JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 80, NO.

8, 2022

ª 2022 PUBLISHED BY ELSEVIER ON BEHALF OF THE

AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

JACC FOCUS SEMINAR: DISEASE OF THE AORTA

JACC FOCUS SEMINAR

Repair of Abdominal Aortic Aneurysms

JACC Focus Seminar, Part 1

Sara E. Hensley, MD, Gilbert R. Upchurch, JR, MD

ABSTRACT

Abdominal aortic aneurysms (AAAs), defined by an aortic diameter >3 cm, affect >1 million people in the United States.
Risk factors for AAA include male sex, family history of AAA, smoking, Caucasian ethnicity, and age. Patients with known
AAA should undergo regular surveillance via ultrasonography. Medical management, including smoking cessation and
blood pressure management, is recommended for asymptomatic patients who do not meet the threshold for interven-
tion. Repair options include endovascular aortic repair and open surgical repair, with good outcomes in long-term follow-
up. Men with AAA >5.5 cm and women with AAA >5.0 cm in general should undergo elective repair. Medical
management, including smoking cessation and blood pressure management, is recommended for asymptomatic patients
who do not meet the threshold for intervention. (J Am Coll Cardiol 2022;80:821–831) © 2022 Published by Elsevier on
behalf of the American College of Cardiology Foundation.

A bdominal aortic aneurysms (AAAs) affect >1

Listen to this manuscript’s
audio summary by
Editor-in-Chief
Dr Valentin Fuster on
www.jacc.org/journal/jacc.
million people in the United States and are
defined by an aortic diameter >3 cm or a
>50% increase in diameter compared with the normal
proximal aorta.1 Previous studies of western popula-
tions in the late 1990s described 4%-8% prevalence
of AAAs in men aged 65-80 years. 2 More recent
studies have shown a decrease in AAA prevalence
and AAA-related mortality in the United States and
parts of Europe in the 21st century in parallel with
decreased smoking rates and increased use of statins
and antihypertensive medications.3 AAAs are more
common in older men, smokers, and patients with a
family history of AAA.
Similar to that of other degenerative diseases, the
natural history of AAAs includes further weakening of
the arterial wall and consequent inability to with-
stand intraluminal blood pressure, resulting in pro-
gressive dilatation and eventual rupture. 4 Rupture is
4
associated with 50%-80% mortality, but mortality
after elective repair is only 1.8%-4.2%. 5 Progression of
AAA can be mitigated by modifying risk factors,
From the Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.
including smoking and hypertension. Elective AAA
repair is associated with improved perioperative
mortality compared with emergent intervention.
Repair options include open surgical repair (OSR) and
endovascular aortic repair (EVAR). Outcomes of AAA
repair have improved since the advent of EVAR, a less
invasive surgical technique. 6,7 Despite advances in
operative techniques, patients who undergo AAA
repair remain at a long-term survival disadvantage
compared with the general population, with cardio-
vascular comorbidities and cancer accounting for
30%-49% and 29% of deaths, respectively, at 5 years.8
STRUCTURE AND FUNCTION OF THE
ABDOMINAL AORTA
The aorta is a large elastic artery characterized by the
ability to expand and recoil in sequence with the
heart to distribute blood to the body.9 The abdominal
aorta (AA) gives rise to the arteries supplying the
abdominal viscera, lumbar spine, and lower extrem-
ities, and it is commonly divided into suprarenal and

Manuscript received December 14, 2021; revised manuscript received March 29, 2022, accepted April 5, 2022.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2022.04.066

