VASCULAR SURGERY e I
Abdominal aortic
aneurysm: epidemiology,
screening and work-up
for repair
Nina Al-Saadi
Matthew J Bown
Abstract
Abdominal aortic aneurysm (AAA) is a dilatation of the infra-renal
abdominal aorta to greater than 3 cm. Population screening is offered
to men in the year of their 65th birthday in the UK. Patients with small,
asymptomatic AAAs (<5.5 cm) are entered into surveillance pro-
grammes and have their cardiovascular risk factors managed aggres-
sively. An AAA
5.5 cm diameter, or one which is symptomatic,
should be considered for surgical repair to prevent rupture. Aneurysm
repair can be undertaken using either an open surgical or endovascu-
lar approach; the decision should be tailored to the individual patient
and made by the surgeon and patient, with input from a multi-
disciplinary team.
Keywords AAA; AAA repair; abdominal aortic aneurysm; aneurysms;
aorta; risk factors; screening; surveillance
Introduction
An aneurysm is a focal, permanent dilatation of an artery or vessel
to more than 50% of its normal diameter (Figure 1). The natural
history of aortic aneurysms is asymptomatic growth followed by
rupture, which is fatal in many cases. For the infra-renal
abdominal aorta, an absolute diameter of 3 cm is the usual
threshold at which a diagnosis of abdominal aortic aneurysm
(AAA) is made. AAA affects approximately 5% of men1 and
0.74% of women2 over the age of 65 years. Men in the UK aged 65
years are invited for AAA screening using ultrasound. The prev-
alence of AAA in those who attend for AAA screening is around
1%.1 Approximately 14,500 elective (planned) and 2400 emer-
gency AAA repairs are carried out every three years in the UK.
Epidemiology and risk factors
Large-scale cross-sectional studies of AAA screening with ultra-
sound early this century demonstrated that the prevalence of an
infra-renal aortic diameter greater than 3 cm is approximately
5% in men over the age of 65 years.1 Existing evidence suggests
that the prevalence of AAA in women is lower than that in men.
Non-modifiable risk factors for AAA include increasing age, AAA
Nina Al-Saadi MRCS is a Core Surgical Trainee in Vascular Surgery at
University Hospitals of Leicester, UK. Conflicts of interest: none
declared.
Matthew J Bown MD FRCS is Professor of Vascular Surgery at
University of Leicester, UK. Conflicts of interest: none declared.
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is rare before the age of 55 years, and a positive family history for
the disease; having a sibling affected by AAA increases individual
risk by approximately sevenfold.
The strongest risk factor for AAA is cigarette smoking, the
impact of which by far surpasses genetic and all other modifiable
risk factors. Prospective observational studies have demon-
strated that current cigarette smoking can increase the risk of
AAA development by as much as eightfold compared to those
that have never smoked. The duration of smoking also has a
linear correlation with AAA development and growth.3 Indeed, it
is likely that public health measures aimed at smoking cessation
may, in part, explain the reduction in AAA prevalence seen in the
past 10e15 years.4
Other risk factors for development of AAA include hyper-
lipidaemia and other atherosclerotic diseases. Hypertension is
considered to be a risk factor although this remains uncertain.
Interestingly, diabetes appears to protect against both the
development and progression of AAA. The mechanism for this
unexpected observation is unclear. Whether this is due to con-
founding from other factors associated with diabetes, such as the
common use of metformin to treat diabetes, is unknown.
Clinical presentation
Aortic aneurysms are commonly discovered incidentally, as part
of the diagnostic imaging work-up for unrelated conditions or are
found through screening. An abdominal aortic aneurysm may
also be detected as a pulsatile upper abdominal mass through
routine physical examination. Clinical diagnosis depends on
clinician experience and patient factors which including body
habitus and the size of the aneurysm.
Occasionally, patients with unruptured AAAs present with
symptoms, typically abdominal, back or loin pain. Large AAAs
can also compress surrounding structures such as the ureters,
inferior vena cava or duodenum. This may lead to development of
symptoms, but this is uncommon. Patients with AAAs may pre-
sent with ischaemic symptoms in the lower limbs secondary to
acute thrombosis or embolization to the peripheral circulation,
but again this is not common. Very rarely AAA presents with
haemorrhagic and thrombotic complications due to disseminated
intravascular coagulation (DIC). A few (<2%) AAAs are classified
as inflammatory or mycotic (Figure 2). These may present with
abdominal or back pain, weight loss, fevers and/or elevated in-
flammatory makers. These patients may also develop acute renal
failure secondary to inflammatory changes in the retroperitoneum
causing ureteric obstruction. Infective causes should be consid-
ered in patients with unusual AAA presentations or malaise,
particularly when an AAA develops in a younger patient.
AAA rupture has a mortality exceeding 80%. This classically
presents as a triad of abdominal pain radiating to the back,
haemorrhagic shock and a palpable pulsatile abdominal mass.
However, it is important to recognize that not all cases of AAA
will have all of these features. It is not uncommon for patients
with ruptured AAA to be diagnosed as having ureteric colic,
musculoskeletal back pain or other diagnoses commonly pre-
senting to the emergency department. There should therefore be
a high clinical suspicion of ruptured AAA in older patients (>50
years) presenting to the emergency department with unexplained
abdominal, back or loin pain.
283 Ó 2021 Published by Elsevier Ltd.
 VASCULAR SURGERY e I

