Eur J Vasc Endovasc Surg (2015) 49, 66e76

REVIEW

Beneficial Effects of Pre-operative Exercise Therapy in Patients with an

Abdominal Aortic Aneurysm: A Systematic Review
a,b
S. Pouwels , E.M. Willigendael c, M.R.H.M. van Sambeek a, S.W. Nienhuijs d, P.W.M. Cuypers a, J.A.W. Teijink a,b,*

a
Department of Vascular Surgery, Catharina Hospital, Michelangelolaan 2, 5602 ZA Eindhoven, The Netherlands
b
Department of Epidemiology, CAPHRI Research School, Maastricht University, Maastricht, The Netherlands
c
Department of General and Vascular Surgery, Medical Centre Alkmaar, Alkmaar, The Netherlands
d
Department of General Surgery, Catharina Hospital, Eindhoven, The Netherlands

WHAT THIS PAPER ADDS

This review provides an overview of the current evidence on pre-operative exercise therapy in patients with an
abdominal aortic aneurysm (AAA; with or without indication for surgical repair). Pre-operative exercise therapy
has potential beneficial effects on such variables as physical fitness, reduction in cardiovascular risk factors, post-
operative complications, length of stay, and recovery. Further research is needed to investigate the most
effective pre-operative exercise program for patients with AAA.

Objective/background: The impact of post-operative complications in abdominal aortic aneurysm (AAA) surgery
is substantial, and increases with age and concomitant co-morbidities. This systematic review focuses on the
possible effects of pre-operative exercise therapy (PET) in patients with AAA on post-operative complications,
aerobic capacity, physical fitness, and recovery.
Methods: A systematic search on PET prior to AAA surgery was conducted. The methodological quality of the
included studies was rated using the Physiotherapy Evidence Database scale. The agreement between the
reviewers was assessed with Cohen’s kappa.
Results: Five studies were included, with a methodological quality ranging from moderate to good. Cohen’s
kappa was 0.79. Three studies focused on patients with an AAA (without indication for surgical repair) with
physical fitness as the outcome measure. One study focused on PET in patients awaiting AAA surgery and one
study focused on the effects of PET on post-operative complications, length of stay, and recovery.
Conclusion: PET has beneficial effects on various physical fitness variables of patients with an AAA. Whether this
leads to less complications or faster recovery remains unclear. In view of the large impact of post-operative
complications, it is valuable to explore the possible benefits of a PET program in AAA surgery.
Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Article history: Received 21 July 2014, Accepted 14 October 2014, Available online 14 November 2014
Keywords: Abdominal aortic aneurysm, Abdominal surgery, Complications, Exercise training, Physical fitness,
Preconditioning