822 Hensley and Upchurch Jr.
Abdominal Aortic Aneurysm Repair
ABBREVIATIONS infrarenal components. Although the spinal
AND ACRONYMS
cord is supported by a large network of
collateral vessels, the lumbar arteries arising
AAA = abdominal aortic
aneurysm
from the infrarenal aorta contribute signifi-
cantly to the blood supply of the spinal cord,
CT = computed tomography
leaving it vulnerable to ischemia in the
ESVS = European Society for
Vascular Surgery setting of AA pathology.
EVAR = endovascular aortic PATHOPHYSIOLOGY OF AAA
repair
MMP = matrix
Aging is associated with decreased aortic
metalloproteinase
elasticity, decreased ability to accommodate
NICE = National Institute for
Health and Care Excellence
increased intraluminal pressure, and pro-
gressive ectasia. 9 This age-related degenera-
OSR = open surgical repair
tion, along with other factors, including
RCT = randomized controlled
hypertension and smoking, make the
trial
SMC = smooth muscle cell
abdominal aorta vulnerable to aneurysmal
dilatation. “True” aneurysms are defined as
SVS = Society for Vascular
fusiform or saccular dilatations of the vessel
Surgery
wall involving all 3 layers (the intima, media,
and adventitia) and are the most common abdominal
9
aortic pathology (Figure 1). Comparatively, “false” or
pseudo-aneurysms are the result of compromise of
the intima and media layers resulting in an aneurysm
that is contained only by the adventitia and sur-
rounding soft tissues. Alternately, aortic dissections
form when a tear in the intima leads to accumulation
of blood between the intima and media layers.
Although dissections may be associated with aneu-
rysms, they are not considered true aneurysms.
AAAs are associated with a robust inflammatory
response, both locally and systemically in animal
models and human specimens compared with con-
trols. 10 Numerous studies have established the roles
of neutrophils, macrophages, and T cells in aneurysm
pathology. The exact mechanisms through which in-
flammatory cells influence aortic aneurysm formation
are an area of intense research. The media of the
aortic wall contains vascular smooth muscle cells
(SMCs), and it is the site of apoptosis of SMCs and
subsequent degeneration in aneurysm pathology.
Apoptosis of SMCs has been associated with produc-
tion of reactive oxygen species and inflammation.
Matrix metalloproteinases (MMPs) have been found
to play a significant role in the reduction of aortic wall
elastin, collagen, and glycosaminoglycans, all
observed in aneurysm tissue. MMPs are produced
normally in all 3 layers of the vessel wall, but in-
flammatory cell production of additional MMPs in
AAAs upsets the balance of MMPs and their known
inhibitors, which contributes to degeneration of the
media.
JACC VOL. 80, NO. 8, 2022
AUGUST 23, 2022:821–831
HIGHLIGHTS

More than 1 million people in the United
States have abdominal aortic aneurysm;
rupture is associated with high associated
mortality.

Endovascular repair is favored over open
repair by patients and preferred when
anatomically appropriate.

Management of cardiovascular comor-
bidities contributes to long-term out-
comes after repair.
RISK FACTORS
ENVIRONMENTAL. Smoking is associated with for-
mation, accelerated growth, and increased AAA
rupture rates 11 and is the most common modifiable
risk factor for AAA. Much of what we know about the
pathophysiological effects of nicotine and cigarette
smoke on AAAs is derived from animal models. 12 The
exact mechanism by which smoking exacerbates
growth and risk of rupture of AAAs is not fully un-
derstood, but it has been established through animal
models that nicotine induces increased activity of
MMPs4 and decreases aortic wall elasticity.13
MEDICAL COMORBIDITIES. AAAs represent a distinct
pathologic process, but they are associated with
manifestations of atherosclerosis, including coronary
artery disease. AAAs account for 1%-2% of deaths in
the western world, but patients with known AAA
have increased cardiovascular disease mortality. 14
Retrospective cohort studies have shown possible
associations with AAA and hypertension and dysli-
pidemia, although there are contradictory findings in
the literature.2 Interestingly, a recent genome-wide
association study using the Million Veteran Program
database found that diastolic blood pressure, rather
than systolic blood pressure, likely plays a role in AAA
formation.15 Diabetes is a known risk factor for
atherosclerotic disease but has been associated with a
paradoxical reduced rate of AAAs and attenuated
growth of known AAAs.2 Although the pathophysi-
ology of diabetes has been shown to play a role in
multiple pathways of vascular remodeling, including
extracellular membrane and vascular SMC homeo-
stasis and decreased neo-angiogenesis, epidemiologic
and murine studies have suggested that antidiabetic
drugs may also contribute to the protective effect of
the disease.16 Utilization of antidiabetic drugs to
JACC VOL. 80, NO. 8, 2022 Hensley and Upchurch Jr. 823
AUGUST 23, 2022:821–831 Abdominal Aortic Aneurysm Repair

