UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management of asymptomatic abdominal aortic aneurysm

Authors
Ronald L Dalman, MD
Matthew Mell, MD, FACS
Section Editors
Joseph L Mills, Sr, MD
John F Eidt, MD
Emile R Mohler III, MD
Denis L Clement, MD, PhD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Abdominal aortic aneurysm (AAA) is a common and potentially life-threatening condition. Without repair, ruptured AAA is nearly uniformly fatal. Of the 50 percent of patients with ruptured AAA who reach the hospital for treatment, between 30 and 50 percent will die in the hospital [1,2].

For asymptomatic patients, elective repair of the aneurysm is the most effective management to prevent rupture. However, elective aortic surgery is also associated with risks, and thus, elective AAA repair is not recommended until the risk of rupture exceeds the risks associated with repair. For asymptomatic patients, the risk of AAA rupture generally exceeds the risk associated with elective AAA repair when aneurysm diameter exceeds 5.5 cm [3,4]. Other factors such as the patient's age, rate of aneurysm expansion, and the presence of coexistent peripheral artery disease or peripheral aneurysm are also important to consider when determining when to proceed with elective AAA repair.

For patients with asymptomatic AAA who do not have indications for elective repair, medical treatment is aimed at reducing cardiovascular risk in the event that AAA repair is needed, and limiting the rate of aortic expansion. When elective AAA repair is indicated, the choice between open and endovascular AAA repair remains debated. Although elective endovascular AAA repair is associated with lower rates of perioperative (30-day) morbidity and mortality compared with elective open repair (<2 versus approximately 5 percent), long-term outcomes are similar [5].

The management of the patient with asymptomatic AAA will be reviewed here. The clinical features and issues related to diagnosis and screening, management of symptomatic (nonruptured) and ruptured AAA, and details of surgical and endovascular repair are discussed elsewhere. (See "Screening for abdominal aortic aneurysm" and "Epidemiology, risk factors, pathogenesis and natural history of abdominal aortic aneurysm" and "Clinical features and diagnosis of abdominal aortic aneurysm" and "Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm" and "Endovascular repair of abdominal aortic aneurysm" and "Open surgical repair of abdominal aortic aneurysm" and "Surgical and endovascular repair of ruptured abdominal aortic aneurysm".)

ANEURYSM TERMINOLOGY

Aneurysm definition — An abdominal aorta with a maximal diameter >3.0 cm is considered aneurysmal in most adult patients [3,4,6]. Abdominal aortic aneurysm (AAA) most often affects the segment of aorta between the renal and inferior mesenteric arteries (infrarenal) (figure 1); approximately 5 percent involve the renal (pararenal) (image 1) or visceral arteries (suprarenal) [7]. (See "Clinical features and diagnosis of abdominal aortic aneurysm", section on 'Aneurysm definition and anatomy'.)

                                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Nov 10 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Bown MJ, Sutton AJ, Bell PR, Sayers RD. A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair. Br J Surg 2002; 89:714.
  2. Hoornweg LL, Storm-Versloot MN, Ubbink DT, et al. Meta analysis on mortality of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2008; 35:558.
  3. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991; 13:452.
  4. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
  5. Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg 2009; 50:880.
  6. Wanhainen A. How to define an abdominal aortic aneurysm--influence on epidemiology and clinical practice. Scand J Surg 2008; 97:105.
  7. Jongkind V, Yeung KK, Akkersdijk GJ, et al. Juxtarenal aortic aneurysm repair. J Vasc Surg 2010; 52:760.
  8. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm Trial Participants. Lancet 1998; 352:1649.
  9. Lederle FA, Wilson SE, Johnson GR, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002; 346:1437.
  10. Cao P, De Rango P, Verzini F, et al. Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from a randomised trial. Eur J Vasc Endovasc Surg 2011; 41:13.
  11. Ouriel K, Clair DG, Kent KC, et al. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms. J Vasc Surg 2010; 51:1081.
  12. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair. N Engl J Med 2010; 362:1872.
  13. Szilagyi DE, Smith RF, DeRusso FJ, et al. Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 1966; 164:678.
  14. Foster JH, Bolasny BL, Gobbel WG Jr, Scott HW Jr. Comparative study of elective resection and expectant treatment of abdomianl aortic aneurysm. Surg Gynecol Obstet 1969; 129:1.
  15. Thompson AR, Cooper JA, Ashton HA, Hafez H. Growth rates of small abdominal aortic aneurysms correlate with clinical events. Br J Surg 2010; 97:37.
  16. Szilagyi DE, Elliott JP, Smith RF. Clinical fate of the patient with asymptomatic abdominal aortic aneurysm and unfit for surgical treatment. Arch Surg 1972; 104:600.
  17. Katz DA, Littenberg B, Cronenwett JL. Management of small abdominal aortic aneurysms. Early surgery vs watchful waiting. JAMA 1992; 268:2678.
  18. Nevitt MP, Ballard DJ, Hallett JW Jr. Prognosis of abdominal aortic aneurysms. A population-based study. N Engl J Med 1989; 321:1009.