INTRODUCTION preventing AAA rupture and aneurysm related death. In

The development of an abdominal aortic aneurysm (AAA) is
age related, and affects approximately 7.5% of men and
3.0% of women.1 Surgical intervention (open reconstruction
or endovascular) is the only treatment effective in
* Corresponding author. J.A.W. Teijink, Department of Vascular Surgery,
Catharina Hospital, Michelangelolaan 2, 5602 ZA Eindhoven, The
Netherlands.
E-mail address: joep.teijink@catharinaziekenhuis.nl (J.A.W. Teijink).
1078-5884/$ e see front matter Ó 2014 European Society for Vascular
Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejvs.2014.10.008
general, this treatment is reserved for AAAs >55 mm in
diameter and >50 mm in men and women, respectively.2
Surgical intervention, especially open repair, results in sig-
nificant hemodynamic stress and an increased oxygen de-
mand in the peri- and post-operative period.3,4 A minimum
level of aerobic capacity and physical fitness is required to
maintain an adequate response to the physical stress
induced by surgical intervention.
The majority of patients with an AAA eligible for repair
are >65 years of age. Relatively fit octogenarians present-
ing with large AAAs are no longer an exception.5e7 Together
with the advancing age of AAA patients comes a poorer
Pre-operative Exercise Therapy in Patients with AAA
functional capacity due to multiple co-morbidities and an
increased risk for post-operative complications.7,8
An extensive cardiopulmonary co-morbidity is present in
this population compared with the population requiring
non-vascular major abdominal surgery (coronary disease or
congestive heart failure, w50%; hypertension, 30e50%;
chronic obstructive pulmonary disease, 30e40%; chronic
renal disease, w5%; cerebrovascular disease, w6%).5e8 (5-
8) Surgery can also induce a decline in functional capacity
(especially in the elderly), which has detrimental effects on
general health.5e8 By improving the physical condition,
peri-operative complications might be prevented. In the
non-surgical population there is evidence demonstrating
the beneficial effects of exercise on improving fitness in
patients with cardiorespiratory disease.9e12 There is
increasing evidence that pre-operative exercise therapy
(PET) is effective in reducing post-operative complications
and length of hospital stay after surgical interventions.13e16
However, the effectiveness of PET might vary between
different surgical interventions, as well as patient pop-
ulations.13e16 A different approach in the design of PET
programs seems necessary; however, evidence for a specific
design is still lacking.
A recent systematic review by Valkenet et al. (17) showed
that PET programs can be effective in reducing post-
operative complications and length of hospital stay.17
However, this study did not include any subgroup analysis
between different patient groups and their specific surgical
interventions. For example, a patient with colorectal cancer
has, owing to pre-operative chemoradiation, a limited pre-
operative time span for a PET program compared with a
patient scheduled for an elective AAA repair. Also, there is
no evidence for the effectiveness of different PET programs.
So far, the level of evidence is insufficient to have a pref-
erence for an endurance training program or a strength
program, or a combination of both. Each specific patient
population could need a specific program in a specific time
frame.
A systematic review of PET in AAA surgery and the effect
on post-operative complications, aerobic capacity, physical
fitness, and recovery was carried out in an attempt to
answer the following research questions: (1) What is the
effect of an exercise program in patients with an AAA or
iliac artery aneurysm (IAA) (with or without an indication
for surgical repair) on aerobic fitness and physical param-
eters?; (2) What is the effect of PET in patients with an AAA
or IAA scheduled for surgical repair on the post-operative
complications and the length of hospital stay?
METHODS
A systematic literature search was performed. The popula-
tion of interest was patients with an AAA or IAA, and pa-
tients scheduled for surgical repair of an AAA or IAA. The
intervention studied was PET (in case of patients scheduled
for surgical repair) or an exercise program (in case of pa-
tients without an indication for surgical repair) compared
with standard care (no exercise program). Outcome
67
measures were aerobic capacity, physical fitness, post-
operative complications, length of stay, and recovery.
PubMed, Embase, MEDLINE, The Cochrane Library, PEDro,
CINAHL, and Web Of Knowledge were searched from the
earliest date of each database up to May 2014. The search
for publications was performed using the following search
string: ([“Abdominal Aortic Aneurysm” {MeSH} OR EVAR OR
open repair]) AND (“Physical Therapy Modalities” [MeSH]
OR physical therapy OR physiotherapy OR “Exercise”