mitigate AAA formation and progression is the subject

F I G U R E 1 Computed Tomography Image of Infrarenal
of ongoing research.17 Abdominal Aortic Aneurysm
SEX. AAAs are 6 times more prevalent in men than in
women. 2 The exact mechanism of the effect of sex on
AAAs is not fully understood. Although prevalence of
AAAs is decreased in the female population, there is a
4-fold increase in rupture rates in female patients
with AAA.11 Interestingly, the rate of AAAs in patients
aged 40-60 years was 11 times higher in men than in
women, but this decreased to 3 times higher in the
60- to 90-year-old age group, with no discernable
difference in rates in patients aged >90 years.10 Hu-
man and murine studies support the protective role of
estrogen against AAAs. 18,19
GENETICS. Family history of AAA is associated with
an increased risk of developing the disease, up to
2-fold.2 Significant research efforts have been made
to identify genes associated with the formation of
AAA to develop improved diagnosis and treatment
techniques; no distinct high-risk genes have been
identified, however, unlike with thoracic aortic an-
eurysms.20 Genome-wide association studies are be-
ing used to identify target genes for screening and
treatment. One such study developed a 29-variant
genome-wide polygenic risk score for AAA, which
identified a population subset with a 5.9%-8.6%
prevalence of AAA, compared with the 4.9% preva-
lence observed in the Multicentre Aneurysm
Sagittal computed tomography angiography of patient with
Screening Study from 1997 to 1999.15,21 Polygenic risk
infrarenal abdominal aortic aneurysm (yellow rectangle) with
scores may be used to target a more inclusive patient intraluminal thrombus (green arrow) and extension into the left
population that may benefit from future common iliac artery (red arrow).
AAA screening.