  19. Powell JT, Greenhalgh RM. Clinical practice. Small abdominal aortic aneurysms. N Engl J Med 2003; 348:1895.
  20. Brewster DC, Cronenwett JL, Hallett JW Jr, et al. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. J Vasc Surg 2003; 37:1106.
  21. Mitchell MB, Rutherford RB, Krupski WC. Infrarenal aortic aneurysms. In: Vascular Surgery, 4th ed, Rutherford RB (Ed), W.B. Saunders, Philadelphia 1995. p.1032.
  22. Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993; 328:1167.
  23. Bath MF, Gokani VJ, Sidloff DA, et al. Systematic review of cardiovascular disease and cardiovascular death in patients with a small abdominal aortic aneurysm. Br J Surg 2015; 102:866.
  24. Mitchell, MB, Rutherford, RB, Krupski, WC. Infrarenal aortic aneurysms. In: Vascular Surgery, Rutherford, RB (Eds), WB Saunders, Philadelphia 1995. p.1032.
  25. Ouriel K. The PIVOTAL study: a randomized comparison of endovascular repair versus surveillance in patients with smaller abdominal aortic aneurysms. J Vasc Surg 2009; 49:266.
  26. Cao P, CAESAR Trial Collaborators. Comparison of surveillance vs Aortic Endografting for Small Aneurysm Repair (CAESAR) trial: study design and progress. Eur J Vasc Endovasc Surg 2005; 30:245.
  27. Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database Syst Rev 2015; :CD001835.
  28. Filardo G, Lederle FA, Ballard DJ, et al. Effect of age on survival between open repair and surveillance for small abdominal aortic aneurysms. Am J Cardiol 2014; 114:1281.
  29. Lederle FA, Kane RL, MacDonald R, Wilt TJ. Systematic review: repair of unruptured abdominal aortic aneurysm. Ann Intern Med 2007; 146:735.
  30. United Kingdom Small Aneurysm Trial Participants. Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002; 346:1445.
  31. Mell MW, Baker LC. Payer status, preoperative surveillance, and rupture of abdominal aortic aneurysms in the US Medicare population. Ann Vasc Surg 2014; 28:1378.
  32. Ohrlander T, Merlo J, Ohlsson H, et al. Socioeconomic position, comorbidity, and mortality in aortic aneurysms: a 13-year prospective cohort study. Ann Vasc Surg 2012; 26:312.
  33. Naylor AR, Forbes TL. Trans-Atlantic debate: Whether evidence supports reducing the threshold diameter to 5 cm for elective interventions in women with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2014; 48:611.
  34. Lo RC, Lu B, Fokkema MT, et al. Relative importance of aneurysm diameter and body size for predicting abdominal aortic aneurysm rupture in men and women. J Vasc Surg 2014; 59:1209.
  35. Dimick JB, Stanley JC, Axelrod DA, et al. Variation in death rate after abdominal aortic aneurysmectomy in the United States: impact of hospital volume, gender, and age. Ann Surg 2002; 235:579.
  36. Lederle FA. Should abdominal aortic aneurysm be managed differently in women? Scand J Surg 2008; 97:125.
  37. Mehta M, Byrne WJ, Robinson H, et al. Women derive less benefit from elective endovascular aneurysm repair than men. J Vasc Surg 2012; 55:906.
  38. Filardo G, Lederle FA, Ballard DJ, et al. Immediate open repair vs surveillance in patients with small abdominal aortic aneurysms: survival differences by aneurysm size. Mayo Clin Proc 2013; 88:910.
  39. Powell JT, Brown LC, Forbes JF, et al. Final 12-year follow-up of surgery versus surveillance in the UK Small Aneurysm Trial. Br J Surg 2007; 94:702.
  40. Bahia SS, Holt PJ, Jackson D, et al. Systematic Review and Meta-analysis of Long-term survival After Elective Infrarenal Abdominal Aortic Aneurysm Repair 1969-2011: 5 Year Survival Remains Poor Despite Advances in Medical Care and Treatment Strategies. Eur J Vasc Endovasc Surg 2015; 50:320.
  41. Schermerhorn ML, Buck DB, O'Malley AJ, et al. Long-Term Outcomes of Abdominal Aortic Aneurysm in the Medicare Population. N Engl J Med 2015; 373:328.
  42. Lee GK, Ullery BW, Lee JT. Elective EVAR in nonagenarians is safe in carefully selected patients. Ann Vasc Surg 2014; 28:1402.
  43. Hertault A, Sobocinski J, Kristmundsson T, et al. Results of F-EVAR in octogenarians. Ann Vasc Surg 2014; 28:1396.
  44. Tsilimparis N, Perez S, Dayama A, Ricotta JJ 2nd. Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently? J Am Coll Surg 2012; 215:690.
  45. Hughes K, Abdulrahman H, Prendergast T, et al. Abdominal aortic aneurysm repair in nonagenarians. Ann Vasc Surg 2015; 29:183.