[MeSH] OR exercise).
S.P. and E.M.W., who were both blinded to the authors of
papers and titles of journals, separately screened and
selected studies on the basis of title and abstract. After
primary selection, both authors reviewed the full text of the
selected studies and, based on the established selection
criteria, determined suitability for inclusion. For further
eligible studies, cross references were screened. Disagree-
ments were solved by discussion with each other and the
senior author (J.A.W.T.) until consensus was reached.
Inclusion criteria
The inclusion criteria for the studies were as follows: (i) a
randomized controlled or prospective cohort trial; (ii)
eligible participants were all patients with an AAA or IAA
(without indication for surgical repair) and were scheduled
for surgical repair of an AAA or IAA; (iii) the intervention
consisted of a PET program, which was defined as a struc-
tured regimen of physical activities (either a standalone
regimen, home based, or supervised) for specific thera-
peutic goals to gain or increase musculoskeletal and/or
cardiovascular and/or respiratory function; (iv) reported
outcome measurements were improvement of aerobic ca-
pacity and/or physical fitness, post-operative complications,
length of stay, and recovery.
Rating of methodological quality was conducted using
the Physiotherapy Evidence Database (PEDro) scale.18,19
The PEDro scale has 11 criteria, with a maximum score of
10 (range 0e10) as the first item (the specification of the
eligibility criteria) is not included in the total score. Two
authors (S.P. and E.M.W.) separately rated the methodo-
logical quality of each included study, according to the
PEDro scale, and the following classification was used: a
score of <4 indicated poor methodological quality, between
4 and 5 fair quality, 6e8 good quality, and 9e10 excellent
quality.20
The level of agreement between the authors was
assessed by a Cohen’s kappa score, which was determined
as follows: <0.20 poor agreement; 0.21e0.40 fair agree-
ment; 0.41e0.60 moderate agreement; 0.61e0.80 good
agreement; 0.81e1.00 very good agreement.21
Exercise physiology definitions
In exercise physiology and in this systematic review
different terms will be used to describe and measure the
effect of a PET program. Two different terms are often used:
physical activity and physical fitness.22 Physical activity is
defined as any bodily movement produced by skeletal
68
muscles, which results in energy expenditure. The amount
of energy required to accomplish activity can be measured
in kilojoules (kJ) or kilocalories (kcal).22
Physical fitness or “being physically fit” is defined as “the
ability to carry out daily tasks with vigor and alertness,
without undue fatigue and with ample energy to enjoy lei-
sure time pursuits and to meet unforeseen emergencies”.22
For measuring the effect of PET programs, a variety of
terms can be used. The most commonly used terms are
“aerobic threshold”, “ventilatory threshold”, and “VO2
peak”.23 When the body uses energy, two systems are used:
(i) the aerobic system, which uses oxygen and burns car-
bohydrates and fats; (ii) the anaerobic system, which
doesn’t require oxygen. The aerobic threshold is the level of
effort at which anaerobic energy pathways start to be a
significant part of the energy production.23
VO2 peak is defined as the highest value of VO2 attained
at the particular test, most commonly an incremental or
high energy test, designed to bring the subject to the limit
of tolerance.23
Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.
S. Pouwels et al.
The ventilatory threshold is the point during exercise at
which pulmonary ventilation becomes disproportionately
high with respect to the oxygen consumption. This point is
believed to be the onset of use of the anaerobic
pathway.23
RESULTS
The primary literature search produced 712 results,
including 40 duplicates. After screening of the titles and
abstracts, eight studies were found to be possibly relevant
and underwent a full text critical appraisal, which resulted
in three being excluded. One study was only available in
Danish,24 one was a research protocol,25 and one was an
invited commentary.26
Fig. 1 summarizes the search results. The methodological
quality of the included studies ranged from moderate to
good, indicated by the PEDro scale (Table 1). A Cohen’s
kappa of 0.79 reflected a good agreement between the
authors (S.P. and E.M.W.). Table 2 gives an overview of the
results of the included studies.
Pre-operative Exercise Therapy in Patients with AAA
Table 1. Assessment of methodological quality using the Physiotherapy Evidence Database (PEDro) score.18
Study Criteriaa
1 2 3 4
Dronkers et al., 200830    
Kothmann et al., 200929    
Myers et al., 201028    
Barakat et al., 20143  e e 
Tew et al., 201227    
a
PEDro criteria: (1) specification of eligibility criteria (this criterion was not counted for the final score); (2) random allocation; (3) con-
