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endovascular repair associated with lower morbidity and mortality than open repair (N Engl J Med 2008 Jan 31)
Description:
Also called:
Types:
Organs Involved:
Incidence/Prevalence:
prevalence of AAA
o varies from 1.3% to 8.9% in men and 1% to 2.2% in women (Lancet 2005 Apr 30;365(9470):1577)
o varies from 2% to 7.8% (Ann Intern Med 1993 Sep 1;119(5):411 full-text)
o prevalence of AAAs 2.9-4.9 cm varies with age, gender, family history and tobacco use
typical prevalence in men ranges from 1.3% at ages 45-54 years to 12.5% at ages 75-84
years
typical prevalence in women ranges from 0% at ages 45-54 years to 5.2% at ages 75-84
years
Reference - ACC/AHA 2005 guidelines (J Am Coll Cardiol 2006 Mar 21;47(6):1239
PDF)
prevalence of ruptured AAA
o cause of death annually for about 1.2% males and 0.6% females > 65 years old
o 21-66% of patients survive to surgery, with 50% mortality following surgery
o Reference - Ann Intern Med 1993 Sep 1;119(5):411 full-text
Pathogenesis:
smoking
clinical vascular disease
male
older age
increased blood pressure
increased total cholesterol
family history of AAA
Reference - based on 6 cohort studies Click for Details
o smoking most important risk factor, based on a cross-sectional screening study of 73,451
veterans 50-79 years old
1,031 (1%) had AAA > 4 cm on ultrasound
smoking increased risk almost 6x, risk increased with duration and smoking and
decreased with duration of quitting
other risk factors included older age, family history, atherosclerosis, hypertension, high
cholesterol
Reference - Ann Intern Med 1997 Mar 15;126(6):441 in J Watch 1997 Apr 15;17(8):63
o risk factors for AAA include smoking, older age, family history of AAA, atherosclerotic
diseases, male sex; while diabetes and black race negatively associated with AAA
52,745 veterans ages 50-79 years without history of AAA underwent successful
ultrasound screening for AAA
AAA > 4 cm detected in 613 (1.2%), results consistent with 1.4% detection rate in earlier
cohort of 73,451 veterans
odds ratios for major associations with AAA for combined cohorts (total population of
126,196) were
5.07 for smoking
1.94 for family history of AAA
1.71 for age (per 7 years)
1.66 for atherosclerotic diseases;
0.53 for black race
0.52 for diabetes
0.18 for female sex
excess prevalence associated with smoking accounted for 75% of all AAAs > 4 cm
Reference - Arch Intern Med 2000 May 22;160(10):1425
classic risk factors for atherosclerotic diseases associated with AAA
based on a cohort of 29,133 Finnish male smokers, aged 50-69 years
mean follow-up 5.8 years
risk of AAA associated with
age (relative risk 4.56, 95% CI 2.42-8.61 for > 65 vs. 55 years)
smoking years (relative risk 2.25, 95% CI 1.33-3.81 for > 40 vs. 32 years)
systolic blood pressure (relative risk 1.92, 95% CI 1.13-3.25 for > 160 vs.
130 mmHg)
diastolic blood pressure (relative risk 1.8, 95% CI 1.05-3.08 for > 100 vs. 85
mmHg)
serum total cholesterol (relative risk 1.85, 95% CI 1.09-3.12 for > 6.5 vs. 5
mmol/L [> 250 mg/dL vs. 193 mg/dL])
Reference - Epidemiology 2001 Jan;12(1):94
smoking, male sex and hypertension are risk factors for AAA
based on cohort of 5,356 men and women aged 65-79 years participating in randomized
trial
current hypertension associated with 30-40% increased risk of AAA while use of
antihypertensive medication associated with 70-80% increased risk
men were nearly 6x more likely to develop AAA than women
smoking was an independent risk factor for AAA, with level of exposure more significant
than duration
Reference - Br J Surg 2000 Feb;87(2):195
clinical vascular disease strongly associated with AAA
based on prospective study of 4,741 patients > 64 years old
ratio of transverse diameter of maximum infrarenal aorta and aorta just below superior
mesenteric artery, defined as I/S ratio; AAA defined as I/S ratio 1.2
overall incidence of AAA 9.5%, with 14.2% in men and 6.2% in women
risk factors for AAA include age, male sex, coronary artery disease, peripheral vascular
disease, carotid occlusive disease, smoking and elevated LDL levels
no relationship found between blood pressure and presence of AAA, although patients
treated for hypertension more likely to have AAA
Reference - Arterioscler Thromb Vasc Biol 1996 Aug;16(8):963 in QuickScan Reviews in
Fam Pract 1997 Feb;21(11):11
family history associated with increased risk, especially for older male relatives of persons
with AAA
study of 214 living relatives > 50 years old of 150 consecutive patients undergoing repair
of infrarenal AAA vs. 284 controls
comparing persons with family history of AAA vs. controls
4.6% vs. 1.4% had AAA > 3 cm detected by ultrasound or had prior AAA
repair
1.2% vs. 0 had aortic dilatation (2-2.9 cm)
Reference - Ann Intern Med 1999 Apr 20;130(8):637 in J Watch 1999 Jun 1;19(11);87,
summary in Am Fam Physician 1999 Sep 15;60(4):1234
Complications:
rupture
erosion of adjacent structures
embolization, thrombosis
fistulization, including aortocaval fistula (high-output congestive heart failure)
disseminated intravascular coagulation (DIC) reported in 3% to 4% patients having surgery for AAA
o DIC reported in 2 of 67 (3%) patients having surgery for AAA (Ann Vasc Surg 1996 Jul;10(4):396)
o DIC reported in 3 of 76 (4%) patients having surgery for AAA (Arch Surg 1983 Nov;118(11):1252)
Associated conditions:
coronary artery disease -- AAA associated with increased incidence of cardiovascular disease and mortality
o based on cohort of 4,734 men and women > 65 years old followed for 4.5 years
o 8.8% had AAA (88% of which had 3-3.5 cm diameter)
o comparing persons with vs. without AAA
all-cause mortality 6.51 vs. 3.28 per 100 person-years
cardiovascular mortality 3.43 vs. 1.38 per 100 person-years
incident cardiovascular disease 4.73 vs. 3.1 per 100 person-years
o Reference - Ann Intern Med 2001 Feb 6;134(3):182
arterial infection with Salmonella cholerasius or S. typhimurium
iliac artery aneurysm (extension of AAA, pulsatile mass on rectal exam, occasionally ruptures into
gastrointestinal tract)
inguinal hernias in men, possibly related to degeneration of connective tissue (Br J Surg 1999 Sep;86(9):1155
in BMJ 1999 Oct 2;319(7214):930)
History
Chief Concern (CC):
can be familial (X-linked most common, also autosomal dominant), but same groups have atherosclerosis
smoking
Physical
General Physical:
normal vital signs may be present initially with rupture, but patients can become severely hypotensive rapidly
Abdomen:
Extremities:
Diagnosis
Making the diagnosis:
Rule out:
Testing to consider:
Imaging studies:
AAA may appear as incidental finding on abdominal x-ray (stippled calcifications to left of spine)
ultrasound
o B-mode ultrasound most practical, cost-effective for serial size
o portable ultrasound in emergency department might improve diagnostic certainty but no
reliable evidence for impact on clinical outcomes
systematic review found only 1 case series for abdominal aortic aneurysm
portable ultrasound reported to have 100% sensitivity
estimated positive likelihood ratio 14.6 and negative likelihood ratio 0.06 for abdominal
aortic aneurysm
no studies reported mortality rates
no studies reported complication rates, time to diagnosis or time to operative treatment
for patients with abdominal aortic aneurysm
Reference - CCOHTA technology report 2006 Mar:63 PDF
o Finnish Medical Society Duodecim evidence-based guideline on indications and preparation of
patient for ultrasonographic examinations can be found at National Guideline Clearinghouse 2007
Mar 19:10478
computed tomography (CT)
o CT can detect retroperitoneal rupture
o CT may show suprarenal extension and other abdominal abnormalities which may influence
aneurysm repair
CT estimates of AAA size are larger than ultrasound estimates
o based on an analysis of 334 patients in national endograft trial who had both CT and ultrasound
measurements
o maximal AAA diameter ranged from 4-8 cm on CT