  46. de Blic R, Alsac JM, Julia P, et al. Elective treatment of abdominal aortic aneurysm is reasonable in patients >85 years of age. Ann Vasc Surg 2014; 28:209.
  47. Arya S, Kim SI, Duwayri Y, et al. Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities. J Vasc Surg 2015; 61:324.
  48. Brady AR, Thompson SG, Fowkes FG, et al. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation 2004; 110:16.
  49. Dawson J, Vig S, Choke E, et al. Medical optimisation can reduce morbidity and mortality associated with elective aortic aneurysm repair. Eur J Vasc Endovasc Surg 2007; 33:100.
  50. Faggiano P, Bonardelli S, De Feo S, et al. Preoperative cardiac evaluation and perioperative cardiac therapy in patients undergoing open surgery for abdominal aortic aneurysms: effects on cardiovascular outcome. Ann Vasc Surg 2012; 26:156.
  51. Newman AB, Arnold AM, Burke GL, et al. Cardiovascular disease and mortality in older adults with small abdominal aortic aneurysms detected by ultrasonography: the cardiovascular health study. Ann Intern Med 2001; 134:182.
  52. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607.
  53. United Kingdom EVAR Trial Investigators, Greenhalgh RM, Brown LC, et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010; 362:1863.
  54. Lederle FA, Freischlag JA, Kyriakides TC, et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009; 302:1535.
  55. Grant SW, Grayson AD, Grant MJ, et al. What are the risk factors for renal failure following open elective abdominal aortic aneurysm repair? Eur J Vasc Endovasc Surg 2012; 43:182.
  56. Brown LC, Brown EA, Greenhalgh RM, et al. Renal function and abdominal aortic aneurysm (AAA): the impact of different management strategies on long-term renal function in the UK EndoVascular Aneurysm Repair (EVAR) Trials. Ann Surg 2010; 251:966.
  57. Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation 2005; 111:816.
  58. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation 2008; 117:1883.
  59. Lederle FA, Johnson GR, Wilson SE, et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med 2000; 160:1425.
  60. Twine CP, Williams IM. Systematic review and meta-analysis of the effects of statin therapy on abdominal aortic aneurysms. Br J Surg 2011; 98:346.
  61. Bahia SS, Vidal-Diez A, Seshasai SR, et al. Cardiovascular risk prevention and all-cause mortality in primary care patients with an abdominal aortic aneurysm. Br J Surg 2016; 103:1626.
  62. Lindholt JS, Sørensen J, Søgaard R, Henneberg EW. Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial. Br J Surg 2010; 97:826.
  63. de Bruin JL, Baas AF, Heymans MW, et al. Statin therapy is associated with improved survival after endovascular and open aneurysm repair. J Vasc Surg 2014; 59:39.
  64. Heart Protection Study Collaborative Group. Randomized trial of the effects of cholesterol-lowering with simvastatin on peripheral vascular and other major vascular outcomes in 20,536 people with peripheral arterial disease and other high-risk conditions. J Vasc Surg 2007; 45:645.
  65. Feeney JM, Burns K, Staff I, et al. Prehospital HMG Co-A reductase inhibitor use and reduced mortality in ruptured abdominal aortic aneurysm. J Am Coll Surg 2009; 209:41.
  66. Le Manach Y, Ibanez Esteves C, Bertrand M, et al. Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing vascular surgery. Anesthesiology 2011; 114:98.
  67. Kertai MD, Boersma E, Westerhout CM, et al. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med 2004; 116:96.
  68. McNally MM, Agle SC, Parker FM, et al. Preoperative statin therapy is associated with improved outcomes and resource utilization in patients undergoing aortic aneurysm repair. J Vasc Surg 2010; 51:1390.
  69. Diehm N, Becker G, Katzen B, et al. Statins are associated with decreased mortality in abdominal, but not in thoracic aortic aneurysm patients undergoing endovascular repair: propensity score-adjusted analysis. Vasa 2008; 37:241.
  70. Schouten O, Lever TM, Welten GM, et al. Long-term cardiac outcome in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2008; 36:646.
  71. Leurs LJ, Visser P, Laheij RJ, et al. Statin use is associated with reduced all-cause mortality after endovascular abdominal aortic aneurysm repair. Vascular 2006; 14:1.
  72. Kurzencwyg D, Filion KB, Pilote L, et al. Cardiac medical therapy among patients undergoing abdominal aortic aneurysm repair. Ann Vasc Surg 2006; 20:569.
  73. Kertai MD, Boersma E, Westerhout CM, et al. A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg 2004; 28:343.
  74. Tazaki J, Morimoto T, Sakata R, et al. Impact of statin therapy on patients with coronary heart disease and aortic aneurysm or dissection. J Vasc Surg 2014; 60:604.
  75. Sukhija R, Aronow WS, Sandhu R, et al. Mortality and size of abdominal aortic aneurysm at long-term follow-up of patients not treated surgically and treated with and without statins. Am J Cardiol 2006; 97:279.