cealed allocation; (4) prognostic similarity at baseline; (5) participant blinding; (6) therapist blinding; (7) outcome assessor blinding; (8)
>85% follow up of at least one key outcome; (9) intention to treat analysis; (10) between or within group statistical comparison; (11) point
estimates of variability provided.18
Three of the included studies investigated an exercise
program in patients with an AAA (without indication for
surgical repair),27e29 with a duration ranging from 6 weeks
to 12 months. Barakat et al. studied a PET program for 6
consecutive weeks in patients awaiting elective infrarenal
AAA repair.3 Dronkers et al. studied an inspiratory muscle
training program for at least 2 weeks before surgery in
patients awaiting elective AAA repair.30
Effects of an exercise program in patients with an AAA,
without indication for surgical repair
Compliance. Tew et al. found a 94% compliance rate to an
exercise program (three sessions a week for a period of 12
consecutive weeks), with 371 of 396 sessions attended.27
Physical fitness parameters. Three studies investigated
physical fitness parameters. Myers et al. found a significant
increase in exercise time in the intervention group after 12
months training (from 495.8
182.0 s to 701.2
209.0 s;
p ¼ .01 between groups).28 The peak VO2 did not differ
between baseline values and after 12 months of training,
and between groups (exercise group: 18.5
5.9 mL/kg/min
to 20.0
5.5 mL/kg/min; control group: 21.6
7.8 mL/kg/
min to 20.2
7.9 mL/kg/min (p ¼ .29 between groups)).28
Kothmann et al. found a 10% increase in aerobic
threshold (equivalent to 1.1 mL O2/kg/min) after 6 weeks of
supervised exercise training, between the intervention and
control group.29
Tew et al. showed that the ventilatory threshold (from
12.8
2.4 mL/kg/min to 15.3
3.9 mL/kg/min) increased
in the intervention group after pre-operative training for 12
consecutive weeks.27 Between groups there was a signifi-
cant difference in ventilatory threshold (p ¼ .02). There
were no significant changes in both groups for peak values
of heart rate, blood lactate, perceived exertion, and respi-
ratory exchange ratio (p > .05).27
Training intensity. Myers et al. reported training intensity as
a percentage of target heart rate.28 Each patient docu-
mented their heart rate in a diary. Over the year, heart rate
recordings documented a mean training intensity of
98
7%. Training intensity did not differ between home
based or supervised exercise training (average heart rate
99
7% of the target and 97
8% of the target,
respectively).28
69
5 6 7 8 9 10 11 Total
e e      8
e e e     7
e e e     7
e e e     5
e e e     7
Effects of pre-operative exercise therapy in patients
scheduled for surgical repair of an AAA
Compliance. Barakat et al. reported a minimum attendance
of the supervised exercise program classes during 6 weeks
of 70%,3 with 12 of the 20 patients attending 100% of the
classes.
Physical fitness parameters. After a three training sessions
a week program for 6 consecutive weeks, Barakat et al.
showed that peak VO2 significantly improved, from 18.2 mL
(range 15.4e19.9 mL) O2/kg/min to 19.9 mL (range 17.1e
21.1 mL) O2/kg/min (p ¼ .05).3 The aerobic threshold also
improved significantly, from 12.2 mL (range 10.5e14.9 mL)
O2/kg/min to 14.4 mL (range 12.3e15.4 mL) O2/kg/min
(p ¼ .023).3
Post-operative complications. Dronkers et al. investigated
the effects of an inspiratory muscle training program con-
sisting of six sessions a week for 6 weeks prior to surgery in
20 patients at high risk for post-operative pulmonary
complications.30 Dronkers et al. reported the development
of atelectasis in eight patients in the control group and
three in the intervention group (p ¼ .07).30 The atelectasis
was evident on the chest Xrays for a median of 1.5 days in
the control group and of 0 days in the intervention group
(p ¼ .07).30
Respiratory function. Before AAA surgery, Dronkers et al.
found no change in mean maximal inspiratory pressure
(MIP; from 68
19 cmH2O to 72
22 cmH2O [p ¼ .32])
after 6 weeks of pre-operative inspiratory muscle training in
the intervention group.30 Over the same period the mean
MIP in the control group changed from 83
15 cmH2O to
80
24 cmH2O (p ¼ .60). There was also no significant
difference between the groups (p ¼ .29).30
Before surgery, the mean inspiratory muscle endurance
increased significantly from 32
8 cmH2O to 43
9 cmH2O
(p ¼ .05) after pre-operative training in the intervention
group and from 39
10 cmH2O to 43
9 cmH2O (p ¼ .36)
in the control group. There were no significant differences
between both groups (p ¼ .12).30
Patient satisfaction. In the intervention group of the study
of Dronkers et al.,30 eight patients completed a question-
naire 2 weeks after discharge. The questionnaire showed
high patient motivation to complete the pre-operative
Table 2. Overview of included studies.

