Epidemiological aspects on

abdominal aortic aneurysms (AAA)

David Bergqvist MD PhD, FRCS, FEBVS, Kevin Mani MD PhD and Anders

Wanhainen MD PhD.

Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital,

Uppsala, Sweden

Corresponding author: Professor David Bergqvist, Department of Surgical Sciences, Section

of Vascular Surgery, Uppsala University Hospital, SE-751 85 Uppsala, Sweden.

1
Abstract

In this overview, the present day knowledge on the epidemiology of abdominal aortic
aneurysms (AAA) is summarized based on a review of the current literature. The prevalence
of AAA and incidence of rupture is analyzed, and the natural history of the disease is
illustrated both concerning the AAA as such and the survival of the patient. This knowledge is
important when contemplating on screening for AAA, which is being implemented in several
countries worldwide.
Keywords: Abdominal aortic aneurysm; epidemiology; screening

2
Introduction

The aim of this overview is to summarize the present day knowledge on the epidemiology of
abdominal aortic aneurysms (AAA). This is made by scrutinizing facts from relevant
literature based on search methodology suggested in modern health technology assessment.
First, prevalence of AAA and incidence of rupture of the disease is discussed, whereafter
natural history is illustrated both concerning the AAA as such and the survival of the patient.
These aspects of AAA disease are of importance both in clinical decision making and when
contemplating on screening, which is the most efficient method to decrease mortality in AAA
[1]. Fig 1 schematically illustrates the occurrence and fate of AAA within the population.

Defintion of AAA
In order to adequately discuss the epidemiology of the disease, one obvious prerequisite is
that we are confident in the definition of AAA and that we use a similar definition to make
comparisons possible. Unfortunately there are several definitions of AAA, some of the most
common being listed in Table I. When studying the prevalence of AAA in a specific
population, the choice of definition of the disease has a great impact on the prevalence, Table
II [2]. This dilemma is also indicated in Fig 2. The definition of AAA becomes especially
important in screening situations, where a positive diagnosis turns a healthy individual into a
patient with a potentially life threatening disease. The definition most often used in clinical
practice is to regard an infrarenal abdominal aorta of 30 mm or more as an AAA [3]. The
basis for this definition is an angiographic study of the normal distribution of abdominal
aortic diameter in the population, and the fact that an infrarenal aortic diameter of 30 mm is
well above the average diameter for both sexes [4]. Thirty millimeters as the upper limit for
normal aortic diameter among elderly men was confirmed in a recent population-based
magnetic resonance tomography study of aortic size [5].

Prevalence
The prevalence of AAA has been studied based on two modalities: autopsy series [6,7] and
ultrasonographic screening programs [8-12].
Autopsy data
Autopsy based frequencies are reliable as long as the autopsy rate is high, which rarely is the
situation today. At autopsy, diagnosis of a rupture is very reliable, but small aneurysms may
be missed or are simply not measured. Based on more than 45.000 autopsies over a 30 years
period and a very high necropsy rate, 85% of all deaths in the community and more than 90%
of all hospital deaths, the age- and sex- specific frequency was reported in a study from
Malmö, Sweden [7]. AAA was found to be uncommon before the age of 55. In men, the
prevalence then increased rapidly reaching a peak of about 6% at 80-85 years, and then
decreased. In women, AAA appeared some 15 years later and was 2-4 times less common
than in men (fig 3). Over the study period (1958-1986), an increase of the age-standardized
prevalence was observed, more so in males. This increase in prevalence has continued in both
men and women according to a Scottish study during the period 1981-2000 [13].

Data from ultrasonography

The above described observations have been verified in ultrasonographic studies [14-16].
With ultrasonography it has also been shown that the prevalence varies in different
geographical regions, where an exceptionally high prevalence was described in a northern
Swedish community, Norsjö (Table II). Although some diagnostic uncertainty exists, the size
distribution of AAA has been established for instance in the VA study by Lederle et al [17],

3
from 4.6 % ≥ 3 cm to 0.3 % ≥ 5.5 cm and 0.03 % ≥ 8.0 cm. From screening studies it is also
possible to establish a diameter distribution of the normal aorta [2].