o
o
o
Prognosis
Prognosis:
15-20% show no increase in size, > 80% progressive enlargement, 15-20% grow > 0.5 cm/year
some aneurysms quiescent for months to years then sudden increase
large aneurysms usually grow more rapidly
any aneurysm may rupture, risk increases with size
aneurysms growing > 0.5 cm/6 months tend to rupture
retroperitoneal ruptures may be contained but can blowout at any time
risk of rupture in 5 years - < 4.5 cm 9%, 4.5-7 cm 35%, > 7 cm 75%
risk factors for rupture include larger AAA diameter, female sex, higher mean arterial blood pressure
and current smoking
o based on ultrasound surveillance of 2,257 patients with 4,102 patient-years of follow-up
o 103 episodes of AAA rupture
o number of ruptures per 100 patient-years was 0.3 for AAAs < 4 cm, 1.5 for AAAs 4-4.9 cm and 6.5
for AAAs 5-5.9 cm
o Reference - Ann Surg 1999 Sep;230(3):289 in J Watch 1999 Oct 15;19(20):157 or in Am Fam
Physician 2000 Feb 1;61(3):875
aneurysm size is a strong predictor of risk of rupture and
o based on professional association guidelines
o estimated annual risk of AAA rupture
< 4.0 cm (0%)
4.0 to 4.9 cm (0.5% to 5%)
5.0 to 5.9 cm (3% to 15%)
6.0 to 6.9 cm (10% to 20%)
7.0 to 7.9 cm (20% to 40%)
8.0 cm (30% to 50%)
o 5.5 cm considered best threshold for repair in "average" AAA patients
o Reference - American Association for Vascular Surgery and Society for Vascular Surgery guidelines
(J Vasc Surg 2003 May;37(5):1106)
AAA > 5-5.5 cm has high rupture rate if untreated (i.e. patients unfit for surgery)
o based on 3 cohort studies
o prospective study of 476 patients (mean age 73 years) with AAA > 5 cm initially considered unfit
for surgery
CT performed every 6 months for mean 4 years
173 eventually had elective surgery
50 (10.5%) had rupture of AAA
annual rupture rate for AAAs 5-5.9 cm were 1% for men and 4% for women
annual rupture rate for AAA 6 cm or larger 14% for men and 22% for women
Reference - J Vasc Surg 2003 Feb;37(2):280 in J Watch Online 2003 Mar 18
o study of 198 veterans with AAA at least 5.5 cm who refused or were unfit for elective AAA repair
Reference - prospective study of 69 patients who had AAA resection for non-ruptured AAA, 8
(11.6%) died within 30 days after surgery (Current Controlled Trials in Cardiovascular Medicine
2005 Sep 7;6:14)
Glasgow Aneurysm Score predicts postoperative survival after open surgical or endovascular
intervention
o Glasgow Aneurysm Score (GAS) = age in years plus
7 points if myocardial disease (previous myocardial infarction and/or ongoing angina)
10 points if cerebrovascular disease (any stroke or transient ischemic attack)
14 points if renal disease (history of acute or chronic renal failure, creatinine level > 133
mcmol/L [1.51 mg/dL], and/or creatinine clearance < 50 mL/minute)
o original GAS developed based on 500 randomly selected patients treated for AAA in general
surgical units in Glasgow hospitals 1980-1990, and also included 17 points if shock (Cardiovasc
Surg 1994 Feb;2(1):41)
o GAS predicts postoperative mortality after endovascular AAA repair
prospective study of 5,498 patients (median age 73 years) with non-ruptured
asymptomatic infrarenal AAA at least 4 cm (median 5.6 cm) who received endovascular
self-expanding stent-graft and were followed at least 1 month, median GAS 78.8
155 patients (2.8%) died within 30 days
30-day mortality
1.1% with GAS < 74.4
2.1% with GAS 74.4-83.6
5.3% with GAS > 83.6
Reference - Br J Surg 2006 Feb;93(2):191
o GAS appears to predict postoperative morbidity and mortality after elective open AAA repair
based on 3 retrospective studies
GAS predicted morbidity and mortality after elective open AAA repair
retrospective study of 1,911 patients undergoing open AAA repair with
outcomes at 30 days
GAS > 76 (vs. < 76) predicted
mortality (9% vs. 3%)
severe complications (31% vs. 15%)
cardiac complications (12% vs. 4%)
intensive care unit stay > 5 days (12% vs. 6%)
Reference - Eur J Vasc Endovasc Surg 2003 Dec;26(6):612
GAS predicted postoperative death, severe postoperative complications, myocardial
infarction, and stroke in retrospective study of 403 patients undergoing elective open
repair of infrarenal AAA (Br J Surg 2003 Jul;90(7):838)
GAS, Leiden score, modified Leiden score and Vanzetto score each predicted in-hospital
mortality in retrospective study of 286 patients undergoing elective infrarenal AAA
repair; Eagle risk score less accurate for predicting in-hospital mortality; only modified
Leiden score predicted postoperative complications (Eur J Vasc Endovasc Surg 2004
Jul;28(1):52)
poor preoperative lung and renal function are associated with postoperative mortality
o based on prospective cohort study
o cohort of 820 patients aged 60-80 years who had open surgery in UK Small Aneurysm Trial
o 5.6% overall postoperative mortality risk
o postoperative mortality risk significantly associated with higher serum creatinine (p = 0.002) and
lower forced expiratory volume in 1 second (p = 0.003)
o postoperative mortality risk significantly associated with older age (p = 0.03, but p = 0.08 after
adjusting for creatinine level and lower forced expiratory volume in 1 second)
o Reference - Br J Surg 2000 Jun;87(6):742
Treatment
Treatment overview:
no good evidence to support medication as primary treatment to reduce AAA expansion or risk of AAA
rupture
surgery
o surgery recommended for AAA > 5.5 cm (grade B recommendation [inconsistent or limited
evidence]) or symptomatic AAA of any diameter (grade C recommendation [lacking direct
evidence])
o surgery for AAA < 5.5 cm does not reduce mortality within 5 years (level 1 [likely reliable]
evidence) but might improve survival after 5 years (level 2 [mid-level] evidence)
o intervention not recommended for asymptomatic infrarenal or juxtrarenal AAA < 5 cm in men or <
4.5 cm in women (grade A recommendation [consistent high-quality evidence])
endovascular aneurysm repair (EVAR)
o EVAR has lower perioperative mortality than open repair (level 1 [likely reliable] evidence) but
similar all-cause mortality at 2-4 years (level 2 [mid-level] evidence)
o EVAR may not improve all-cause mortality in patients unfit for open surgery (level 2 [mid-level]
evidence)
recommendations for ultrasound screening intervals based on aneurysm diameter vary
o if > 4.5 cm, every 3-6 months
o if 4-4.5 cm, every 6-12 months
o if 3.5-4 cm, every 1-2 years
o if < 3.5 cm, every 3 years
reduction of traditional cardiovascular risk factors recommended - see Cardiovascular disease prevention
overview
Medications:
no statistically significant associations found for beta blockers, calcium channel blockers, alpha
blockers, angiotensin receptor blockers or thiazide diuretics
o Reference - Lancet 2006 Aug 19;368(9536):659, editorial can be found in Lancet 2006 Aug
19;368(9536):622, commentary can be found in Lancet 2006 Nov 4;368(9547):1571, Am Fam
Physician 2006 Nov 15;74(10):1780
o DynaMed commentary -- cohort of patients admitted to hospital with AAA may not best reflect
cohort of patients with AAA
antichlamydial antibiotics may reduce AAA expansion rate but reduction in clinical outcomes (rupture,
surgery) not established (level 3 [lacking direct] evidence)
o based on 2 randomized trials too small to demonstrate clinical differences
o doxycycline may reduce AAA expansion rate (level 3 [lacking direct] evidence)
based on small randomized trial without clinical outcomes
32 patients with AAA 3-5.5 cm randomized to doxycycline 150 mg vs. placebo daily for
3 months and followed for 18 months
41% doxycycline vs. 7% placebo patients had AAA expansion > 5 mm (NNT 3)
Reference - J Vasc Surg 2001 Oct;34(4):606
doxycycline brand names include Monodox, Vibramycin, Vibra-Tabs, Doryx
o roxithromycin may reduce AAA expansion rate but may not affect clinical outcomes (level 3
[lacking direct] evidence)
based on small randomized trial
92 men with AAA 3-4.9 cm diameter were randomized to roxithromycin 300 mg vs.