Screening Study (MASS),5 have demonstrated both clinical

Figure 1 Computed tomography angiogram (CTA) 3D reconstruction
of an infra-renal abdominal aortic aneurysm with right common iliac
artery aneurysm. The length of healthy aorta from the renal arteries to
the aneurysm makes this anatomically suitable for endovascular repair
(EVAR). For EVAR, the right stent graft limb would need to extend to
the external iliac artery with embolization of the internal iliac artery, to
prevent endoleak.
effectiveness (reduced mortality) and economic effectiveness
(acceptable cost) for AAA screening in men. In the MASS study
the cost was £36K per quality life year gained at 4 years; how-
ever, this was estimated to reduce to £8K by 10 years due to
repair of AAA in men in the surveillance group who would
otherwise die from rupture.
These trials led to the implementation of AAA screening
programmes globally. Screening at a population level is now
carried out in all four UK nations (England, Scotland, Wales and
Northern Ireland) and in Sweden, with some screening also
offered in the USA, Germany and Denmark. The NHS currently
offers the largest AAA screening programme, with all men being
offered an ultrasound scan in the year of their 65th birthday.
In the UK, screening is carried out using abdominal ultra-
sound scanning: a sensitive, specific and inexpensive method of
detecting AAAs. It is carried out by technicians trained to follow
a set protocol to measure the maximum inner-to-inner aortic
diameter of the infra-renal aorta.
 Men with an aortic diameter <3.0 cm are discharged.
 Men with aortic diameter 3.0e5.4 cm are entered into
surveillance.
 Men with aortic diameter
5.5 cm are referred to a
vascular surgeon.
In the US, the Veterans Administration AAA screening pro-
gramme offers targeted AAA screening to men aged 65e75 with a
history of cigarette smoking. Although this targeted screening
strategy is more cost effective,6 it is not known if it results in
reduced clinical effectiveness. In Denmark, the Danish VIVA
trial7 demonstrated that inviting men aged 65e74 years for
screening for peripheral arterial disease, high blood pressure and
AAA reduced all-cause mortality compared to no screening. This
multicomponent screening model is not currently used in the UK
and further studies are needed to assess its effectiveness.