  76. Sweeting MJ, Thompson SG, Brown LC, et al. Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms. Br J Surg 2012; 99:655.
  77. Kent KC, Zwolak RM, Egorova NN, et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg 2010; 52:539.
  78. Bergqvist D. Pharmacological interventions to attenuate the expansion of abdominal aortic aneurysm (AAA) - a systematic review. Eur J Vasc Endovasc Surg 2011; 41:663.
  79. Golledge J, Norman PE. Current status of medical management for abdominal aortic aneurysm. Atherosclerosis 2011; 217:57.
  80. Rughani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database Syst Rev 2012; :CD009536.
  81. Assar AN. Medical treatment of small abdominal aortic aneurysm. J Cardiovasc Surg (Torino) 2012; 53:517.
  82. Kokje VB, Hamming JF, Lindeman JH. Editor's Choice - Pharmaceutical Management of Small Abdominal Aortic Aneurysms: A Systematic Review of the Clinical Evidence. Eur J Vasc Endovasc Surg 2015; 50:702.
  83. Lederle FA, Noorbaloochi S, Nugent S, et al. Multicentre study of abdominal aortic aneurysm measurement and enlargement. Br J Surg 2015; 102:1480.
  84. Forsdahl SH, Singh K, Solberg S, Jacobsen BK. Risk factors for abdominal aortic aneurysms: a 7-year prospective study: the Tromsø Study, 1994-2001. Circulation 2009; 119:2202.
  85. Wilmink TB, Quick CR, Day NE. The association between cigarette smoking and abdominal aortic aneurysms. J Vasc Surg 1999; 30:1099.
  86. Lederle FA, Nelson DB, Joseph AM. Smokers' relative risk for aortic aneurysm compared with other smoking-related diseases: a systematic review. J Vasc Surg 2003; 38:329.
  87. 2011 WRITING GROUP MEMBERS, 2005 WRITING COMMITTEE MEMBERS, ACCF/AHA TASK FORCE MEMBERS. 2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011; 124:2020.
  88. Buckley C, Wyble CW, Borhani M, et al. Accelerated enlargement of experimental abdominal aortic aneurysms in a mouse model of chronic cigarette smoke exposure. J Am Coll Surg 2004; 199:896.
  89. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg 1999; 230:289.
  90. Smoking, lung function and the prognosis of abdominal aortic aneurysm. The UK Small Aneurysm Trial Participants. Eur J Vasc Endovasc Surg 2000; 19:636.
  91. Warner MA, Offord KP, Warner ME, et al. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc 1989; 64:609.
  92. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2.
  93. Dalman RL, Tedesco MM, Myers J, Taylor CA. AAA disease: mechanism, stratification, and treatment. Ann N Y Acad Sci 2006; 1085:92.
  94. Nakahashi TK, Hoshina K, Tsao PS, et al. Flow loading induces macrophage antioxidative gene expression in experimental aneurysms. Arterioscler Thromb Vasc Biol 2002; 22:2017.
  95. Tenforde AS, Cheng CP, Suh GY, et al. Quantifying in vivo hemodynamic response to exercise in patients with intermittent claudication and abdominal aortic aneurysms using cine phase-contrast MRI. J Magn Reson Imaging 2010; 31:425.
  96. Myers J, McElrath M, Jaffe A, et al. A randomized trial of exercise training in abdominal aortic aneurysm disease. Med Sci Sports Exerc 2014; 46:2.
  97. Myers JN, White JJ, Narasimhan B, Dalman RL. Effects of exercise training in patients with abdominal aortic aneurysm: preliminary results from a randomized trial. J Cardiopulm Rehabil Prev 2010; 30:374.
  98. Propanolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg 2002; 35:72.
  99. Gadowski GR, Pilcher DB, Ricci MA. Abdominal aortic aneurysm expansion rate: effect of size and beta-adrenergic blockade. J Vasc Surg 1994; 19:727.
  100. Brophy CM, Tilson JE, Tilson MD. Propranolol stimulates the crosslinking of matrix components in skin from the aneurysm-prone blotchy mouse. J Surg Res 1989; 46:330.
  101. Leach SD, Toole AL, Stern H, et al. Effect of beta-adrenergic blockade on the growth rate of abdominal aortic aneurysms. Arch Surg 1988; 123:606.
  102. Lindholt JS, Henneberg EW, Juul S, Fasting H. Impaired results of a randomised double blinded clinical trial of propranolol versus placebo on the expansion rate of small abdominal aortic aneurysms. Int Angiol 1999; 18:52.
  103. Yamamoto D, Takai S, Jin D, et al. Molecular mechanism of imidapril for cardiovascular protection via inhibition of MMP-9. J Mol Cell Cardiol 2007; 43:670.
  104. Rizzoni D, Rodella L, Porteri E, et al. Effects of losartan and enalapril at different doses on cardiac and renal interstitial matrix in spontaneously hypertensive rats. Clin Exp Hypertens 2003; 25:427.