placebo PO once daily for 28 days
AAA size monitored annually by ultrasound, men with AAA > 5 cm referred for surgery
mean follow-up 1.5 years
comparing roxithromycin vs. placebo
mean AAA expansion rate 1.56 vs. 2.75 mm/year (p = 0.02)
33% vs. 47% had AAA expansion rate > 2 mm/year (not significant in crude
analysis, statistically significant in logistic regression analysis)
12% vs. 14% referred for surgery (not significant)
Reference - Br J Surg 2001 Aug;88(8):1066, Ugeskr Laeger 2002 Dec 9;164(50):5916
roxithromycin brand names include Surlid, Rulide, Biaxsig, Roxar, Roximycin
Surgery:
Patient selection:
surgery probably indicated for suprarenal or type IV thoracoabdominal aneurysms > 5.5 cm (grade
B recommendation [inconsistent or limited evidence])
o Reference - American College of Cardiology/American Heart Association (ACC/AHA) 2005
guidelines for peripheral arterial disease (lower extremity, renal, mesenteric and abdominal aortic)
can be found in J Am Coll Cardiol 2006 Mar 21;47(6):1239 PDF
surgery for AAA < 5.5 cm does not reduce mortality within 5 years (level 1 [likely reliable] evidence)
but might improve survival after 5 years (level 2 [mid-level] evidence)
o based on 2 randomized trials with 2,226 patients
o surgery does not improve 5-year survival for AAA < 5.5 cm (level 1 [likely reliable] evidence)
based on randomized trial
1,136 patients 50-79 years old with asymptomatic AAA 4-5.4 cm diameter who did not
have high surgical risk were randomized to immediate open surgical repair vs.
surveillance
surveillance group had ultrasound or CT every 6 months with repair for
symptomatic aneurysms or aneurysms > 5.5 cm
mean follow-up 4.9 years (range 3.5-8 years)
comparing surgery vs. surveillance
92.6% vs. 61.6% had aneurysm repair by end of study
25.1% vs. 21.5% overall mortality (not significant)
3% vs. 2.6% death related to AAA (not significant)
0.4 vs. 1.9% rupture of AAA (7 of 11 ruptures in surveillance group resulted in
death), rate of AAA rupture was 0.6%/year in surveillance group
survival trends did not favor surgery in any prespecified subgroup
Reference - ADAM trial (N Engl J Med 2002 May 9;346(19):1437), editorial can be
found in N Engl J Med 2002 May 9;346(19):1484, commentary can be found in POEMs
in J Fam Pract 2002 Aug;51(8):671, N Engl J Med 2002 Oct 3;347(14):1112 (correction
can be found in N Engl J Med 2002 Dec 5;347(23):1902)
immediate repair vs. surveillance had no significant differences in most quality of
life measures
surgery group had increased rate of impotence after 1 year (p < 0.03)
surgery group had better general health scores (p < 0.0001), particularly in first
2 years after randomization
no significant differences in other quality of life measures
Reference - J Vasc Surg 2003 Oct;38(4):745
o surgery of small AAA (4-5.5 cm) associated with short-term mortality risk and small longterm survival benefit at 6-10 years (level 2 [mid-level] evidence)
based on randomized trial with borderline statistical significance
1,090 patients ages 60-76 years with AAA 4-5.4 cm diameter were randomized to early
elective surgery vs. surveillance by ultrasound (with repair for symptomatic aneurysms or
aneurysms > 5.5 cm or expanding > 1 cm/year)
mean follow-up 8 years (range 6-10 years)
comparing surgery vs. surveillance
5.5% 30-day mortality led to early disadvantage with surgery
survival equivalent at 2, 3, 4 and 6 years
28.2% vs. 28.5% mortality at 6 years
43% vs. 48.2% mortality at end of study (p = 0.05, NNT 20)
restricted mean duration of survival at 9 years was 6.5 vs. 6.7 years (not
significant)
92.4% vs. 62% had aneurysm repair by end of study
benefit in early surgery group may be associated with lifestyle changes, especially
smoking cessation which was 12.8 times more likely after aneurysm repair
no overall differences in quality of life at 1 year but early surgery group had positive
improvement in current health perceptions and less negative change in bodily pain
References - UK Small Aneurysm Trial
N Engl J Med 2002 May 9;346(19):1445, editorial can be found in N Engl J
Med 2002 May 9;346(19):1484, summary can be found in Am Fam Physician
2002 Sep 15;66(6):1086, commentary can be found in N Engl J Med 2002 Oct
3;347(14):1112, N Engl J Med 2005 Sep 15;353(11):1181
Lancet 1998 Nov 21;352(9141):1649, 1656, commentary can be found in
Lancet 1999 Jan 30;353(9150):407
61% surveillance group eventually had surgery (Evidence-Based Medicine 1999
May/Jun;4(3):88)
o Cochrane review on surgery for small AAAs not updated since 1999; systematic review last
updated 1999 May 5 (Cochrane Library 1999 Issue 4:CD001835)
surgery recommended for symptomatic AAA of any diameter (grade C recommendation [lacking direct
evidence])
o based on case series, consensus opinion or standard of care
o Reference - American College of Cardiology/American Heart Association (ACC/AHA) 2005
guidelines for peripheral arterial disease (lower extremity, renal, mesenteric and abdominal aortic)
can be found in J Am Coll Cardiol 2006 Mar 21;47(6):1239 PDF
intervention not recommended for asymptomatic infrarenal or juxtarenal AAA < 5 cm in men or < 4.5
cm in women (grade A recommendation [consistent high-quality evidence])
o based on data derived from multiple randomized trials or meta-analyses
o American College of Cardiology/American Heart Association (ACC/AHA) 2005 guidelines for
peripheral arterial disease (lower extremity, renal, mesenteric and abdominal aortic) can be found in
J Am Coll Cardiol 2006 Mar 21;47(6):1239 PDF
Perioperative management:
Surgical approaches:
Surgical complications:
lower annual hospital volume of AAA repair associated with higher mortality (level 2 [mid-level]
evidence)
o based on meta-analysis of observational studies
o in analysis of 21 studies plus UK Hospital Episode Statistics data with 421,299 elective AAA
repairs
9.5% overall mortality rate
Endovascular stent-graft:
FDA recommends using AneuRx Stent Graft only in patients meeting appropriate risk-benefit profile who can
be treated according to instructions, based on 1.5% perioperative mortality in analysis of 942 patients (FDA
MedWatch 2003 Dec 17)
endovascular aneurysm repair (EVAR) has lower perioperative mortality than open repair (level 1
[likely reliable] evidence) but similar all-cause mortality at 2-4 years (level 2 [mid-level] evidence)
o based on 4 randomized trials with ascertainment bias for long-term outcomes
systematic review of 4 randomized trials comparing endovascular repair vs. open repair in 1,532
patients with large AAAs
endovascular repair had lower 30-day mortality (1.6% vs. 4.8%, NNT 32)
endovascular repair had shorter hospital stay (weighted median 6.2 vs. 11.5 days)
outcomes at 2-4 years limited by not attributing deaths to AAA if autopsy not done
comparing endovascular vs. open repair at 2-4 years in 3 trials with 1,473 patients
3% vs. 5.7% AAA-related mortality (p = 0.02, NNT 37)
16.8% vs. 17.6% all-cause mortality (not significant, 95% CI ranges from NNT
24 to NNH 30)
Reference - Ann Intern Med 2007 May 15;146(10):735, editorial can be found in Ann
Intern Med 2007 May 15;146(10):749, commentary can be found in Ann Intern Med
2008 Feb 5;148(3):245
systematic review of 2 randomized trials comparing endovascular repair vs. open surgical repair for
AAA at least 5.5 cm with follow-up at least 2 years
endovascular repair had lower 30-day mortality (1.6% vs. 4.7%, NNT 33)
endovascular repair had higher rates of postoperative complications and reinterventions
no significant differences in mortality at 2 years or quality of life after 3-6 months
Reference - AHRQ Evidence Report on Abdominal Aortic Aneurysm, Endovascular and
Open Surgical Repairs 2006 Aug:144
EVAR trial 1
1,082 patients > 60 years old with AAA at least 5.5 cm randomized to endovascular vs.