MANAGEMENT OF PATIENTS WITH AAA

SCREENING. The United States Preventative Services
Task Force recommends one-time ultrasound
screening for AAA in men aged 65-75 years with
smoking history (Grade B) and selective screening
in men aged 65-75 years who have never smoked
(Grade C). 22 Ultrasonography has a sensitivity of
95% to 100% and a specificity of nearly 100%.23
This screening algorithm reduces AAA-related mor-
tality, AAA rupture, and emergency surgery over
24
13-15 years of follow-up. Screening for AAA is
underutilized in the United States despite the pas-
sage of supportive legislation in 2007. 25 In a study of
Medicare patients diagnosed with AAA, 40% of pa-
tients underwent repair within 6 months of their first
abdominal imaging, and 35.1% of patients with
ruptured AAA were imaged in the preceding
6 months.25 Per the United States Preventative Ser-
vices Task Force, there is insufficient evidence to
recommend for or against screening in women, and
one study showed that 5 times more women would
need to be screened to prevent 1 aneurysm-related
death compared with men 24 ; however, female pa-
tients do account for at least 33% of ruptured AAA
hospitalizations and 41% of AAA-associated deaths. 26
Although it is known that the overall prevalence of
AAA in female patients is less than in male patients,
female patients with a history of smoking and coro-
nary artery disease have a prevalence of AAA similar
to that of their male counterparts. 27 Therefore, the
female population should not be overlooked, partic-
ularly those with a family history of AAA, smoking
history, and cardiovascular comorbidities. Patients
aged >75 years have been excluded from screening in
the past because of increased operative mortality
from OSR and decreased life expectancy. With the
advent of EVAR, patients aged >75 years who are
reasonable operative candidates with good life ex-
pectancy should be considered for screening ultra-
sound examination.28
824 Hensley and Upchurch Jr.
Abdominal Aortic Aneurysm Repair
T A B L E 1 Surveillance Recommendations for Abdominal Aortic Aneurysms Based on Aortic Diameter
Society for Vascular Surgery
(SVS Guidelines, 2017)30
National Health Services
(NHS AAA Screening Program, 2017)
European SVS
(ESVS Guidelines, 2019)
Values are definition; surveillance interval unless otherwise indicated. Although there is variability in specific time interval recommendations for abdominal aortic aneurysm
(AAA) surveillance, aortas with diameter >3 cm should be imaged regularly to monitor for disease progression.
Patients with abdominal aortic diameter >3 cm on
initial screening examination should be enrolled in a
surveillance imaging program.
Vascular Surgery (SVS) recommends surveillance with
ultrasonography (I-A) at time intervals based on
aortic diameter. Patients with AAA diameter >4 cm
should be referred to a vascular surgeon if available
for continued surveillance and management. 28
SURVEILLANCE. Although the exact screening inter-
val recommendations vary, the importance of regular
surveillance is made clear by the observation of Mell
et al29 that gaps in surveillance were the greatest
predictor of rupture risk in Medicare patients with
AAAs. Frequency of surveillance imaging is deter-
mined by using aortic diameter (Table 1). Medical
management of patients with AAA is key during the
surveillance period, including smoking cessation. 30
There is limited evidence supporting specific medi-
cations for prevention of AAA expansion in humans,
although it is generally accepted that comorbidities
such as hyperlipidemia, hypertension, and diabetes
should be treated. The majority of patients with AAA
have concomitant cardiovascular disease, and thus a