Screening in men Screening in women

Most AAAs are asymptomatic until they rupture. This previously
caused a major challenge in the prevention of death from AAA.
Early detection before the point of rupture and timely interven-
tion leads to reduced aneurysm-related mortality. Randomized
controlled trials (RCTs), including the Multicentre Aneurysm
In the UK, aortic aneurysm related deaths have fallen faster in
men compared to women; this can possibly be attributed to AAA
screening in men.4 Women are not currently included in AAA
screening programmes as there is no RCT evidence demonstrating
the effectiveness of AAA screening in women. The main reason

Figure 2 (a) Inflammatory AAA with dense white inflammation across the retroperitoneum overlying the aneurysm sac and encasing the second
part of the duodenum. (b) Saccular mycotic aneurysm of the posterior aorta at the level of the superior mesenteric artery.

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 VASCULAR SURGERY e I
for this is that the prevalence of AAA in women is lower than in
men. However, a woman with an AAA is four times more likely to
experience rupture than a man.8 Studies have also shown that the
prevalence of AAA in certain high-risk groups of women,
including smokers and those with cardiovascular disease,9 is
higher than the overall prevalence of AAA in men currently
offered screening. There is therefore the potential for targeted
AAA screening for women in high-risk groups to be both clinically
and cost effective, but this concept has not been proven.
Surveillance
Surgery i.e. repair of the aneurysm, remains the main therapeutic
option to prevent AAA growth and rupture. However, as aneu-
rysm repair is associated with significant risks it is only recom-
mended when the risk of rupture is greater than the risk of surgery
for that individual. The main determinant of AAA rupture risk is
aneurysm size (Table 1).10e13 Patients with an AAA often have
other significant co-morbidities, such as coronary artery, periph-
eral arterial or respiratory disease, or malignancy. In the era of
personalized medicine, a single measure, such as maximum AAA
diameter is insufficient to decide on the risks and benefits of
aneurysm repair, a potentially risky intervention.
Conservative management, in the form of aneurysm surveil-
lance is offered to individuals in whom the risk of rupture is low,
or in whom the risk of repair is high. Surveillance takes the form
of scheduled abdominal ultrasound scans to monitor AAA
diameter and growth. The frequency for surveillance varies
globally, as a rule, the larger the aneurysm, the increased fre-
quency of surveillance. In the UK individuals with small aneu-
rysms (3.0e4.4 cm) undergo surveillance annually, whereas
individuals with medium aneurysms (4.5e5.4 cm) undergo
surveillance 3-monthly.
On average individuals with small AAAs spend between 3 and
7 years in a surveillance programme, depending on aneurysm
size at the time of detection.14 With individuals spending years in
surveillance before being referred for surgery, this time presents
an opportunity for interventions to reduce the rate of AAA
growth, the risk of AAA rupture and overall patient mortality
(cardiovascular disease related deaths).
Outcomes for AAA repair
Open surgical repair Endovascular repair
N[1355 (39%) N[2090 (61%)
Death in hospital 2.3% 0.4%
Return to theatre 6.8% 2.1%
Readmission to hospital 4.7% 5.7%
Haemorrhage 1.1% 0.8%
Chest infection 9.2% 1.1%
Renal failure 5.2% 1.1%
Cardiac complication 4.1% 0.8%
Lower limb ischaemia 2.6% 0.9%
Data from the National Vascular Registry 2020 report showing outcomes for
repair of AAA by both open surgical repair (OSR) and endovascular aortic stent
grafts (EVAR).
Table 1
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Smoking has been identified as the most important modifiable
risk factor causing accelerated AAA growth.4 Therefore, all pa-
tients with asymptomatic AAA who smoke are offered referral to
stop smoking services. It is also recommended that all patients
with hypertension are on appropriate therapies to reduce the risk
of AAA rupture.14 Studies have found that the principal pre-
ventable cause of mortality in men under AAA surveillance is
cardiovascular disease. In order to prevent surgical outcomes
and reduce all-cause mortality, all patients with AAA are now
offered information and intervention for the secondary preven-
tion of cardiovascular disease.15 They are offered lifestyle and
dietary advice, as well as statin and anti-platelet therapy.
There are currently no medical therapies that have been proven
to alter the growth of AAAs. Observational evidence suggested an
association between diabetic patients who were taking metformin
and slower aneurysm growth; however, there is no evidence from
RCTs. The effect of antibiotics, including azithromycin, roxi-
thromycin and doxycycline, have been evaluated by RCTs.16 No
association was found between azithromycin or doxycycline use
and aneurysm growth. Roxithromycin has been tested in small pilot
studies and an association observed with slower AAA growth.
There is a need for further studies to establish if this relationship
exists with other macrolide antibiotics and if its use outweighs the
effects of antibiotic resistance. Trials of antiplatelet therapy, cal-
cium channel blockers, beta-blockers, and ACE inhibitors have not
shown any significant effect on AAA growth.16
The current recommendation is for patients from AAA
screening to be referred to vascular specialists for consideration
of aneurysm repair when their AAA is >5.5 cm, when they are
symptomatic, or when their AAA is >4.0 cm and growing at a
rate of greater than 1 cm/year. In asymptomatic patients with
incidentally found AAA, the threshold diameter for consideration
of aortic aneurysm repair is again >5.5 cm. This is based on RCT
evidence demonstrating the safety of surveillance for patients
with AAA below this threshold.17 For common iliac aneurysms
the threshold diameter is between 3.5 and 4.0 cm, unlike for
AAAs there is no RCT evidence in support of this.
Symptomatic aortic aneurysms should be considered for repair,
even if small, as they have a very high risk of rupture. While in-
flammatory aneurysms that are sub-threshold can be managed
using steroids and regular surveillance, it may in addition be
necessary to relieve any concomitant ureteric obstruction.
Improving surgical outcomes
Repair of an AAA is associated with significant risk and periop-
erative and postoperative morbidity or mortality. Some of the
risks for people choosing to have planned AAA repair in UK
vascular units with either open surgery or endovascular repair
are shown in Table 2 (National Vascular Registry data). To
minimize these risks, and optimize patients prior to surgery, the
use of the preoperative surveillance period to assess and improve
‘fitness’ for surgery has been proposed. This is referred to as
‘prehabilitation’.
Prehabilitation and offering people with small AAA cardio-
vascular risk assessment and interventions is likely to reduce
perioperative and postoperative cardiovascular complications,
but this has not been formally tested or proven in trials. Evidence
from efficacy RCTs has shown the potential benefit of
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 VASCULAR SURGERY e I