  105. Saraff K, Babamusta F, Cassis LA, Daugherty A. Aortic dissection precedes formation of aneurysms and atherosclerosis in angiotensin II-infused, apolipoprotein E-deficient mice. Arterioscler Thromb Vasc Biol 2003; 23:1621.
  106. Daugherty A, Manning MW, Cassis LA. Angiotensin II promotes atherosclerotic lesions and aneurysms in apolipoprotein E-deficient mice. J Clin Invest 2000; 105:1605.
  107. Cassis LA, Gupte M, Thayer S, et al. ANG II infusion promotes abdominal aortic aneurysms independent of increased blood pressure in hypercholesterolemic mice. Am J Physiol Heart Circ Physiol 2009; 296:H1660.
  108. Inoue N, Muramatsu M, Jin D, et al. Involvement of vascular angiotensin II-forming enzymes in the progression of aortic abdominal aneurysms in angiotensin II- infused ApoE-deficient mice. J Atheroscler Thromb 2009; 16:164.
  109. Liao S, Miralles M, Kelley BJ, et al. Suppression of experimental abdominal aortic aneurysms in the rat by treatment with angiotensin-converting enzyme inhibitors. J Vasc Surg 2001; 33:1057.
  110. Yang HH, Kim JM, Chum E, et al. Effectiveness of combination of losartan potassium and doxycycline versus single-drug treatments in the secondary prevention of thoracic aortic aneurysm in Marfan syndrome. J Thorac Cardiovasc Surg 2010; 140:305.
  111. Kaschina E, Schrader F, Sommerfeld M, et al. Telmisartan prevents aneurysm progression in the rat by inhibiting proteolysis, apoptosis and inflammation. J Hypertens 2008; 26:2361.
  112. Fujiwara Y, Shiraya S, Miyake T, et al. Inhibition of experimental abdominal aortic aneurysm in a rat model by the angiotensin receptor blocker valsartan. Int J Mol Med 2008; 22:703.
  113. Habashi JP, Judge DP, Holm TM, et al. Losartan, an AT1 antagonist, prevents aortic aneurysm in a mouse model of Marfan syndrome. Science 2006; 312:117.
  114. da Cunha V, Tham DM, Martin-McNulty B, et al. Enalapril attenuates angiotensin II-induced atherosclerosis and vascular inflammation. Atherosclerosis 2005; 178:9.
  115. Hackam DG, Thiruchelvam D, Redelmeier DA. Angiotensin-converting enzyme inhibitors and aortic rupture: a population-based case-control study. Lancet 2006; 368:659.
  116. Thompson A, Cooper JA, Fabricius M, et al. An analysis of drug modulation of abdominal aortic aneurysm growth through 25 years of surveillance. J Vasc Surg 2010; 52:55.
  117. Sweeting MJ, Thompson SG, Brown LC, et al. Use of angiotensin converting enzyme inhibitors is associated with increased growth rate of abdominal aortic aneurysms. J Vasc Surg 2010; 52:1.
  118. https://clinicaltrials.gov/ct2/results?term=NCT01118520+&Search=Search (Accessed on September 29, 2016).
  119. Schouten O, van Laanen JH, Boersma E, et al. Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth. Eur J Vasc Endovasc Surg 2006; 32:21.
  120. Kiru G, Bicknell C, Falaschetti E, et al. An evaluation of the effect of an angiotensin-converting enzyme inhibitor on the growth rate of small abdominal aortic aneurysms: a randomised placebo-controlled trial (AARDVARK). Health Technol Assess 2016; 20:1.
  121. Wassef M, Baxter BT, Chisholm RL, et al. Pathogenesis of abdominal aortic aneurysms: a multidisciplinary research program supported by the National Heart, Lung, and Blood Institute. J Vasc Surg 2001; 34:730.
  122. Nagashima H, Aoka Y, Sakomura Y, et al. A 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, cerivastatin, suppresses production of matrix metalloproteinase-9 in human abdominal aortic aneurysm wall. J Vasc Surg 2002; 36:158.
  123. Evans J, Powell JT, Schwalbe E, et al. Simvastatin attenuates the activity of matrix metalloprotease-9 in aneurysmal aortic tissue. Eur J Vasc Endovasc Surg 2007; 34:302.
  124. Kalyanasundaram A, Elmore JR, Manazer JR, et al. Simvastatin suppresses experimental aortic aneurysm expansion. J Vasc Surg 2006; 43:117.
  125. Jones A, Deb R, Torsney E, et al. Rosiglitazone reduces the development and rupture of experimental aortic aneurysms. Circulation 2009; 119:3125.
  126. Zhang Y, Naggar JC, Welzig CM, et al. Simvastatin inhibits angiotensin II-induced abdominal aortic aneurysm formation in apolipoprotein E-knockout mice: possible role of ERK. Arterioscler Thromb Vasc Biol 2009; 29:1764.
  127. Steinmetz EF, Buckley C, Shames ML, et al. Treatment with simvastatin suppresses the development of experimental abdominal aortic aneurysms in normal and hypercholesterolemic mice. Ann Surg 2005; 241:92.