statin and an antihypertensive agent should be
considered if clinically appropriate.30
INTERVENTION. Many AAAs are asymptomatic until
rupture and are found incidentally on diagnostic im-
aging or via screening ultrasound. 30 The decision to
proceed with intervention for AAA is based on pres-
ence of symptoms, including back and abdominal
pain, end-organ dysfunction, and risk of rupture
(Central Illustration). Emergent intervention is indi-
cated in cases of impending or active rupture diag-
nosed via clinical presentation or imaging in patients
with known AAA. Patients with symptoms attribut-
able to AAA, but without evidence of rupture on
computed tomography (CT) scan, should be consid-
ered for urgent intervention.
For asymptomatic AAAs, the risk–benefit ratio of
surgical intervention vs risk of rupture must be
JACC VOL. 80, NO. 8, 2022
AUGUST 23, 2022:821–831
Location Aorta <3 cm Small Medium Large
United States 10 y 3-3.9 cm; 3 y 4-4.9 cm; 1 y 5-5.4 cm; 6 mo
United Kingdom No follow-up 3-4.4 cm; 1 y 4.5-5.4 cm; 3 mo 4.5-5.4 cm; 3 mo
33þ countries 5-10 y 3-3.9 cm; 3 y 4-4.9 cm; 1 y 5-5.4 cm; 3-6 mo
in Europe
weighed carefully and reassessed at least annually.
To date, AAA diameter is the best prediction of
The Society for rupture risk, although there are multiple studies
evaluating assessment of biomechanics of AAAs using
advanced imaging techniques as more specific tools
for predicting rupture risk in the future. 31 The annual
rupture risk in men with AAAs of 4.0-4.9 cm and 5.0-
5.9 cm is 0.5%-5% and 3%-15%, respectively. 23 The
risk of AAA rupture beyond the 5.5 cm threshold ex-
ceeds the risks associated with elective surgical
intervention in asymptomatic patients based on
multiple randomized controlled trials (RCTs). 32-34 The
SVS, European Society for Vascular Surgery (ESVS),
and National Institute for Health and Care Excellence
(NICE) guidelines are in general agreement regarding
the indications for treatment of asymptomatic AAAs:
saccular aneurysm, diameter >4.0 cm with growth
rate >1 cm in 1 year, diameter $5 cm in female pa-
tients, or diameter $5.5 cm in male patients.
Although guidelines provide diameter threshold rec-
ommendations for the timing of intervention in
women, it is an area of ongoing research and con-
troversy. Multiple studies have reported increased
perioperative morbidity and mortality in women un-
dergoing elective aneurysm repair compared with
men.35-37 The paucity of data on women with AAAs,
likely secondary to lower prevalence and delayed
diagnosis among other factors, makes it difficult to
develop clear evidence-based guidelines.24 Perhaps
there is a role in the near future for developing a
female-specific risk assessment to assist in decision-
making that incorporates higher rates of periopera-
tive complications in women and measurements such
as aneurysm indexed to body size, which has been
shown to be of more importance in determining
rupture risk for women.38
The decision to proceed with a surgery (whether
open or endovascular) can be complex. The patient’s
overall fitness to undergo an invasive procedure and
their life expectancy should both be taken into
consideration. Tools such as the SVS mortality risk
JACC VOL. 80, NO. 8, 2022 Hensley and Upchurch Jr. 825
AUGUST 23, 2022:821–831 Abdominal Aortic Aneurysm Repair

C ENTR AL I LL U STRA T I O N Management of Patients With Abdominal Aortic Aneurysms

<2 Years
Ruptured? • Men: Fusiform AAA >5.4 cm Life Expectancy?
• Women: Fusiform AAA >5.0 cm
Saccular Aneurysm

>2 Years
No
Medical
Yes Management

• AAA <5.4 cm in Men Operative Prohibitive

Anatomy • AAA <5.0 cm in Women Mortality Risk?
Appropriate for No
EVAR?