preoperative exercise therapy.18,19 The sample sizes in these
trials is small and there is currently no evidence of effectiveness
(effect on clinical outcomes). Exercise programmes as a form of
prehabilitation does appears to be a promising area for improved
patient care; there are ongoing trials in AAA patients.
The potential role of the use of remote ischaemic pre-
conditioning (RIPC) and beta blocker therapy in the preopera-
tive period has also been explored. Evidence from RCTs has
identified no benefit of using RIPC or beta blockers de novo, and
therefore this is not recommended for use in patients undergoing
elective AAA surgery.
Work-up for surgical repair
Once the size threshold for surgical intervention is met patient
suitability for AAA repair, and the best surgical approach, have
to be determined. Patients can be offered open surgical repair
(OSR), standard endovascular repair (EVAR) or complex endo-
vascular repair (EVAR performed using a custom-made stent
graft or other adjuvants). In some people conservative AAA
management, often referred to as ‘turned-down’ for AAA repair,
is the safer option. The decision on the appropriate treatment
option must be made between the surgeon and the patient and is
supported by input from the multi-disciplinary aortic team,
including specialist vascular nurse, anaesthetist, and when
required, physicians specializing in care of the elderly or frail,
cardiology or respiratory medicine. Approximately 80% of UK
elective AAA cases were discussed in a formal multidisciplinary
team meeting in 2018 (National Vascular Registry data).20
Open surgical repair has been proven to be a durable treatment
for the management of AAAs. It is however, a major surgical
procedure performed under general anaesthesia, with patients
usually requiring admission to intensive care in the immediate
postoperative period. EVAR has been described to have revolu-
tionized the management of AAAs by offering a minimally inva-
sive approach to the repair of infra-renal and more complex aortic
aneurysms e with thoracic, fenestrated and branched devices.
Endovascular repair can be performed under local or regional
anaesthesia; although to do this the patient is required to lie flat
and relatively still for the duration of the procedure (general
anaesthesia is therefore preferred for more complex procedures).
Furthermore, not all aortic aneurysms are anatomically suitable
for endovascular repair and this is assessed using a contrast
enhanced computed tomography (CT) aortogram.
Preoperatively, patients require an anaesthetic review by a
consultant anaesthetist. Depending the patient’s comorbid status,
the planned approach to repair and the operating centre, they
may also require further tests such as an echocardiogram (ECHO)
and pulmonary function tests as part of the preoperative work
up. Specifically, the patient’s physiological reserve must be taken
into account when planning for OSR and the patient’s renal
function and requirement for intravenous hydration in the peri-
operative period must be taken into consideration when planning
for EVAR. Patients will also need appropriate preoperative