  128. Golledge J, Cullen B, Moran C, Rush C. Efficacy of simvastatin in reducing aortic dilatation in mouse models of abdominal aortic aneurysm. Cardiovasc Drugs Ther 2010; 24:373.
  129. Shiraya S, Miyake T, Aoki M, et al. Inhibition of development of experimental aortic abdominal aneurysm in rat model by atorvastatin through inhibition of macrophage migration. Atherosclerosis 2009; 202:34.
  130. Wemmelund H, Høgh A, Hundborg HH, et al. Statin use and rupture of abdominal aortic aneurysm. Br J Surg 2014; 101:966.
  131. Ferguson CD, Clancy P, Bourke B, et al. Association of statin prescription with small abdominal aortic aneurysm progression. Am Heart J 2010; 159:307.
  132. Karlsson L, Bergqvist D, Lindbäck J, Pärsson H. Expansion of small-diameter abdominal aortic aneurysms is not reflected by the release of inflammatory mediators IL-6, MMP-9 and CRP in plasma. Eur J Vasc Endovasc Surg 2009; 37:420.
  133. Mosorin M, Niemelä E, Heikkinen J, et al. The use of statins and fate of small abdominal aortic aneurysms. Interact Cardiovasc Thorac Surg 2008; 7:578.
  134. Schlösser FJ, Tangelder MJ, Verhagen HJ, et al. Growth predictors and prognosis of small abdominal aortic aneurysms. J Vasc Surg 2008; 47:1127.
  135. Dawson JA, Choke E, Loftus IM, et al. A randomised placebo-controlled double-blind trial to evaluate lipid-lowering pharmacotherapy on proteolysis and inflammation in abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2011; 41:28.
  136. Rahman MN, Khan JA, Mazari FA, et al. A randomized placebo controlled trial of the effect of preoperative statin use on matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases in areas of low and peak wall stress in patients undergoing elective open repair of abdominal aortic aneurysm. Ann Vasc Surg 2011; 25:32.
  137. Takagi H, Matsui M, Umemoto T. A meta-analysis of clinical studies of statins for prevention of abdominal aortic aneurysm expansion. J Vasc Surg 2010; 52:1675.
  138. Lindholt JS, Ashton HA, Scott RA. Indicators of infection with Chlamydia pneumoniae are associated with expansion of abdominal aortic aneurysms. J Vasc Surg 2001; 34:212.
  139. Vammen S, Lindholt JS, Ostergaard L, et al. Randomized double-blind controlled trial of roxithromycin for prevention of abdominal aortic aneurysm expansion. Br J Surg 2001; 88:1066.
  140. Høgh A, Vammen S, Ostergaard L, et al. Intermittent roxithromycin for preventing progression of small abdominal aortic aneurysms: long-term results of a small clinical trial. Vasc Endovascular Surg 2009; 43:452.
  141. Liu J, Xiong W, Baca-Regen L, et al. Mechanism of inhibition of matrix metalloproteinase-2 expression by doxycycline in human aortic smooth muscle cells. J Vasc Surg 2003; 38:1376.
  142. Curci JA, Mao D, Bohner DG, et al. Preoperative treatment with doxycycline reduces aortic wall expression and activation of matrix metalloproteinases in patients with abdominal aortic aneurysms. J Vasc Surg 2000; 31:325.
  143. Baxter BT, Pearce WH, Waltke EA, et al. Prolonged administration of doxycycline in patients with small asymptomatic abdominal aortic aneurysms: report of a prospective (Phase II) multicenter study. J Vasc Surg 2002; 36:1.
  144. Petrinec D, Liao S, Holmes DR, et al. Doxycycline inhibition of aneurysmal degeneration in an elastase-induced rat model of abdominal aortic aneurysm: preservation of aortic elastin associated with suppressed production of 92 kD gelatinase. J Vasc Surg 1996; 23:336.
  145. Lawrence DM, Singh RS, Franklin DP, et al. Rapamycin suppresses experimental aortic aneurysm growth. J Vasc Surg 2004; 40:334.
  146. Rouer M, Xu BH, Xuan HJ, et al. Rapamycin limits the growth of established experimental abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2014; 47:493.
  147. Lindeman JH, Abdul-Hussien H, van Bockel JH, et al. Clinical trial of doxycycline for matrix metalloproteinase-9 inhibition in patients with an abdominal aneurysm: doxycycline selectively depletes aortic wall neutrophils and cytotoxic T cells. Circulation 2009; 119:2209.
  148. Walsh DB. Presidential address: Time to lead! J Vasc Surg 2009; 49:519.
  149. Meijer CA, Stijnen T, Wasser MN, et al. Doxycycline for stabilization of abdominal aortic aneurysms: a randomized trial. Ann Intern Med 2013; 159:815.
  150. Morris DR, Cunningham MA, Ahimastos AA, et al. TElmisartan in the management of abDominal aortic aneurYsm (TEDY): The study protocol for a randomized controlled trial. Trials 2015; 16:274.