Besides male gender and high age, AAA is known to be associated with atherosclerotic
disease, smoking and a positive family history of AAA [18-20]. Screening studies among
such high-risk populations have revealed the highest prevalence estimates. In US screening of
siblings of patients with AAA, approximately 20% of brothers and 5% of sisters were
reported to have an AAA. The increased prevalence in close relatives to patients with AAA is
important to be aware of [7,18,19,21,22]. The frequency of AAA is also increased in patients
with aneurysms in the popliteal artery and the thoracic aorta [23] [24].There could also be a
correlation between AAA and intracranial aneurysms, although weaker [25]. Although
women generally have a low prevalence of AAA, the prevalence in the female population can
be higher in presence of several risk factors [20,26].

Incidence of rupture
Studies of rupture incidence are either retrospective, i.e. based on routine mortality statistics
and autopsy reports [27-30], or prospective studies of small aneurysms [11,31-33].
Uncertainty in cause of death in cases where autopsy is not performed affects validity of the
analyses [27]. The autopsy rate has previously been high in Sweden, and in Table III the
incidence of AAA rupture in various regions of Sweden based on autopsy data is summarized.
The incidence actually seems to have increased over time, this in spite of the increased
number of elective repairs [30]. Also regarding incidence of rupture there is a marked sex
difference with much higher incidence in men, which is not the case for ruptured thoracic
aneurysms or death in aortic dissections [34]. Due to the fact that many patients with AAA
rupture die before arriving to the hospital and the diagnostic difficulties, the total mortality is
high, well above 75% in the majority of studies [27].In a population-based study from the UK
[28], three quarters of the patients with a ruptured AAA did not reach the operation theatre,
and only 48% of those operated on survived. For the same reasons, the total mortality will be
only marginally influenced by improving postoperative survival after surgery for rupture
[27,35]. To substantially influence total mortality the aneurysms have to be detected and
treated electively before rupture.

Natural history
Concering the AAA
Leaving an aneurysm untretated will eventually cause expansion although in individual
patients, the expansion rate is unpredictable (Bengtsson et al 1993). The mathematical mean
expansion rate, however, is exponential (Bengtsson et al 1993), meaning that the larger the
aneurysm the higher will be the expansion rate [36-41]. The annual mean expansion rate of
small aneurysms has been reported at 2.5 to 5mm, or 10% [42,43]. Factors other than the
aneurysm diameter that have been associated with a higher expansion rate include female
gender, smoking and hypertension [42-46]. To date, there is no established medical
intervention that reduces the expansion rate of AAAs [47]. There are, however, indications
that statin treatment might be associated with a lower expansion rate [43]. As smoking is
associated with an increased growth rate, smoking cessation is the only available method to
reduce the growth rate of a small AAA [48].

The risk of AAA rupture is associated with aneurysm size. Aneurysms with a diameter below
50 mm have a very low rupture rate, while aneurysms between 50 and 60 mm have a 5 to
10% risk of rupture per year [31,32,49-51]. The yearly risk of rupture increases significantly
above 60 mm and is more than 30% for aneurysms above 70 mm in diameter [31]. Female

4
sex, smoking, hypertension, a positive family history and chronic obstructive pulmonary
disease are also associated with an increased risk of rupture [33,52-54].

Concering patient survival

Today, obviously true natural history studies cannot be made because no surgeon will leave
all aneurysms in a population untreated. There are, however, in older studies consistent
indications of increased mortality among patients with large, usually palpable AAAs (>50
mm), which are not treated. After 5 years only about 20% of the patients are still alive, and
approximately 50% of the deaths are due to rupture [55-59]. In Fig 4 a 68-year old normal
male population is given for comparison. Although, this can be discussed from a scientific
point of view, it indicates a substantially decreased long term survival among patients with
large AAA who are not treated operatively. The rupture free survival is also decreased as
shown in the UK small aneurysm trial [52].