70
Study (þdesign) Participants Intervention Primary outcome Study results
n (M/F) Characteristics I: n (age [y]
SD) Treatment Comparison measure
C: n (age
SD)
Dronkers et al., 20 (5/15) Candidates for I: 10.0 (59.0
6.0) IMT, starting at Instruction in Post-operative Atelectasis:
2008 (RCT)30 elective AAA at C: 10.0 (70.0
6.0) 20% of the diaphragmatic pulmonary
high risk of PPCs patients Pi-max, breathing, complications  I: 3
6 days a week, incentive MIME after  C: 8
15 min per session spirometry, inspiratory  p ¼ .07
for at least 2 weeks forced expiration muscle training
techniques Compliance Duration of atelectasis:
(defined as
usual care)  I: 0 days
 C: 1.5 days
 p ¼ .07

Increase MIME before

surgery:

 I: 32
8 to
43
14 cmH2O
(p ¼ .05)
 C: 39
10 to
43
9 cmH2O
(p ¼ .36)
 no difference
between groups
(p ¼ .12)

Kothmann et al., 25 (20/5) Patients with AAA I: 17.0 (69.5
?) 6 weeks hospital Regular care Change in AT:
2009 (RCT)29 under surveillance C: 8.0 (69.4
?) based exercise aerobic threshold
(<5.5 cm on program. Two  10% increase
abdominal supervised sessions (equivalent to
ultrasound) per week, which 1.1 ml O2/kg/min)
consisted of 30 in intervention
min exercise on a group compared
static bicycle
with control
(p ¼ .01)

S. Pouwels et al.
 Pre-operative Exercise Therapy in Patients with AAA
Myers et al., 57 (53/4) Patients with AAA I: 26.0 (73.1
6.0) Exercise training Regular care Mean energy
2010 (RCT)28 (<5.5 cm) C: 31.0 (70.4
9.0) (supervised or expenditure
at home, or Exercise capacity  I: mean energy
combination). Goal Risk markers expenditure of
of training was to before and 2269
1207
achieve a mean after training kcal/wk. Increased
energy expenditure exercise capacity
of 2000 kcal/wk. The
(42% increase in
supervised sessions
included treadmill
treadmill time,
cycle ergometry, stair 24% increase in
climbing, elliptical estimated
training, and rowing metabolic
three times weekly equivalents,
for 45 min followed p ¼ .01)
by 10 min of resistance  Between I and C
training p ¼ .08 for
exercise capacity
and estimated
metabolic
equivalents
 I: significant
reduction in
CRP1 compared
with C (p ¼ .05)

