfromtheUKSmallAneurysmTrial.Onbehalfof
theUKSmallAneurysmTrialparticipants.BrJSurg200087:742.
187.DillavouED,MulukSC,MakarounMS.Improvinganeurysmrelatedoutcomes:nationwidebenefitsof
endovascularrepair.JVascSurg200643:446.
188.LeeWA,CarterJW,UpchurchG,etal.Perioperativeoutcomesafteropenandendovascularrepairof
intactabdominalaorticaneurysmsintheUnitedStatesduring2001.JVascSurg200439:491.
189.SieunarineK,LawrenceBrownMM,GoodmanMA.Comparisonoftransperitonealandretroperitoneal
approachesforinfrarenalaorticsurgery:earlyandlateresults.CardiovascSurg19975:71.
190.BrownLC,ThompsonSG,GreenhalghRM,etal.Incidenceofcardiovasculareventsanddeathafter
openorendovascularrepairofabdominalaorticaneurysmintherandomizedEVARtrial1.BrJSurg
201198:935.
191.BlankensteijnJD,deJongSE,PrinssenM,etal.Twoyearoutcomesafterconventionalorendovascular
repairofabdominalaorticaneurysms.NEnglJMed2005352:2398.
192.DeBruinJL,BaasAF,ButhJ,etal.Longtermoutcomeofopenorendovascularrepairofabdominal
aorticaneurysm.NEnglJMed2010362:1881.
193.EVARtrialparticipants.Endovascularaneurysmrepairversusopenrepairinpatientswithabdominal
aorticaneurysm(EVARtrial1):randomisedcontrolledtrial.Lancet2005365:2179.
194.BecqueminJP,PilletJC,LescalieF,etal.Arandomizedcontrolledtrialofendovascularaneurysmrepair
versusopensurgeryforabdominalaorticaneurysmsinlowtomoderateriskpatients.JVascSurg
201153:1167.
195.LederleFA,FreischlagJA,KyriakidesTC,etal.Longtermcomparisonofendovascularandopenrepair
ofabdominalaorticaneurysm.NEnglJMed2012367:1988.
196.ParavastuSC,JayarajasingamR,CottamR,etal.Endovascularrepairofabdominalaorticaneurysm.
CochraneDatabaseSystRev2014:CD004178.
197.StatherPW,SidloffD,DattaniN,etal.Systematicreviewandmetaanalysisoftheearlyandlate
outcomesofopenandendovascularrepairofabdominalaorticaneurysm.BrJSurg2013100:863.
198.KarthikesalingamA,ThompsonMM.Vasculardisease:Repairofinfrarenalaorticaneurysmthedebate
isOVER.NatRevCardiol201310:122.
199.SchermerhornML,O'MalleyAJ,JhaveriA,etal.Endovascularvs.openrepairofabdominalaortic
aneurysmsintheMedicarepopulation.NEnglJMed2008358:464.
200.PatelR,SweetingMJ,PowellJT,etal.Endovascularversusopenrepairofabdominalaorticaneurysm
in15years'followupoftheUKendovascularaneurysmrepairtrial1(EVARtrial1):arandomised
controlledtrial.Lancet2016388:2366.
201.http://www.xrayrisk.com/calculator/calculator.php(AccessedonNovember04,2016).
202.BerringtondeGonzlezA,MaheshM,KimKP,etal.Projectedcancerrisksfromcomputed
tomographicscansperformedintheUnitedStatesin2007.ArchInternMed2009169:2071.
203.http://content.onlinejacc.org/cgi/reprint/47/6/e1.pdf(AccessedonMarch23,2010).

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204.CoscasR,MaumiasT,CapdevilaC,etal.Miniinvasivetreatmentofabdominalaorticaneurysms:
currentrolesofendovascular,laparoscopic,andopentechniques.AnnVascSurg201428:123.
205.DeMartinoRR,GoodneyPP,NolanBW,etal.Optimalselectionofpatientsforelectiveabdominalaortic
aneurysmrepairbasedonlifeexpectancy.JVascSurg201358:589.
206.SiracuseJJ,GillHL,GrahamAR,etal.Comparativesafetyofendovascularandopensurgicalrepairof
abdominalaorticaneurysmsinlowriskmalepatients.JVascSurg201460:1154.
207.VallabhaneniR,FarberMA,SchneiderF,RiccoJB.Debate:whetheryoung,goodriskpatientsshould
betreatedwithendovascularabdominalaorticaneurysmrepair.JVascSurg201358:1709.
208.SandfordRM,ChokeE,BownMJ,SayersRD.Whatisthebestoptionforelectiverepairofan
abdominalaorticaneurysminayoungfitpatient?EurJVascEndovascSurg201447:13.
209.LeeK,TangE,DuboisL,etal.Durabilityandsurvivalaresimilarafterelectiveendovascularandopen
repairofabdominalaorticaneurysmsinyoungerpatients.JVascSurg201561:636.
Topic15188Version19.0