open AAA repair
1,017 patients (94%) complied with allocated treatment
comparing endovascular vs. open AAA repair at 30 days
1.7% vs. 4.7% mortality (p = 0.009, NNT 34)
9.8% vs. 5.8% rate of secondary interventions (p = 0.02, NNH 25)
Reference - EVAR 1 trial (Lancet 2004 Sep 4;364(9437):843), editorial can be found in
Lancet 2004 Sep 4-10;364(9437):818; commentary can be found in Am Fam Physician
2005 Jun 15;71(12):2368
EVAR and open aneurysm repair appear to have similar all-cause mortality at 4
years (level 2 [mid-level] evidence)
follow-up rates were 100% at 1 year, 70% at 2 years, 47% at 3 years and 24%
at 4 years
comparing endovascular vs. open AAA repair at 4 years in intent-to-treat
analysis (all 1,082 patients)
18.4% vs. 20.2% deaths from any cause (not statistically significant)
3.5% vs. 6.3% aneurysm-related deaths (p = 0.04, NNT 36)
41% vs. 9% postoperative complications (p < 0.0001, NNH 3)
no difference in quality of life after 12 months
Reference - Lancet 2005 Jun 25;365(9478):2179, editorial can be found in
Lancet 2005 Jun 25;365(9478):2156, commentary can be found in Lancet 2005
Sep 10;366(9489):890, 890, BMJ 2005 Sep 24;331(7518):644, BMJ 2005 Nov
5;331(7524):1081, Perspect Vasc Surg Endovasc Ther 2006 Mar;18(1):74
DREAM trial
based on randomized trial with inadequate statistical power for mortality outcome
endovascular repair has lower perioperative complication rate than open repair
(level 1 [likely reliable] evidence) and possibly lower perioperative mortality (level 2
[mid-level] evidence)
based on randomized trial
351 patients (mean age 70 years) with AAA at least 5 cm randomized to
endovascular vs. open AAA repair
6 patients who did not undergo surgery were excluded
comparing endovascular vs. open AAA repair at 30 days
1.2% vs. 4.6% mortality (NNT 30 but not statistically significant, p =
0.1)
based on cohort of 1,190 patients in EUROSTAR registry who had endovascular stentgraft with Stentor or Vanguard graft and were followed for up to 8 years
7.1% conversion to open repair
2.4% aneurysm rupture
19.9% all-cause mortality
3% aneurysm-related mortality
48% survival at 8 years free of these events
frequent procedure-related complications were endoleak (13 per 100 patient-years),
stenosis/thrombosis (4.6 per 100 patient-years) and stent migration (4.3 per 100 patientyears)
Reference - Arch Surg 2007 Jan;142(1):33
o retrospective report of first 100 patients treated with endovascular repair at Mayo Clinic can be
found in Mayo Clin Proc 2003 Oct;78(10):1234 full-text, commentary can be found in Mayo Clin
Proc 2004 Apr;79(4):570 PDF
endovascular repair associated with shorter hospitalization (level 2 [mid-level] evidence)
o based on small randomized trial
o 40 patients with low surgical risk profile randomized to endovascular vs. open repair
o mean duration of hospitalization 4.5 vs. 11.5 days (p = 0.001)
o no significant differences in functional autonomy and quality of life measures
o Reference - J Vasc Interv Radiol 2005 Aug;16(8):1093
insufficient evidence to recommend emergency endovascular repair for ruptured AAA
o based on Cochrane review
o systematic review of randomized trials comparing emergency EVAR vs. open surgical repair in
patients with confirmed ruptured AAA
o no randomized trials identified
o Reference - systematic review last updated 2006 Nov 1 (Cochrane Library 2007 Issue
1:CD005261)
emergency EVAR and open repair appear to have similar outcomes in patients with ruptured AAA
(level 2 [mid-level] evidence)
o based on observational study of 100 patients with ruptured AAA
o 49 patients treated with emergency EVAR compared to 51 patients treated with open surgery
o comparing emergency EVAR vs. open repair
35% vs. 39% in-hospital or 30-day mortality (not statistically significant)
40% vs. 42% all-cause mortality at 3 months (not statistically significantly)
59% primary complication rate in both groups at 3 months
o Reference - J Vasc Surg 2006 Jun;43(6):1111
review of endovascular repair of AAA can be found in N Engl J Med 2008 Jan 31;358(5):494
review of endovascular repair of AAA can be found in Mayo Clin Proc 1999 Oct;74(10):999
discussion of endovascular repair with stent graft can be found in Postgrad Med 2001 Jun;109(6):93
National Institute for Health and Clinical Excellence (NICE) guidance on stent-graft placement in abdominal
aortic aneurysm can be found in NICE 2006 Mar:IPG163
Canadian Society for Vascular Surgery consensus statement on endovascular aneurysm repair can be found in
CMAJ 2005 Mar 29;172(7):867
Follow-up:
15,775 patients aged 65-80 years randomized to control vs. invitation for screening
ultrasound and followed for up to 5 years
in screening group, patients rescanned annually if aneurysm 3-4.4 cm, rescanned every 3
months if aneurysm 4.5-5.9 cm
surgical criteria were aneurysm > 6 cm, increase in diameter > 1 cm/year, or development
of symptoms attributable to aneurysm
of those invited for screening, 68.4% accepted
4% had AAA (7.6% in men, 1.3% in women)
41% of those with AAA satisfied criteria for surgery, and 16% had surgery
none of 31 patients who had elective surgery died within 1 year, whereas 3 of 4
who had emergency surgery died (all 3 had been considered unfit for surgery)
of 2,493 people who declined screening initially, 5 died from ruptured AAA
in control group, 20 men and 2 women presented with ruptured AAA, 19 of whom died
within 1 year
comparing screening invitation vs. control in men
16.6% vs. 15.7% overall mortality (not significant)
0.25% vs. 0.5% mortality from AAA rupture (not significant)
0.28% vs. 0.62% incidence of ruptured AAA (NNT 295)
comparing screening invitation vs. control in women
10.7% vs. 10.2% overall mortality (not significant)
0.064% vs. 0.043% mortality from AAA rupture (not significant)
0.064% vs. 0.043% incidence of ruptured AAA (not significant)
Reference - Br J Surg 1995 Aug;82(8):1066, commentary can be found in POEMs in J
Fam Pract 1996 Apr;42(4):350
potentially cost-effective approaches to AAA screening for men at age 60-80 years
o single screening with abdominal palpation
o single screening with ultrasound
o repeated screening not cost-effective
o Reference - systematic review by Canadian Task Force on the Periodic Health Examination (Ann
Intern Med 1993 Sep 1:119(5):411 full-text)
rescreening men with negative initial screen at 4 years reported to have little practical value (level 3
[lacking direct] evidence)