The adequate AAA size at which elective repair is recommended in asymptomatic patients
has been established to 55 mm in two large, randomized multi-centre studies [31,51,60].
However, an individual approach is recommended, where the operative risk of the patient is
balanced against risk of rupture and expected long-term survival. Elective operative treatment
is associated with a perioperative mortality of 2-5% in large randomized or population-based
studies [31,51,61-63]. Perioperative mortality is lower after endovascular repair than after
open surgical repair [64,65]. National variations in perioperative mortality after AAA repair
exist in register data [66]. Short-term outcome is highly dependent on patient comorbidities,
and mortality is increased in patients with renal dysfunction, cardiac disease and pulmonary
dysfunction [67]. In addition, increased age and female gender are associated with higher
short-term mortality [63]. Most but not all [68] reports indicate a reduced operative mortality
after elective AAA repair over time [63,69-71]. A minority of AAA repairs are performed in
symptomatic patients, e.g. with tender aneurysms. In these cases operation is performed as an
urgent intervention, and the perioperative mortality is approximately twice as high as in
elective asymptomatic repair [63,72]. Longterm survival after elective AAA repair is good
(90% 5-year survival) compared to the normal population [73].

The operative mortality after ruptured AAA repair is approximately 35% [63]. Some groups
have reported stable mortality rate after AAA repair [68,71,74,75], whereas others have found
a decreasing mortality over time [63,70,76,77]. For the patients that survive the ruptured AAA
repair, the longterm survival is almost as good as after intact AAA repair [73].

Screening
Knowledge on epidemiology and natural history of AAA has been a prerequisite to be able to
evaluate screening for this potentially fatal disease. Today there are randomized controlled
trials and metaanalyzes showing a survival benefit in terms of avoided deaths in AAA rupture
when screening is introduced in a population [78] [1,79]. Screening for AAA fulfils most of
the criteria listed by the WHO to motivate screening [80]. Screening with ultrasonography
(not looking for other pathologies) is a rapid procedure (mean duration <5 min.), which also
makes it cost-effective [18]. Today it is motivated to screen the general population of 65 year
old males, first degree relatives to patients with AAA and patients with popliteal or femoral
aneurysms. Screening programs for AAA have been or are being instituted in several
countries [81-83]. Ongoing research is analyzing if there is also a benefit in 70 year old
females. The possible effects of general health interventions to avoid future cardiovascular
events in the population with small aneurysms would also merit further studies.

5
Table I

Definition of infrarenal AAA

Author Definition
1. McGregor et al Aortic diameter ≥ 30 mm
Wanhainen et al
2. Sterpetti et al Aortic diameter ≥ 1.5 x suprarenal
aortic diameter

3. Collin et al Aortic diameter ≥ 40 mm or

infrarenal aortic diameter
exceeding suprarenal aortic
diameter by at least 0.5 cm

4. ISCVS/SVS Aortic diameter ≥ 1.5 x normal

infrarenal aortic diameter,
predicted from a nomogram

6
Table II

Prevalence of AAA when screening 65-75 years old inhabitants of the Norsjö

municipality according to different AAA definitions (from table I).

[2]

Definition 1 2 3 4

Men 16.9% 6.9% 10.5% 12.9%

Women 3.5% 1.2% 2.3% 9.8%

7
Table III

Incidence of ruptured AAA in the population-based studies.

Population Period Incidence per

100 000 inhab.

Bengtsson, Bergqvist 1996, 240 000 1971-86 5.6

Malmö [7]

Drott et al 1992, Gothenburg [84] 400 000 1970-79 4.1

1980-88 6.9

Johansson, Swedenborg 1986, 1 500 000 1980 5.9

Stockholm [85]

Acosta et al 2006, Malmö [30] 260 000 2000-04 10.6

1 600 000 1989 7.8

8
Fig 1

Survival

Death OP

Rupture Death

Survival

AAA in the Elective

population operation
Death
Death
without rupture

9
Fig 2

Schematic drawing of the aortic diameter during a lifetime.

10
Fig 3

Sex-specific percentage by age of patients with abdominal aortic aneurysms confirmed by

necroscopy, Malmö 1958-1986. [7]

11
Fig 4

12
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