Low/Medium
Continued Surveillance

Yes High Anatomy Appropriate

No Palliative Care
for EVAR?
vs
Elective Repair
Open Repair

Endovascular Yes
Repair Open Repair Endovascular Repair

Hensley SE, et al. J Am Coll Cardiol. 2022;80(8):821–831.

An algorithm for managing patients with abdominal aortic aneurysms including both open and endovascular repair options. AAA ¼ abdominal aortic aneurysm;
EVAR ¼ endovascular aortic repair.

calculator and the Vascular Quality Initiative periop-
erative risk score should be used to make informed
decisions about pursuing surgery. EVAR should be
used at centers that perform at least 10 cases every
year and have documented perioperative mortality
and conversion rates to open repair of #2% of cases
(2-C) (SVS guidelines). For patients unfit for OSR, the
probability of mortality and Vascular Quality Initia-
tive perioperative risk score should be used in
conjunction with life expectancy to decide whether to
proceed with endovascular intervention vs medical
management only. For patients who present with a
ruptured AAA, SVS recommends EVAR over OSR for
treatment if the patient’s anatomy is amenable to
endovascular intervention (1-C).
International guidelines for AAA management
include the 2019 ESVS guidelines and the UK-based
2020 NICE guidelines. The variability between these
2 management paradigms has been a topic of recent
controversy. The NICE guidelines favor an open
repair-first approach, while the ESVS guidelines
describe an EVAR-first approach to AAA treatment.
Powell and Wanhainen 39 compared these 2 guidelines
in detail and found that the open repair vs EVAR-first
approach can be attributed to differing perspectives,
particularly economic views, and methodologies of
the committees that developed the guidelines.
Although these international recommendations
continue to fuel the EVAR vs OSR debate, it is impor-
tant to note that in the United States, most continue to
follow the SVS guidelines as EVAR remains the pri-
mary method by which AAAs are repaired.
REPAIR OPTIONS FOR AAA:
OPEN VS ENDOVASCULAR
Open repair of AAAs is indicated in patients who do
not meet anatomic requirements for EVAR or in those
who have mycotic aneurysms/infected grafts or
complications after EVAR requiring re-intervention.30
Briefly, OSR involves a transperitoneal or retroperi-
toneal incision and replacement of the aorta with a
prosthetic graft (Figure 2). In the setting of suspected
infection, repair options include utilization of
rifampin-soaked grafts, extra-anatomic bypass with
aneurysm exclusion, or creation of neoaorta using
femoral vein. 40 The inferior extent of the aneurysmal
pathology and associated aortic occlusive disease
determine the distal anastomotic site and whether
further reconstruction is required.
EVAR is currently the primary method by which
AAAs are repaired. Generally, EVAR involves arterial
826 Hensley and Upchurch Jr.
Abdominal Aortic Aneurysm Repair
F I G U R E 2 Open Repair of AAA
Intraoperative photo showing proximal and distal control of an abdominal aortic aneurysm (AAA) with incision of the AAA and exposure of the
intraluminal thrombus (black arrow) (A) and after repair with an aorto-bi-iliac bypass graft (B). Reproduced with permission from the Division
of Vascular Surgery, University of Florida, Gainesville, Florida, USA.
access via the femoral artery and deployment of a
stent graft from the infrarenal aorta to the iliac ar-
teries. The stent graft consists of a metallic skeleton
covered by impermeable fabric and should exclude
the aneurysm sac from the aortic blood flow.41 In
preparation for EVAR, CT scanning with intravenous
contrast is used to generate a 3-dimensional model of
the patient’s aorta. Measurements based on this
model further assist in determining suitability for
EVAR and designing the stent graft with the goal of
obtaining adequate proximal and distal seal and
exclusion of the aneurysm sac. Anatomic parameters
for EVAR include measurements of aortic neck
diameter/length and neck angulation.41
values vary according to different manufacturers’
device instructions for use. Significant advances have
been made in endovascular device design that aim to
expand the conformability of stent grafts to less
favorable anatomy. These design advances include
fenestrations in the fabric and stent graft extensions
preserving flow to critical aortic branches.
ELIGIBILITY AND PATIENT SELECTION
FOR EVAR
Since the advent of EVAR in the 1990s, numerous
studies have been conducted comparing open vs
endovascular repair of AAAs. From 1995 to 2008,
there was a notable decline in AAA repair operative
mortality (4.9% vs 2.4%) in the Medicare population,
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AUGUST 23, 2022:821–831
which was partially attributable to the introduction of
EVAR.7 The utilization of EVAR increased drastically
from 2000 to 2010, from 5.4% to 74% of the total
number of AAA repairs in the United States, in
conjunction with improvements in perioperative im-
aging and increased availability of specialized endo-
vascular operating rooms with intraoperative imaging
capabilities. 6 Multiple trials have reported a decrease
in perioperative mortality, early aneurysm-related
mortality, and length of stay in ruptured and non-
ruptured patients who undergo EVAR vs OSR 42
(Table 2).
Early studies included the EVAR 1 (UK EndoVas-
Specific cular Aneurysm Repair 1) trial, which was a national,
multicenter RCT conducted from 1999 to 2004 that
compared EVAR vs OSR in patients who were
considered suitable candidates for both procedures.5
The EVAR 1 trial reported decreased operative mor-
tality and initial improvement of aneurysm-related
survival in the patients who underwent EVAR, but
this benefit was negated after 4 postoperative years
due to increased aneurysm-related mortality in the
EVAR group.42
The DREAM (Dutch Randomized Endovascular
Management) trial was a large multicenter RCT con-
ducted in 2009 to compare long-term mortality of
EVAR vs OSR. 43 Similar to the EVAR 1 trial, patients
who were candidates for either procedure were ran-
domized to endovascular or open repair groups.
Short-term survival benefit in the EVAR group was
JACC VOL. 80, NO. 8, 2022 Hensley and Upchurch Jr. 827
AUGUST 23, 2022:821–831 Abdominal Aortic Aneurysm Repair