o based on large cohort study without long-term follow-up
o 5,151 veterans aged 50-79 without AAA (defined as > 3 cm) on initial ultrasound randomly
selected for rescreening
11.6% had died (not related to AAA)
0.4% had interim diagnosis of AAA
o 2,622 patients were rescreened and 58 (2.2%) had AAA but most were small (45 were 3-3.5 cm, 10
were 3.5-4 cm, 3 were 4-4.9 cm)
o Reference - Arch Intern Med 2000 Apr 24;160(8):1117
review of ultrasound screening can be found in Ann Intern Med 2003 Sep 16;139(6):516, correction can be
found in Ann Intern Med 2003 Nov 18;139(10):873, summary can be found in Am Fam Physician 2004 Mar
1;69(5):1247
discussion of evidence for national screening program in United Kingdom can be found in BMJ 2004 May
8;328(7448):1122, editorial can be found in BMJ 2004 May 8;328(7448):1087 (correction can be found in
BMJ 2004 Jun 19;328(7454):1486)
American College of Cardiology/American Heart Association (ACC/AHA) 2005 guidelines for peripheral
arterial disease (lower extremity, renal, mesenteric and abdominal aortic) (J Am Coll Cardiol 2006 Mar
21;47(6):1239 PDF)
AHRQ Evidence Report on Abdominal Aortic Aneurysm, Endovascular and Open Surgical Repairs 2006
Aug:144
MEDLINE search 2007 Feb 7 using PubMed Clinical Queries (therapy) for "abdominal aortic aneurysm"
Click for Details
o Click here to repeat MEDLINE search
o 40 studies included in this summary
Leurs LJ, Buth J, Harris PL, Blankensteijn JD. Impact of Study Design on Outcome after
Endovascular Abdominal Aortic Aneurysm Repair. A Comparison between the
Randomized Controlled DREAM-trial and the Observational EUROSTAR-registry. Eur J
Vasc Endovasc Surg. 2007 Feb;33(2):172-6.
Rutherford RB. Endovascular aneurysm repair and outcome in patients unfit for open
repair of abdominal aortic aneurysm (EVAR trial 2): randomized controlled trial. Perspect
Vasc Surg Endovasc Ther. 2006 Mar;18(1):76-7.
Rutherford RB. Endovascular aneurysm repair versus open repair in patients with
abdominal aortic aneurysm (EVAR trial 1): randomized controlled trial. Perspect Vasc
Surg Endovasc Ther. 2006 Mar;18(1):74-6.
Senekowitsch C, Assadian A, Assadian O, Hartleb H, Ptakovsky H, Hagmuller GW.
Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair:
influence on postoperative colon ischemia. J Vasc Surg. 2006 Apr;43(4):689-94.
Laohapensang K, Rerkasem K, Chotirosniramit N. Mini-laparotomy for repair of
infrarenal abdominal aortic aneurysm. Int Angiol. 2005 Sep;24(3):238-44.
Laohapensang K, Rerkasem K, Chotirosniramit N. Left retroperitoneal versus midline
transperitoneal approach for abdominal aortic aneurysms (AAAs) repair. J Med Assoc
Thai. 2005 May;88(5):601-6.
Soulez G, Therasse E, Monfared AA, Blair JF, Choiniere M, Elkouri S, Beaudoin N,
Giroux MF, Cliche A, Lelorier J, Oliva VL. Pain and quality of life assessment after
endovascular versus open repair of abdominal aortic aneurysms in patients at low risk. J
Vasc Interv Radiol. 2005 Aug;16(8):1093-100.
EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for
open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial.
Lancet. 2005 Jun 25-Jul 1;365(9478):2187-92.
EVAR trial participants. Endovascular aneurysm repair versus open repair in patients
with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet.
2005 Jun 25-Jul 1;365(9478):2179-86.
Blankensteijn JD, de Jong SE, Prinssen M, van der Ham AC, Buth J, van Sterkenburg
SM, Verhagen HJ, Buskens E, Grobbee DE; Dutch Randomized Endovascular Aneurysm
Management (DREAM) Trial Group. Two-year outcomes after conventional or
endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2005 Jun
9;352(23):2398-405.
Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for abdominal aortic
aneurysms: single centre randomised controlled trial. BMJ. 2005 Apr 2;330(7494):750.
Mercer KG, Spark JI, Berridge DC, Kent PJ, Scott DJ. Randomized clinical trial of
intraoperative autotransfusion in surgery for abdominal aortic aneurysm. Br J Surg. 2004
Nov;91(11):1443-8.
Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer CA, Tuohy RJ, Parsons
RW, Dickinson JA. Population based randomised controlled trial on impact of screening
on mortality from abdominal aortic aneurysm. BMJ. 2004 Nov 27;329(7477):1259.
Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, Buskens E,
Grobbee DE, Blankensteijn JD; Dutch Randomized Endovascular Aneurysm
Management (DREAM)Trial Group. A randomized trial comparing conventional and
endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004 Oct
14;351(16):1607-18.
Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG; EVAR trial
participants. Comparison of endovascular aneurysm repair with open repair in patients
with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results:
randomised controlled trial. Lancet. 2004 Sep 4-10;364(9437):843-8.
Lederle FA, Johnson GR, Wilson SE, Acher CW, Ballard DJ, Littooy FN, Messina LM;
Aneurysm Detection and Management Veterans Affairs Cooperative Study. Quality of
life, impotence, and activity level in a randomized trial of immediate repair versus
surveillance of small abdominal aortic aneurysm. J Vasc Surg. 2003 Oct;38(4):745-52.
Vammen S, Lindholt JS, Ostergaard LJ, Fasting H, Henneberg EW. [Reduction of the
expansion rate of small abdominal aortic aneurysms with roxithromycin. Results from a
randomized controlled trial] Ugeskr Laeger. 2002 Dec 9;164(50):5916-9.
Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA, Thompson SG,
Walker NM; Multicentre Aneurysm Screening Study Group. The Multicentre Aneurysm
Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on
mortality in men: a randomised controlled trial. Lancet. 2002 Nov 16;360(9345):1531-9.
Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study
(MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based
on four year results from randomised controlled trial. BMJ. 2002 Nov
16;325(7373):1135.
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 May 9;346(19):1445-52.
Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, Acher CW, Ballard DJ,
Messina LM, Gordon IL, Chute EP, Krupski WC, Busuttil SJ, Barone GW, Sparks S,
Graham LM, Rapp JH, Makaroun MS, Moneta GL, Cambria RA, Makhoul RG, Eton D,
Ansel HJ, Freischlag JA, Bandyk D; Aneurysm Detection and Management Veterans
Affairs Cooperative Study Group. Immediate repair compared with surveillance of small
abdominal aortic aneurysms. N Engl J Med. 2002 May 9;346(19):1437-44.