Continued

71
Table 2-continued

72
Study (þdesign) Participants Intervention Primary outcome Study results
n (M/F) Characteristics I: n (age [y]
SD) Treatment Comparison measure
C: n (age
SD)
Barakat et al., 20 (17/3) Patients scheduled I: 20.0 (74.9
5.9) Supervised pre-operative Exercise capacity VO2 peak:
2014 (PCCS)3 for elective exercise program for a (measured as VO2
infrarenal AAA total of 6 weeks, 3 peak and aerobic  Before: 18.2
interventions sessions per week. threshold) ml/kg/min (range
(open or Each exercise session Compliance 15.4e19.9
endovascular) comprised of a total ml/kg/min)
of 1 h, consisting of  After: 19.9 ml/
6e8 different exercises,
kg/min (17.1e21.1
including: heel raises,
cycle ergometer, step-ups,
ml/kg/min)
arm weights, knee  p ¼ 0.05
extensions, chair sit-ups,
knee flexions, and graded AT:
treadmill exercise, with
a 5 min warm up/cool  Before: 12.2 ml/
down routine at the kg/min (range
beginning/end of each 10.5e14.9 ml/
session kg/min)
 After: 14.4 ml/
kg/min (range
12.3e15.4 ml/
kg/min)
 p ¼ .02

Time at AT:

 Before: 137.0 s
(range 86.8e234.5 s)
 After: 200.5 s
(range 93.8e397.5 s)
 p ¼ .05

Total time:

 Before: 379.0 s

S. Pouwels et al.
(233.3e653.3 s)
 After: 603.5 s
(406.5e715.0 s)
 p < .01
 Pre-operative Exercise Therapy in Patients with AAA
Tew et al., 25 (21/4) Patients with an I: 11.0 (71.0
8.0) Supervised exercise Standard care Exercise capacity Ventilatory threshold:
2012 (RCT)27 asymptomatic, C: 14.0 (74.0
6.0) training three times a (encouragement (measured as VO2 I: Baseline
infrarenal AAA week, for 12 consecutive to exercise only) peak and aerobic 12.8
2.4 ml/kg/min
30e50 mm in weeks. Each session threshold) After 12 weeks
diameter consists of a mixture Cardiovascular 15.3
3.9 ml/kg/min
of treadmill walking risk markers C: Baseline
and cycle ergometry for 12.2
3.3 ml/kg/min
35e45 min After 12 weeks
12.2
3.1 ml/kg/min
(p ¼ .02 between I
and C after 12 weeks)
VO2 peak:
I: Baseline
19.3
4.5 ml/kg/min
After 12 weeks
21.1
6.7 ml/kg/min
C: Baseline
17.9
5.4 ml/kg/min
After 12 weeks
18.0
5.7 ml/kg/min
(p ¼ .18 between I and
C after 12 weeks)
SBP:
I: Baseline
149.0
25.0 mmHg After
12 weeks 138.0
20.0 mmHg
C: Baseline
152.0
26.0 mmHg After
12 weeks 148.0
15.0 mmHg
(p ¼ .10 between I and C
after 12 weeks)
hs-CRP:
I: Baseline
1.4
1.1 mg/L After
12 weeks 0.9
0.9 mg/L
C: Baseline
2.3
1.5 mg/L After 12
weeks 2.6
1.6 mg/L
(p ¼ .01 between I and C
after 12 weeks)
Note. M ¼ male; F ¼ female; I ¼ intervention; C ¼ control; RCT ¼ randomized controlled trial; PCCS ¼ prospective cohort comparative study; AAA ¼ abdominal aortic aneurysm; PPC ¼ post-
operative pulmonary complications; IMT ¼ inspiratory muscle training, Pi-max ¼ maximum inspiratory pressure; MIME ¼ mean inspiratory muscle endurance; CRP ¼ C-reactive protein;
AT ¼ aerobic threshold; VO2 peak ¼ maximum oxygen uptake; SBP ¼ systolic blood pressure; hs-CRP ¼ high sensitivity CRP.