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GRAPHICS
Anatomyabdominalaorticaneurysm

Graphic60682Version13.0

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Pararenalabdominalaorticaneurysm

Alarge6by5.4cmpararenalAAAcanbeseeninthecoronalCTreconstruction(A)encroachingon
therightrenalartery(arrow).Inthecrosssectionalimages,therightrenalartery(arrowinB)andthe
leftrenalartery(arrowinC)canbeseen.
AAA:abdominalaorticaneurysmCT:computedtomography.
Graphic87567Version1.0

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AAAruptureprimarilyoccursinlargeraneurysms

Riskofruptureofanabdominalaorticaneurysm(AAA)overtimeaccordingto
thefirstmeasurementofaneurysmdiameterin1792menand465women.The
riskofruptureincreasedmarkedlyinaneurysmslargerthan5.5cmindiameter.
Datafrom:Powell,JT,Greenhalgh,RM,NEnglJMed2003348:1895.
Graphic57275Version4.0

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Patientsundergoingelectiverepairofanabdominal
aorticaneurysmdobetterateightyears

IntheUKSmallAneurysmtrialof1090patientswithamediumsizedabdominal
aorticaneurysm,thereisnodifferenceinsurvivalwithearlyelectivesurgery
comparedwithinitialsurveillance.However,byeightyearspatientsundergoing
earlysurgeryhaveasignificantlybetteroutcomethanthoseinthesurveillance
group(P=0.05).Ibarsrepresentthe95percentconfidenceintervalsforthe
pointestimates.
Datafrom:TheUnitedKingdomSmallAneurysmTrialParticipants.NEnglJMed
2002346:1445.
Graphic76015Version4.0

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Theneedforsurgicalrepairofanabdominalaortic
aneurysmincreasesovertime

IntheUSADAMtrialof1136patientswithamoderatesizedabdominalaortic
aneurysm,theneedforsurgicalrepairinthoserandomizedtoinitialsurveillance
increasedovertime.
DatafromLederle,FA,Wilson,SE,Johnson,GRetal,NEnglJMed2002:346:1437.
Graphic77529Version2.0

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Abdominalaorticaneurysmrepair

(Top)Foropensurgicalrepairofabdominalaorticaneurysm,theaortaisclamped
andtheaneurysmsacopened.Agraftissuturedintotheaortaproximallyand
distally.Atubegraft(illustrated)orabifurcatedgraftisuseddependinguponthe
extentofiliacarterydisease(aneurysmorstenosis).Oncethegraftisinplace,the
aneurysmsacandretroperitoneumareclosedoverthegraft.
(Bottom)Forendovascularrepair,thefoldedendograftisintroducedthroughthe
femoral(oriliac)arteryand,onceitisproperlyposititioned,theselfexpanding
endograftisdeployed.Iliacarteryextensionsarepositionedanddeployedto
completetherepair.
Graphic56289Version1.0

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ContributorDisclosures
RonaldLDalman,MD Nothingtodisclose MatthewMell,MD,FACS Nothingtodisclose JosephLMills,
Sr,MD Grant/Research/ClinicalTrialSupport:CescaTherapeutics[Criticallimbischemia(Hepatocytegrowth
factor)]VoyagerTrial[Peripheralarterydisease(Rivoxaraban)]NTA3CTAAATrial[Abdominalaortic
aneurysm].Consultant/AdvisoryBoards:GoreBypassSummit[Veinbypass(PTFEgraftsandendografts)].
OtherFinancialInterest:ElsevierRutherford[Vascularsurgery(RutherfordandComprehensiveVascularand
EndovascularSurgerytextbooks)]. JohnFEidt,MD Nothingtodisclose EmileRMohlerIII,
MD Grant/Research/ClinicalTrialSupport:NIH,PluristemandCelgene[PAD(Mesenchymalstemcells)].
PatentHolder:UniversityofPennsylvania[Cardiovascular(Vascularhealthprofilebloodtest)].Equity
Ownership/StockOptions:Cytovas[Cardiovascularbiomarker(Vascularhealthprofilebloodtest)]. DenisL
Clement,MD,PhD Nothingtodisclose KathrynACollins,MD,PhD,FACS Nothingtodisclose
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.
Conflictofinterestpolicy

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