Risk of asymptomatic abdominal aortic aneurysm (AAA) rupture in men, excluding people with aortopathy
Powella(1999) Laerdle 2002) Twinea(2015) Earnshaw (2019)

Setting RCT (UK small aneurysms trial & 198 US Veterans, unfit (81%) Systematic review Screening
non-randomized patients) or declined AAA repair 1892 citations 18,652 men
2,257 (79% male) 11 studies 31 ruptures
103 ruptures 1514 patients
347 ruptures
Follow up e Mean 1.5 years 1.2e10.6 years Mean 2.5 years
Mean age 70 years 74 years 71e81 years Mean 67 years
Smoking (past) 37% (93%) 34% (95%) e 35% (90%)
3.0e4.4 cm 0.3% (3.9) 0.03% (0.02e0.05)b
4.5e5.4 cm 1.5% (4.0e4.9) 0.28% (0.17e0.44)b
5.0e5.5cm 0.4% (0.22e0.73)b
>5.5 cm e 5.3% (3.1e7.5)b
5.5e5.9cm 6.5% (5.0e5.9) 9.4% 3.5% (1.6e8.7)b
6.0e6.9cm 10.2% 4.1% (-.7-9.0)b
6.5e6.9 cm 19.1%

7.0 cm 32.5% 6.3% (-1.8-14)b

8.0 cm 25.7% ruptured within 6 months

Data sourced from papers by Brown and Powell (2001),13 Laerdle et al. (2002, USS or CT),14 Twine et al. (2019)15 and Earnshaw et al. (2015).16 Twine et al, include the
Laerdle and Powell series in their analysis. They also found that mortality from rupture was half that of other causes, and that around one third of patients who suffered
an AAA rupture were offered surgical repair, 58% of operated patients survived. Only 11% and 8.4% of men with small or medium sized AAA survived rupture in the series
by Powell et al. and Earnshaw et al. respectively.

a
Studies including both men and women.
b
95% confidence interval (CI).