73
74
intervention, but revealed no influence on the quality of life
of the PET program.
DISCUSSION
This systematic review highlights the current evidence on
the effects of PET and other exercise programs in patients
with an AAA (with and without indication for surgical
repair). The studies report on the measured effects of PET
on aerobic capacity, physical fitness, post-operative com-
plications, length of stay, and duration of recovery. The
methodological quality of the five included studies ranged
from moderate to good.
Recently, two studies reviewed the effect of PET on
physiological function,31 complications, and recovery after
surgery.17 They both concluded that the evidence for
beneficial effects of PET was limited. The major disadvan-
tage of these studies was a very heterogeneous patient
population with non-comparable PET programs.
Positive effects of pre-operative PET programs (endur-
ance or cardiopulmonary) have been described in the AAA
population and the elderly in general. PET reduces the risk
of all cause (peri-operative) mortality and morbidity in the
AAA patient population owing to an improvement of car-
diopulmonary fitness.32,33 Also, pre-operative fitness levels
are associated with higher survival rates in patients un-
dergoing open surgical AAA repair and other major
abdominal surgery.34,35
PET can be beneficial in various types of surgery and may
reduce post-operative complications. The incidence of post-
operative (pulmonary) complications varies, depending on
their definition and type of surgery. The reported incidence
of post-operative pulmonary complications varies between
5% and 30%.36,37 Post-operative complications are the pri-
mary reason for post-operative morbidity and mortality and
increased length of hospital stay, medical consumption, and
healthcare costs.36e39 In the case of pulmonary complica-
tions, atelectasis predisposes a patient to more clinically
relevant complications, such as pneumonia.40 Atelectasis
occurring from the second post-operative day onward is
considered to affect blood oxygenation and bronchial
mucus production.36
Several studies in different surgical specialties investi-
gated whether PET reduces post-operative complications
and improves physical fitness. Two studies reported positive
results on PET-induced improved pre-operative physical
fitness in patients awaiting lung resection surgery.13
Two additional studies showed reduced post-operative
complications and length of hospital stay in cardiac sur-
gery after a PET program (pre-operative pulmonary phys-
iotherapy and exercise training).15
The available literature on the effects of PET on important
primary endpoints like post-operative complications, length
of hospital stay, and duration of recovery all suffer from the
same difficulties. The PET protocols used are diverse. Is
there any evidence for an optimal effective training pro-
gram in a potentially high risk (elderly) patient group? On
the matter of the training intensity, evidence suggests that
S. Pouwels et al.
continuous exercise at a higher intensity leads to greater
improvements of the aerobic threshold.40e42 Also, very high
intensity interval training is more effective than continuous
moderate exercise training.25,43 A superior training effect of
exercise training at 95% of the peak heart rate compared
with an exercise regimen at 70% of the peak heart rate has
been reported.43 Evidence suggests that with respect to the
length of the training, regular exercise for the duration of at
least 12 weeks at a moderate intensity significantly im-
proves the level of fitness in elderly people.44,45
Patient safety during the exercise program in this elderly
population has been studied and records a risk of serious
adverse events of approximately 1:10,000 with exercise
testing in high risk patients.46 Recently, Gommans et al.
reported a low risk of adverse events in an exercise popu-
lation of patients with peripheral arterial disease undergo-
ing a supervised exercise therapy program.47
Future perspectives
The specific goal of pre-operative exercise training is to
prepare patients for surgery in the best possible way to
reduce complications, length of stay, and healthcare costs.
This is the first systematic review on the effects of PET in
AAA surgery, but with only five heterogeneous studies
eligible for inclusion there is room and a necessity for future
research. Current evidence shows PET in AAA surgery has
potential beneficial effects. To be able to perform high
quality future research, definitions of PET, including exercise
length, intensity, and method, should be determined and
compared.
Future improvements in standards of care and optimal
pre-operative preparation should not only focus of the
surgical team and the hospital organization, but also on
incorporating the active role of the patient.
CONCLUSION
PET may have beneficial effects on various physical fitness
variables in patients with an AAA. Whether this leads to
fewer complications or faster recovery remains promising
but unclear, because of the great heterogeneity and small
sample size of the included studies. In view of the large
impact of post-operative complications, it would be valu-
able to explore the possible benefits of a PET program in
AAA surgery.
FUNDING
None.
CONFLICT OF INTEREST
None.
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