Matsumoto M, Hata T, Tsushima Y, Hamanaka S, Yoshitaka H, Shinoura S, Sakakibara
N. Minimally invasive vascular surgery for repair of infrarenal abdominal aortic
aneurysm with iliac involvement. J Vasc Surg. 2002 Apr;35(4):654-60.
Propanolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic
aneurysms: results of a randomized trial. J Vasc Surg. 2002 Jan;35(1):72-9.
Wong JC, Torella F, Haynes SL, Dalrymple K, Mortimer AJ, McCollum CN; ATIS
Investigators. Autologous versus allogeneic transfusion in aortic surgery: a multicenter
randomized clinical trial. Ann Surg. 2002 Jan;235(1):145-51.
Mosorin M, Juvonen J, Biancari F, Satta J, Surcel HM, Leinonen M, Saikku P, Juvonen T.
Use of doxycycline to decrease the growth rate of abdominal aortic aneurysms: a
randomized, double-blind, placebo-controlled pilot study. J Vasc Surg. 2001
Oct;34(4):606-10.
Vammen S, Lindholt JS, Ostergaard L, Fasting H, Henneberg EW. Randomized doubleblind controlled trial of roxithromycin for prevention of abdominal aortic aneurysm
expansion. Br J Surg. 2001 Aug;88(8):1066-72.
Tornwall ME, Virtamo J, Haukka JK, Albanes D, Huttunen JK. Life-style factors and risk
for abdominal aortic aneurysm in a cohort of Finnish male smokers. Epidemiology. 2001
Jan;12(1):94-100.
Brady AR, Fowkes FG, Greenhalgh RM, Powell JT, Ruckley CV, Thompson SG. 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 Jun;87(6):742-9.
Lederle FA, Johnson GR, Wilson SE, Chute EP, Hye RJ, Makaroun MS, Barone GW,
Bandyk D, Moneta GL, Makhoul RG. 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
May 22;160(10):1425-30.
Vardulaki KA, Walker NM, Day NE, Duffy SW, Ashton HA, Scott RA. Quantifying the
risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm.
Br J Surg. 2000 Feb;87(2):195-200.
Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under
ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999
Sep;230(3):289-96.
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 Mar;18(1):52-7.
Clagett GP, Valentine RJ, Jackson MR, Mathison C, Kakish HB, Bengtson TD. A
randomized trial of intraoperative autotransfusion during aortic surgery. J Vasc Surg.
1999 Jan;29(1):22-30.
[No authors listed] 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 Nov 21;352(9141):1649-55.
Spark JI, Chetter IC, Kester RC, Scott DJ. Allogeneic versus autologous blood during
abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg. 1997 Dec;14(6):482-6.
Farrer A, Spark JI, Scott DJ. Autologous blood transfusion: the benefits to the patient
undergoing abdominal aortic aneurysm repair. J Vasc Nurs. 1997 Dec;15(4):111-5.
Sieunarine K, Lawrence-Brown MM, Goodman MA. Comparison of transperitoneal and
retroperitoneal approaches for infrarenal aortic surgery: early and late results. Cardiovasc
Surg. 1997 Feb;5(1):71-6.
Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screening on the incidence of
ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study. Br
J Surg. 1995 Aug;82(8):1066-70.
Sicard GA, Reilly JM, Rubin BG, Thompson RW, Allen BT, Flye MW, Schechtman KB,
Young-Beyer P, Weiss C, Anderson CB. Transabdominal versus retroperitoneal incision
for abdominal aortic surgery: report of a prospective randomized trial. J Vasc Surg. 1995
Feb;21(2):174-81.
Samy AK, Murray G, MacBain G. Glasgow aneurysm score. Cardiovasc Surg. 1994
Feb;2(1):41-4.
7 studies included in summarized systematic reviews
Norman JG, Fink GW. The effects of epidural anesthesia on the neuroendocrine response
to major surgical stress: a randomized prospective trial. Am Surg. 1997 Jan;63(1):75-80.
[No authors listed] The U.K. Small Aneurysm Trial: design, methods and progress. The
UK Small Aneurysm Trial participants. Eur J Vasc Endovasc Surg. 1995 Jan;9(1):42-8.
Gold MS, Russo J, Tissot M, Weinhouse G, Riles T. Comparison of hetastarch to albumin
for perioperative bleeding in patients undergoing abdominal aortic aneurysm surgery. A
prospective, randomized study. Ann Surg. 1990 Apr;211(4):482-5.
Prinssen M, Buskens E, Nolthenius RP, van Sterkenburg SM, Teijink JA, Blankensteijn
JD. Sexual dysfunction after conventional and endovascular AAA repair: results of the
DREAM trial. J Endovasc Ther. 2004 Dec;11(6):613-20.
Prinssen M, Buskens E, Blankensteijn JD; DREAM trial participants. Quality of life
endovascular and open AAA repair. Results of a randomised trial. Eur J Vasc Endovasc
Surg. 2004 Feb;27(2):121-7.
Scott RA, Bridgewater SG, Ashton HA. Randomized clinical trial of screening for
abdominal aortic aneurysm in women. Br J Surg. 2002 Mar;89(3):283-5.
Scott RA, Vardulaki KA, Walker NM, Day NE, Duffy SW, Ashton HA. The long-term
benefits of a single scan for abdominal aortic aneurysm (AAA) at age 65. Eur J Vasc
Endovasc Surg. 2001 Jun;21(6):535-40.
166 studies not included in this summary
Hoornweg LL, Wisselink W, Vahl A, Balm R; On behalf of the Amsterdam Acute
Aneurysm Trial Collaborators. The Amsterdam Acute Aneurysm Trial: Suitability and
Application Rate for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.
Eur J Vasc Endovasc Surg 2007 Jun;33(6):679
Dale W, Hemmerich J, Ghini EA, Schwarze ML. Can induced anxiety from a negative
earlier experience influence vascular surgeons' statistical decision-making? A randomized
field experiment with an abdominal aortic aneurysm analog. J Am Coll Surg. 2006
Nov;203(5):642-52.
Moore NN, Lapsley M, Norden AG, Firth JD, Gaunt ME, Varty K, Boyle JR. Does Nacetylcysteine prevent contrast-induced nephropathy during endovascular AAA repair? A
randomized controlled pilot study. J Endovasc Ther. 2006 Oct;13(5):660-6.
Ward HB, Kelly RF, Thottapurathu L, Moritz TE, Larsen GC, Pierpont G, Santilli S,
Goldman S, Krupski WC, Littooy F, Reda DJ, McFalls EO. Coronary artery bypass
grafting is superior to percutaneous coronary intervention in prevention of perioperative
myocardial infarctions during subsequent vascular surgery. Ann Thorac Surg. 2006
Sep;82(3):795-800.
Boker A, Haberman CJ, Girling L, Guzman RP, Louridas G, Tanner JR, Cheang M,
Maycher BW, Bell DD, Doak GJ. Variable ventilation improves perioperative lung
function in patients undergoing abdominal aortic aneurysmectomy. Anesthesiology. 2004
Mar;100(3):608-16.
Hsia J, Criqui MH, Rodabough RJ, Langer RD, Resnick HE, Phillips LS, Allison M,
Bonds DE, Masaki K, Caralis P, Kotchen JM; Women's Health Initiative Investigators.
Estrogen plus progestin and the risk of peripheral arterial disease: the Women's Health
Initiative. Circulation. 2004 Feb 10;109(5):620-6.
Eriksson P, Jones KG, Brown LC, Greenhalgh RM, Hamsten A, Powell JT. Genetic
approach to the role of cysteine proteases in the expansion of abdominal aortic
aneurysms. Br J Surg. 2004 Jan;91(1):86-9.