  151. Mosorin M, Juvonen J, Biancari F, et al. Use of doxycycline to decrease the growth rate of abdominal aortic aneurysms: a randomized, double-blind, placebo-controlled pilot study. J Vasc Surg 2001; 34:606.
  152. Lindholt JS, Sorensen HT, Michel JB, et al. Low-dose aspirin may prevent growth and later surgical repair of medium-sized abdominal aortic aneurysms. Vasc Endovascular Surg 2008; 42:329.
  153. Golledge J, Wolanski P, Parr A, Buttner P. Measurement and determinants of infrarenal aortic thrombus volume. Eur Radiol 2008; 18:1987.
  154. Golledge J, Muller R, Clancy P, et al. Evaluation of the diagnostic and prognostic value of plasma D-dimer for abdominal aortic aneurysm. Eur Heart J 2011; 32:354.
  155. Golledge J, Tsao PS, Dalman RL, Norman PE. Circulating markers of abdominal aortic aneurysm presence and progression. Circulation 2008; 118:2382.
  156. Houard X, Touat Z, Ollivier V, et al. Mediators of neutrophil recruitment in human abdominal aortic aneurysms. Cardiovasc Res 2009; 82:532.
  157. Touat Z, Ollivier V, Dai J, et al. Renewal of mural thrombus releases plasma markers and is involved in aortic abdominal aneurysm evolution. Am J Pathol 2006; 168:1022.
  158. Dai J, Louedec L, Philippe M, et al. Effect of blocking platelet activation with AZD6140 on development of abdominal aortic aneurysm in a rat aneurysmal model. J Vasc Surg 2009; 49:719.
  159. Koch AE, Haines GK, Rizzo RJ, et al. Human abdominal aortic aneurysms. Immunophenotypic analysis suggesting an immune-mediated response. Am J Pathol 1990; 137:1199.
  160. Newman KM, Jean-Claude J, Li H, et al. Cytokines that activate proteolysis are increased in abdominal aortic aneurysms. Circulation 1994; 90:II224.
  161. Pagano MB, Zhou HF, Ennis TL, et al. Complement-dependent neutrophil recruitment is critical for the development of elastase-induced abdominal aortic aneurysm. Circulation 2009; 119:1805.
  162. Lindeman JH, Rabelink TJ, van Bockel JH. Immunosuppression and the abdominal aortic aneurysm: Doctor Jekyll or Mister Hyde? Circulation 2011; 124:e463.
  163. Sun J, Zhang J, Lindholt JS, et al. Critical role of mast cell chymase in mouse abdominal aortic aneurysm formation. Circulation 2009; 120:973.
  164. Sun J, Sukhova GK, Yang M, et al. Mast cells modulate the pathogenesis of elastase-induced abdominal aortic aneurysms in mice. J Clin Invest 2007; 117:3359.
  165. Mäyränpää MI, Trosien JA, Fontaine V, et al. Mast cells associate with neovessels in the media and adventitia of abdominal aortic aneurysms. J Vasc Surg 2009; 50:388.
  166. Sillesen H, Eldrup N, Hultgren R, et al. Randomized clinical trial of mast cell inhibition in patients with a medium-sized abdominal aortic aneurysm. Br J Surg 2015; 102:894.
  167. De Martino RR, Brooke BS, Robinson W, et al. Designation as "unfit for open repair" is associated with poor outcomes after endovascular aortic aneurysm repair. Circ Cardiovasc Qual Outcomes 2013; 6:575.
  168. Lim J, Wolff J, Rodd CD, et al. Outcome in Men with a Screen-detected Abdominal Aortic Aneurysm Who are not Fit for Intervention. Eur J Vasc Endovasc Surg 2015; 50:732.
  169. Lederle FA. The rise and fall of abdominal aortic aneurysm. Circulation 2011; 124:1097.
  170. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA 2002; 287:2968.
  171. Western CE, Carlisle J, McCarthy RJ, Currie IC. Palliation of abdominal aortic aneurysms in the endovascular era. Eur J Vasc Endovasc Surg 2013; 45:37.
  172. Parkinson F, Ferguson S, Lewis P, et al. Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair. J Vasc Surg 2015; 61:1606.
  173. Chun KC, Schmidt AS, Bains S, et al. Surveillance outcomes of small abdominal aortic aneurysms identified from a large screening program. J Vasc Surg 2016; 63:55.
  174. Grega DS, Sherman RG. Responsiveness of neurogenic hearts to octopamine. Comp Biochem Physiol C 1975; 52:5.
  175. RESCAN Collaborators, Bown MJ, Sweeting MJ, et al. Surveillance intervals for small abdominal aortic aneurysms: a meta-analysis. JAMA 2013; 309:806.
  176. Badger SA, Jones C, McClements J, et al. Surveillance strategies according to the rate of growth of small abdominal aortic aneurysms. Vasc Med 2011; 16:415.