T A B L E 2 Summary of Relevant Studies Comparing Open vs Endovascular Aortic Repair

UK EVAR 15 DREAM43,59,60 OVER44,45,61

Study characteristics
Country United Kingdom Belgium/the Netherlands United States
Years of study 1999-2004 2000-2003 2002-2008
Eligibility Men and women aged >60 y fit Men and women fit for open repair Men and women fit for open repair with:
for open repair with AAA with AAA >5 cm with anatomy 1) AAA >5 cm; 2) associated iliac
>5.5 cm on CT scan with amenable to EVAR aneurysm >3 cm; or 3) AAA >4.5 cm
anatomy amenable to EVAR with rapid enlargement or saccular
morphology with anatomy amenable
to EVAR
Exclusion criteria Patients unfit for open repair Emergent repairs, inflammatory Previous abdominal aortic surgery,
aneurysms, connective tissue urgent repairs
disease, history of organ
transplant, life expectancy <2 y
Patients randomized
Total 1,252 351 881
EVAR 626 (12 deaths) 173 (1 death) 444
OSR 626 (19 deaths) 178 (1 death) 437
Patients undergoing
treatment
EVAR 598 elective EVAR, 12 elective 171 427
OSR, 4 emergency OSR (96%
per protocol)
OSR 567 elective OSR, 31 elective 173 416
EVAR, 4 emergency OSR (91%
per protocol)
Patient characteristics
Mean  SD age, y 74  6.1 EVAR: 70.7  6.6 EVAR: 69.6  7.8
OSR: 69.5  6.8 OSR: 70.5  7.8
Mean  SD AAA 6.7  1.0 EVAR: 6.06  0.9 EVAR: 5.7  0.8
diameter, cm OSR: 6.0  0.85 OSR: 5.7  1.0
Male 90% EVAR: 93% EVAR: 99.3%
OSR: 90.2% OSR: 99.5%
Study outcomes
Follow-up, y 8 15 8
Operative mortality
(30 day) (%)
EVAR 1.8 1.2 0.2
OSR 4.3 4.6 2.3
OR: 0.44; 95% CI: 0.21 to 0.92; RR: 3.9; 95% CI: 0.9 to 32.9; P ¼ 0.006
P ¼ 0.029 P ¼ 0.10
All-cause mortality >4 y (%) 6-15 y (event incidence) >4-8 y
EVAR 8.4 59 (n ¼ 119) 24.9
OSR 7.9 54 (n ¼ 125) 21.5
HR: 1.11; 95% CI: 0.84 to 1.47; RR: 1.0; 95% CI: 0.69 to 1.45; HR: 1.18; 95% CI: 0.87 to 1.60; P ¼ 0.29
P ¼ 0.469 P ¼ 1.0
AAA-related mortality >4 y (%) 6-15 y (event incidence) Duration of follow-up (%)
EVAR 0.8 3 (n ¼ 119) 2.7
OSR 0.2 1 (n ¼ 124) 3.7
HR: 4.73; 95% CI: 1.01 to 22.07; RR: 0.36; 95% CI: 0.01 to 3.41; Between-group difference: –1.0; 95% CI:
P ¼ 0.048 P ¼ 0.42 –3.3 to 1.4
Re-interventions 0 to > 4 y (%) 0 to 15 y (event incidence) Duration of follow-up (%)
EVAR 12.6 99 (n ¼ 168) 26.7
OSR 2.5 44 (n ¼ 175) 19.8
HR: 2.86; 95% CI: 2.09 to 3.92; RR: 0.42; 95% CI: 0.29 to 0.60; Between-group difference: 6.9; 95% CI:
P < 0.0001 P < 0.001 2.0 to 17.5