Rittoo D, Gosling P, Burnley S, Bonnici C, Millns P, Simms MH, Smith SR, Vohra RK.
Randomized study comparing the effects of hydroxyethyl starch solution with Gelofusine
on pulmonary function in patients undergoing abdominal aortic aneurysm surgery. Br J
Anaesth. 2004 Jan;92(1):61-6.
Webster SE, Smith J, Thompson MM, Bell PR, Naylor AR. Does the sequence of clamp
application during open abdominal aortic aneurysm surgery influence distal
embolisation? Eur J Vasc Endovasc Surg. 2004 Jan;27(1):61-4.
Hayashi Y, Ohtani M, Sawa Y, Hiraishi T, Akedo H, Kobayashi Y, Matsuda H. Synthetic
human alpha-atrial natriuretic peptide improves the management of postoperative
hypertension and renal dysfunction after the repair of abdominal aortic aneurysm. J
Cardiovasc Pharmacol. 2003 Nov;42(5):636-41.
Duda D, Lorenz W, Celik I. [Mesenteric traction syndrome during the operation of
aneurysms of the abdominal aorta--histamine release and prophylaxis with
antihistaminics] Anaesthesiol Reanim. 2003;28(4):97-103.
Wolowczyk L, Nevin M, Smith FC, Baird RN, Lamont PM. Haemodilutional effect of
standard fluid management limits the effectiveness of acute normovolaemic
haemodilution in AAA surgery--results of a pilot trial. Eur J Vasc Endovasc Surg. 2003
Oct;26(4):405-11.
Torsello GB, Kasprzak B, Klenk E, Tessarek J, Osada N, Torsello GF. Endovascular
suture versus cutdown for endovascular aneurysm repair: a prospective randomized pilot
study. J Vasc Surg. 2003 Jul;38(1):78-82.
Volta CA, Ferri E, Marangoni E, Ragazzi R, Verri M, Alvisi V, Zardi S, Bertacchini S,
Gritti G, Alvisi R. Respiratory function after aortic aneurysm repair: a comparison
between retroperitoneal and transperitoneal approaches. Intensive Care Med. 2003
Aug;29(8):1258-64.
Morishita K, Kawaharada N, Fukada J, Yamada A, Baba T, Abe T. Can minilaparotomy
abdominal aortic aneurysm repair be performed safely and effectively without special
skills? Surgery. 2003 Apr;133(4):390-5.
Lindholt JS, Juul S, Fasting H, Vammen S, Henneberg EW. [Hospital costs and benefits
of screening for abdominal aortic aneurysm. Results from a randomized screening trial]
Ugeskr Laeger. 2003 Feb 3;165(6):579-83.
Duda D, Lorenz W, Celik I. Histamine release in mesenteric traction syndrome during
abdominal aortic aneurysm surgery: prophylaxis with H1 and H2 antihistamines.
Inflamm Res. 2002 Oct;51(10):495-9.
d'Audiffret A, Santilli S, Tretinyak A, Roethle S. Fate of the ectatic infrarenal aorta:
expansion rates and outcomes. Ann Vasc Surg. 2002 Sep;16(5):534-6.
Wijnen MH, Vader HL, Roumen RM. Multi-antioxidant supplementation does not
prevent an increase in gut permeability after lower torso ischemia and reperfusion in
humans. Eur Surg Res. 2002 Jul-Aug;34(4):300-5.
Watters JM, Vallerand A, Kirkpatrick SM, Abbott HE, Norris S, Wells G, Barber GG.
Limited effects of micronutrient supplementation on strength and physical function after
abdominal aortic aneurysmectomy. Clin Nutr. 2002 Aug;21(4):321-7.
Wijnen MH, Vader HL, Van Den Wall Bake AW, Roumen RM. Can renal dysfunction
after infra-renal aortic aneurysm repair be modified by multi-antioxidant
supplementation? J Cardiovasc Surg (Torino). 2002 Aug;43(4):483-8.
Wijnen MH, Roumen RM, Vader HL, Goris RJ. A multiantioxidant supplementation
reduces damage from ischaemia reperfusion in patients after lower torso ischaemia. A
randomised trial. Eur J Vasc Endovasc Surg. 2002 Jun;23(6):486-90.
Vardulaki KA, Walker NM, Couto E, Day NE, Thompson SG, Ashton HA, Scott RA.
Late results concerning feasibility and compliance from a randomized trial of
ultrasonographic screening for abdominal aortic aneurysm. Br J Surg. 2002
Jul;89(7):861-4.
Prinssen M, Buskens E, Blankensteijn JD. The Dutch Randomised Endovascular
Aneurysm Management (DREAM) trial. Background, design and methods. J Cardiovasc
Surg (Torino). 2002 Jun;43(3):379-84.
Bonazzi M, Gentile F, Biasi GM, Migliavacca S, Esposti D, Cipolla M, Marsicano M,
Prampolini F, Ornaghi M, Sternjakob S, Tshomba Y. Impact of perioperative
haemodynamic monitoring on cardiac morbidity after major vascular surgery in low risk
patients. A randomised pilot trial. Eur J Vasc Endovasc Surg. 2002 May;23(5):445-51.
Jones K, Powell J, Brown L, Greenhalgh R, Jormsjo S, Eriksson P. The influence of
4G/5G polymorphism in the plasminogen activator inhibitor-1 gene promoter on the
incidence, growth and operative risk of abdominal aortic aneurysm. Eur J Vasc Endovasc
Surg. 2002 May;23(5):421-5.
Boyle JR. Randomized double-blind controlled trial of roxithromycin for prevention of
abdominal aortic aneurysm expansion. Br J Surg. 2002 Apr;89(4):492.
Gibbs R. Randomized double-blind controlled trial of roxithromycin for prevention of
abdominal aortic aneurysm expansion. Br J Surg. 2002 Apr;89(4):491-2.
Couto E, Duffy SW, Ashton HA, Walker NM, Myles JP, Scott RA, Thompson SG.
Probabilities of progression of aortic aneurysms: estimates and implications for screening
policy. J Med Screen. 2002;9(1):40-2.
Coselli JS, Lemaire SA, Koksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid
drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a
randomized clinical trial. J Vasc Surg. 2002 Apr;35(4):631-9.
Rittoo D, Gosling P, Bonnici C, Burnley S, Millns P, Simms MH, Smith SR, Vohra RK.
Splanchnic oxygenation in patients undergoing abdominal aortic aneurysm repair and
volume expansion with eloHAES. Cardiovasc Surg. 2002 Apr;10(2):128-33.
Lau LL, Halliday MI, Smye MG, Lee B, Hannon RJ, Gardiner KR, Soong CV.
Extraperitoneal approach reduces intestinal and renal dysfunction in elective abdominal
aortic aneurysm repair. Int Angiol. 2001 Dec;20(4):282-7.
Lindholt JS, Juul S, Fasting H, Henneberg EW. Hospital costs and benefits of screening
for abdominal aortic aneurysms. Results from a randomised population screening trial.
Eur J Vasc Endovasc Surg. 2002 Jan;23(1):55-60.
Vretzakis G, Papadopoulos G, Koutsias S, Papaziogas B, Antoniadou E, Pitoulias G,
Papadimitriou D. Alterations in carbon dioxide release during abdominal aortic clamping
for aneurysmal or occlusive repair. Minerva Anestesiol. 2001 Sep;67(9):629-36.
Cohen J, Loewinger J, Hutin K, Sulkes J, Zelikovski A, Singer P. The safety of
immediate extubation after abdominal aortic surgery: a prospective, randomized trial.
Anesth Analg. 2001 Dec;93(6):1546-9.
Waters JH, Gottlieb A, Schoenwald P, Popovich MJ, Sprung J, Nelson DR. Normal saline
versus lactated Ringer's solution for intraoperative fluid management in patients
undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg. 2001
Oct;93(4):817-22.