  177. Mell MW, Baker LC, Dalman RL, Hlatky MA. Gaps in preoperative surveillance and rupture of abdominal aortic aneurysms among Medicare beneficiaries. J Vasc Surg 2014; 59:583.
  178. Lederle FA, Johnson GR, Wilson SE, et al. Relationship of age, gender, race, and body size to infrarenal aortic diameter. The Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Investigators. J Vasc Surg 1997; 26:595.
  179. Ashton HA, Buxton MJ, Day NE, et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002; 360:1531.
  180. Marteau TM. Screening for aortic aneurysm: Detection is not as harmful as it might seem. BMJ 2008; 336:973.
  181. Kauffmann C, Tang A, Dugas A, et al. Clinical validation of a software for quantitative follow-up of abdominal aortic aneurysm maximal diameter and growth by CT angiography. Eur J Radiol 2011; 77:502.
  182. Sarangarm D, Knepper J, Marek J, et al. Post-endovascular aneurysm repair patient outcomes and follow-up are not adversely impacted by long travel distance to tertiary vascular surgery centers. Ann Vasc Surg 2010; 24:1075.
  183. Kitagawa A, Mastracci TM, von Allmen R, Powell JT. The role of diameter versus volume as the best prognostic measurement of abdominal aortic aneurysms. J Vasc Surg 2013; 58:258.
  184. Renapurkar RD, Setser RM, O'Donnell TP, et al. Aortic volume as an indicator of disease progression in patients with untreated infrarenal abdominal aneurysm. Eur J Radiol 2012; 81:e87.
  185. Kauffmann C, Tang A, Therasse E, et al. Measurements and detection of abdominal aortic aneurysm growth: Accuracy and reproducibility of a segmentation software. Eur J Radiol 2012; 81:1688.
  186. Brady AR, Fowkes FG, Greenhalgh RM, et al. Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants. Br J Surg 2000; 87:742.
  187. Dillavou ED, Muluk SC, Makaroun MS. Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. J Vasc Surg 2006; 43:446.
  188. Lee WA, Carter JW, Upchurch G, et al. Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001. J Vasc Surg 2004; 39:491.
  189. Sieunarine K, Lawrence-Brown MM, Goodman MA. Comparison of transperitoneal and retroperitoneal approaches for infrarenal aortic surgery: early and late results. Cardiovasc Surg 1997; 5:71.
  190. Brown LC, Thompson SG, Greenhalgh RM, et al. Incidence of cardiovascular events and death after open or endovascular repair of abdominal aortic aneurysm in the randomized EVAR trial 1. Br J Surg 2011; 98:935.
  191. Blankensteijn JD, de Jong SE, Prinssen M, et al. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005; 352:2398.
  192. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010; 362:1881.
  193. EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005; 365:2179.
  194. Becquemin JP, Pillet JC, Lescalie F, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011; 53:1167.
  195. Lederle FA, Freischlag JA, Kyriakides TC, et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med 2012; 367:1988.
  196. Paravastu SC, Jayarajasingam R, Cottam R, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev 2014; :CD004178.
  197. Stather PW, Sidloff D, Dattani N, et al. Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm. Br J Surg 2013; 100:863.
  198. Karthikesalingam A, Thompson MM. Vascular disease: Repair of infrarenal aortic aneurysm--the debate is OVER. Nat Rev Cardiol 2013; 10:122.
  199. Schermerhorn ML, O'Malley AJ, Jhaveri A, et al. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008; 358:464.
  200. Patel R, Sweeting MJ, Powell JT, et al. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet 2016; 388:2366.
  201. http://www.xrayrisk.com/calculator/calculator.php (Accessed on November 04, 2016).
  202. Berrington de González A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 2009; 169:2071.
  203. http://content.onlinejacc.org/cgi/reprint/47/6/e1.pdf (Accessed on March 23, 2010).
  204. Coscas R, Maumias T, Capdevila C, et al. Mini-invasive treatment of abdominal aortic aneurysms: current roles of endovascular, laparoscopic, and open techniques. Ann Vasc Surg 2014; 28:123.
  205. De Martino RR, Goodney PP, Nolan BW, et al. Optimal selection of patients for elective abdominal aortic aneurysm repair based on life expectancy. J Vasc Surg 2013; 58:589.
  206. Siracuse JJ, Gill HL, Graham AR, et al. Comparative safety of endovascular and open surgical repair of abdominal aortic aneurysms in low-risk male patients. J Vasc Surg 2014; 60:1154.
  207. Vallabhaneni R, Farber MA, Schneider F, Ricco JB. Debate: whether young, good-risk patients should be treated with endovascular abdominal aortic aneurysm repair. J Vasc Surg 2013; 58:1709.
  208. Sandford RM, Choke E, Bown MJ, Sayers RD. What is the best option for elective repair of an abdominal aortic aneurysm in a young fit patient? Eur J Vasc Endovasc Surg 2014; 47:13.
  209. Lee K, Tang E, Dubois L, et al. Durability and survival are similar after elective endovascular and open repair of abdominal aortic aneurysms in younger patients. J Vasc Surg 2015; 61:636.