Table 2

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 VASCULAR SURGERY e I
imaging to determine the extent of disease and the presence of
any co-existent lower limb arterial disease and of any other
conditions such as a horseshoe kidney, or occult malignancy,
which could affect both the surgical approach and potentially the
decision to operate.
Clinical prediction of perioperative risk based on history and
examination is often poor. No single risk prediction score has
been shown to be accurate. Many UK vascular units utilize car-
diopulmonary exercise testing (CPET) to classify operative risk
into ‘low’, ‘medium’ or ‘high’ based on three physiological
variables:
 anaerobic threshold (AT) e the exercise threshold above
which lactate is produced
 peak oxygen consumption (peak VO2) e a measure of
aerobic capacity
 ventilator equivalents (VE) e a measure of respiratory
function.
Lower values for the CPET-derived AT, peakVO2 and VE for
carbon dioxide are associated with poorer postoperative outcomes
and a longer length of stay in hospital. Evaluation of the CPET
graphs can also reveal any underlying cardiac or respiratory disease
requiring further investigation or optimization prior to surgery.
The postoperative course after OSR and EVAR is an important
factor when deciding on the surgical approach. Patients who
undergo OSR often have a longer early postoperative recovery
period (several months), but if no complications arise, they do
not require long-term follow up. Whereas, although EVAR is
associated with less physiological insult to the patient in the
perioperative period (recovery in weeks), regular surveillance
and life-long follow up is required to monitor for graft compli-
cations, such as endoleak, graft migration and graft collapse.
Patients are at an increased risk of requiring re-intervention
following EVAR (Figure 3). (See also AAA repair on pages
289e296 of this issue.)
In the UK, the majority of elective AAA repairs are currently
performed using an endovascular approach. In 2020, the National
Vascular Registry reported 61% of elective infra-renal AAA repairs
Figure 3 Ruptured AAA with large left retroperitoneal haematoma
following EVAR. The right stent graft limb has disconnected from its
socket resulting in aneurysm sac pressurization, growth and rupture.
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were endovascular procedures. For the years 2016e18, 89% of
complex aortic aneurysms in were treated with EVAR (fenestrated
or branched stent grafts). With respect to ruptured AAAs, despite
the adoption of EVAR in many centres, almost 70% of patients
were still treated with an open repair in the last 3 years.20
Guidelines currently recommend that once the threshold for
consideration of AAA repair is met, patients should be reviewed
to consider the best surgical approach (OSR, standard EVAR,
complex EVAR or ‘do nothing’). In this decision the patient’s
wishes and beliefs, comorbidities, fitness for general anaesthetic
and open surgery, as well as their aortic morphology and life
expectancy must all be taken into consideration. Overall, the
decision should be made by the patient and clinician, backed by
the wider multidisciplinary aortic team, using an individualized
approach and taking into account both the persons current and
future health.
Summary
Abdominal aortic aneurysm (AAA) is a life-threatening condi-
tion. Its aetiology is multi-factorial and there are no pharma-
cological therapies that have been proven to prevent AAA
development or progression. Screening and surveillance pro-
grammes have been adopted in men to prevent aneurysm-
related mortality and offer timely intervention. Intervention, in
the form of open or endovascular surgery, to prevent rupture
should be offered to patients with AAA >5.5 cm and acceptable
surgical risk. Patients require a thorough work up prior to any
intervention, taking into account the benefits and risk of each
approach and also patient’s individual requirements and
preference. A
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Practice points
C Abdominal aortic aneurysm (AAA), as defined by an aortic dia-
meter
3.0 cm, is screened for in men in their 65th year by the
four UK AAA screening programmes
C Cigarette smoking is the main modifiable risk factor for AAA growth
C In women, the prevalence of AAA is lower than in men, however,
there is evidence that AAA rupture risk is four times higher
C For AAA 5.5 cm ultrasound surveillance is safe as the rupture
risk is low (0.4% per annum)
C In larger aneurysms,
5.5 cm, AAA rupture is a less frequent
event than previously estimated, perhaps in part due to smoking
cessation, but when it occurs has a mortality of >80%
C Cardiovascular risk factors should be addressed in people with
AAA as they are at increased risk for cardiovascular events,
including non-aneurysm related cardiovascular death
C Prehabilitation prior to AAA repair while not yet proven to be
clinically or cost effective looks promising as a way to improve
patient outcomes; trials are ongoing
C In the absence of accurate clinical risk prediction scores, cardio-
pulmonary exercise testing (CPET) is helpful in evaluating for
cardiac and respiratory disease
C The decision to repair an AAA, or to manage conservatively
(‘do nothing’) is a shared decision between the patient and their
surgeon supported by input from a multidisciplinary team
288 Ó 2021 Published by Elsevier Ltd.