Lindholt JS, Vammen S, Henneberg EW, Fasting H, Juul S. [Optimal interval screening
and observation of abdominal aortic aneurysms] Ugeskr Laeger. 2001 Sep
10;163(37):5034-7.
Cuypers PW, Gardien M, Buth J, Peels CH, Charbon JA, Hop WC. Randomized study
comparing cardiac response in endovascular and open abdominal aortic aneurysm repair.
Br J Surg. 2001 Aug;88(8):1059-65.
Tornwall ME, Virtamo J, Haukka JK, Albanes D, Huttunen JK. Alpha-tocopherol
(vitamin E) and beta-carotene supplementation does not affect the risk for large
abdominal aortic aneurysm in a controlled trial. Atherosclerosis. 2001 Jul;157(1):167-73.
Chichester Aneurysm Screening Group; Viborg Aneurysm Screening Study; Western
Australian Abdominal Aortic Aneurysm Program; Multicentre Aneurysm Screening
Study. A comparative study of the prevalence of abdominal aortic aneurysms in the
United Kingdom, Denmark, and Australia. J Med Screen. 2001;8(1):46-50.
Jones KG, Brull DJ, Brown LC, Sian M, Greenhalgh RM, Humphries SE, Powell JT.
Interleukin-6 (IL-6) and the prognosis of abdominal aortic aneurysms. Circulation. 2001
May 8;103(18):2260-5.
Lau LL, Gardiner KR, Martin L, Halliday MI, Hannon RJ, Lee B, Soong CV.
Extraperitoneal approach reduces neutrophil activation, systemic inflammatory response
and organ dysfunctionin aortic aneurysm surgery. Eur J Vasc Endovasc Surg. 2001
Apr;21(4):326-33.
Lawrence-Brown MM, Norman PE, Jamrozik K, Semmens JB, Donnelly NJ, Spencer C,
Tuohy R. Initial results of ultrasound screening for aneurysm of the abdominal aorta in
Western Australia: relevance for endoluminal treatment of aneurysm disease. Cardiovasc
Surg. 2001 Jun;9(3):234-40.
McGinley J, Lynch L, Hubbard K, McCoy D, Cunningham AJ. Dopexamine
hydrochloride does not modify hemodynamic response or tissue oxygenation or gut
permeability during abdominal aortic surgery. Can J Anaesth. 2001 Mar;48(3):238-44.
Powell JT, Brown LC. The natural history of abdominal aortic aneurysms and their risk
of rupture. Acta Chir Belg. 2001 Jan-Feb;101(1):11-6.
Spencer CA, Jamrozik K, Norman PE, Lawrence-Brown MM. The potential for a
selective screening strategy for abdominal aortic aneurysm. J Med Screen.
2000;7(4):209-11.
Luijendijk RW, Hop WC, van den Tol MP, de Lange DC, Braaksma MM, IJzermans JN,
Boelhouwer RU, de Vries BC, Salu MK, Wereldsma JC, Bruijninckx CM, Jeekel J. A
comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000
Aug 10;343(6):392-8.
Lindholt JS, Vammen S, Fasting H, Henneberg EW. Psychological consequences of
screening for abdominal aortic aneurysm and conservative treatment of small abdominal
aortic aneurysms. Eur J Vasc Endovasc Surg. 2000 Jul;20(1):79-83.
[No authors listed] Smoking, lung function and the prognosis of abdominal aortic
aneurysm. The UK Small Aneurysm Trial Participants. Eur J Vasc Endovasc Surg. 2000
Jun;19(6):636-42.
Lau LL, Halliday MI, Lee B, Hannon RJ, Gardiner KR, Soong CV. Intestinal
manipulation during elective aortic aneurysm surgery leads to portal endotoxaemia and
mucosal barrier dysfunction. Eur J Vasc Endovasc Surg. 2000 Jun;19(6):619-24.
Robinson J, Nawaz S, Beard JD. Randomized, multicentre, double-blind, placebocontrolled trial of the use of aprotinin in the repair of ruptured abdominal aortic
aneurysm. On behalf of the Joint Vascular Research Group. Br J Surg. 2000
Jun;87(6):754-7.
Zannetti S, De Rango P, Parente B, Parlani G, Verzini F, Maselli A, Nardelli L, Cao P.
Role of duplex scan in endoleak detection after endoluminal abdominal aortic aneurysm
repair. Eur J Vasc Endovasc Surg. 2000 May;19(5):531-5.
Ragaller M, Muller M, Bleyl JU, Strecker A, Segiet TW, Ellinger K, Albrecht DM.
Hemodynamic effects of hypertonic hydroxyethyl starch 6% solution and isotonic
hydroxyethyl starch 6% solution after declamping during abdominal aortic aneurysm
repair. Shock. 2000 May;13(5):367-73.
Garrioch MA, McClure JH, Wildsmith JA. Haemodynamic effects of diaspirin
crosslinked haemoglobin (DCLHb) given before abdominal aortic aneurysm surgery. Br J
Anaesth. 1999 Nov;83(5):702-7.
Komori K, Ishida M, Matsumoto T, Kume M, Ohta S, Takeuchi K, Onohara T, Sugimachi
K. Cytokine patterns and the effects of a preoperative steroid treatment in the patients
with abdominal aortic aneurysms. Int Angiol. 1999 Sep;18(3):193-7.
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Reviews:
Guidelines:
American College of Cardiology/American Heart Association (ACC/AHA) 2005 guidelines for peripheral
arterial disease (lower extremity, renal, mesenteric and abdominal aortic) can be found in J Am Coll Cardiol
2006 Mar 21;47(6):1239 PDF or at National Guideline Clearinghouse 2006 May 29:8503
o commentary notes that guideline statement suggesting benefit in patients with abdominal aortic
aneurysms 5-5.4 cm in diameter MISREPRESENTS two cited randomized trials which found no
benefit (N Engl J Med 2006 Apr 6;354(14):1537)
US Preventive Services Task Force recommendations
o USPSTF recommends one-time screening for AAA by ultrasonography in men aged 65-75 years
who have ever smoked (B recommendation)
o USPSTF makes no recommendation for or against screening for AAA in men aged 65-75 years
who have never smoked (C recommendation)
o USPSTF recommends against routine screening for AAA in women (D recommendation)
o Reference - Ann Intern Med 2005 Feb 1;142(3):198, supporting systematic review can be found in
Ann Intern Med 2005 Feb 1;142(3):203, summary can be found at National Guideline
Clearinghouse 2005 Feb 7:6013, commentary can be found in Ann Intern Med 2005 Aug
16;143(4):309
National Institute for Health and Clinical Excellence (NICE) guidance on stent-graft placement in abdominal
aortic aneurysm can be found in NICE 2006 Mar:IPG163
Canadian Society for Vascular Surgery consensus statement on endovascular aneurysm repair can be found in
CMAJ 2005 Mar 29;172(7):867
American College of Radiology (ACR) Appropriateness Criteria for pulsatile abdominal mass can be found
in National Guideline Clearinghouse 2006 Mar 20:8293, previous version can be found in Radiology 2000
Jun;215(Suppl):55
American College of Radiology (ACR) Appropriateness Criteria for palpable abdominal mass can be found at
National Guideline Clearinghouse 2006 Sep 4:9595
Finnish Medical Society Duodecim evidence-based guidelines on aortic aneurysm and dissection can be
found at National Guideline Clearinghouse 2005 Oct 31:7377
American Association for Vascular Surgery and Society for Vascular Surgery guidelines for treatment of
abdominal aortic aneurysms can be found in J Vasc Surg 2003 May;37(5):1106