Overview of relevant randomized controlled studies comparing endovascular aortic repair (EVAR) vs open surgical repair (OSR) in patients with abdominal aortic aneurysms (AAAs) showing
improved 30-day mortality after EVAR compared with OSR and no difference in long-term all-cause mortality.
DREAM ¼ Dutch Randomized Endovascular Management; EVAR 1 ¼ EndoVascular Aneurysm Repair 1; OR ¼ odds ratio; OVER ¼ Open Versus Endovascular Repair; RR ¼ relative risk.
828 Hensley and Upchurch Jr.
Abdominal Aortic Aneurysm Repair
F I G U R E 3 Computed Tomography Image of Endoleak After EVAR
(A) Coronal computed tomography angiography of 5.5-cm thoracoabdominal aortic aneurysm after previous endovascular aortic repair (EVAR)
for abdominal aortic aneurysm in addition to type 1a endoleak (red circle, leak at proximal seal of graft). (B) Type 1b endoleak in the left
common iliac artery (yellow circle, leak at distal seal of graft).
again shown. Long-term follow-up did not report any
significant difference in overall survival at 12 years.
The OVER (Open Versus Endovascular Repair)
Veterans Affairs Cooperative trial was an RCT con-
ducted from 2002 to 2008 to compare long-term
morbidity and mortality of EVAR vs OSR. 44 Similar
to the EVAR 1 and DREAM trials, patients who were
fit for both interventions were randomized to the
endovascular or open repair groups. Short-term
outcomes echoed findings of the EVAR 1 and
DREAM trials, namely decreased perioperative
mortality and aneurysm-related mortality up to 2
years after EVAR. Long-term outcomes showed
improved long-term survival in patients aged <70
years.45 The OVER trial did not find a significant
difference in the number of secondary therapeutic
procedures between groups, whereas the EVAR 1
trial reported a significantly increased rate of addi-
tional procedures in the EVAR group. Lederle
et al,45 however, noted that the EVAR 1 trial did not
include abdominal hernia repairs after open surgery
in its analysis.
The EVAR 1, DREAM, and OVER trials reported
short-term survival benefit of variable duration after
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AUGUST 23, 2022:821–831
EVAR vs OSR (1-2 years in the DREAM and EVAR 1
trials and 5 years in the OVER trial). 43 In the EVAR 1
and OVER studies, all postoperative ruptures
occurred in patients in the EVAR treatment groups. 42
In all 3 studies, there was no significant difference in
all-cause mortality in the long term (8-year follow-up
in EVAR 1, 12 years in DREAM trial, and 8 years in
OVER trial).43 A meta-analysis of 4 large studies
comparing OSR vs EVAR over a 5-year period,
including the EVAR 1, DREAM, and OVER trials, reit-
erated the short-term survival benefits of EVAR
within the first 6 months after repair as well as the
loss of this survival benefit over time.46
There are pros and cons to both open and endo-
vascular repair options. Although surgeons in the
United States generally prefer EVAR, the patient’s
priorities must be taken into account as well. There is
an ongoing cluster-RCT, the PROVE-AAA (Preferences
for Open versus Endovascular Repair for Abdominal
Aortic Aneurysm) trial, which is evaluating the utili-
zation of a decision aid to assess the preferences for
EVAR vs OSR in patients eligible for both types of
repair and alignment of preferences with actual
treatment received. 47
JACC VOL. 80, NO. 8, 2022
AUGUST 23, 2022:821–831
COMPLICATIONS OF EVAR
Endoleaks are unique to endovascular repair and can
occur in 10%-40% of patients undergoing elective
EVAR.48 Endoleaks are defined as persistent flow
within the aneurysm sac after deployment of the
stent graft, and they can lead to aneurysm sac
expansion and rupture. Endoleaks can develop at any
point after EVAR, but 25% are present at the time of
repair.30 Most endoleaks occur within the first 5 years
after surgery and are detected via routine post-
operative imaging. There are 5 types of endoleaks,
and treatment is dependent on type and risk of sac
rupture. Types I and III involve persistent communi-
cation between the vessel lumen and aneurysm sac
resulting in sac expansion and increased rupture risk
requiring intervention (Figure 3).49 Interventions
include endovascular stent graft extension tech-
niques with open revision as a last resort. Endoleaks
occurred in 30.5% of patients who underwent EVAR
in the OVER trial; 50% of all endoleaks resolved
without intervention, and 9.8% of patients with
endoleaks underwent secondary intervention.50
Other possible complications of EVAR include de-
vice migration, postimplant syndrome, limb occlu-
sion requiring arterial re-intervention, graft infection,
and rupture. Rupture after EVAR, although rare (5 of
439 patients in the OVER trial), may not be predicated
based on aneurysm changes on surveillance imaging.
Postimplant syndrome is an inflammatory response
defined as fever and leukocytosis after EVAR, with no
evidence of infectious etiology, and can occur in
14%-60% of patients.51 This condition seems to be
largely benign, although it is likely underreported,
and the pathophysiology is not clearly understood;
the composition of the endograft may play a role in
the inflammatory response, however. Open surgery
remains the definitive treatment option after EVAR
failure. Indications for open revision include endo-
leak refractory to endovascular management, graft
infection, graft occlusion, and graft migration. Inci-
dence of late open conversion after EVAR is 1%-23%.52
LONG-TERM SURVEILLANCE AND FOLLOW-UP
AFTER REPAIR
The SVS describes postoperative surveillance with the
intent to prevent late rupture and aneurysm-related
mortality. It recommends abdominopelvic CT imag-
ing with intravenous contrast every 5 years after OSR
to monitor for anastomotic aneurysm or aneurysm
dilatation in adjacent vessels. Per the SVS guidelines,
post-EVAR surveillance should include a CT scan at
1 month after surgery followed by repeat imaging in
Hensley and Upchurch Jr. 829
Abdominal Aortic Aneurysm Repair
6 months if concerning findings are noted. If there is
no evidence of sac expansion or type I or III endoleaks
in the initial postoperative imaging, annual duplex
ultrasound is recommended for surveillance with a
low threshold to obtain cross-sectional imaging if
changes are noted on ultrasonography. Post-EVAR
imaging surveillance recommendations are an area
of ongoing study and may change as more long-term
modern EVAR data become available.
FUTURE DEVELOPMENTS
ADVANCES IN OPERATIVE MANAGEMENT. There
have been numerous articles published in the last few
years comparing repair strategies. The EVAR 1,
DREAM, and OVER trials were conducted in the
2000s, and there are some questions about the mod-
ern applicability of these trials as endovascular grafts
and techniques have significantly advanced since
then. The UK-Complex Aneurysm Study or UK-
COMPASS trial (UK Comparison Study of Open
Surgery, Endovascular Techniques, and Medical
Management of Juxtarenal Aortic Aneurysms) is an
ongoing risk-adjusted, anatomically stratified cohort
comparison study that aims to analyze all patients in
England who underwent repair in 2017-2019 for up to
2 years.53 In addition, the UK-COMPASS study will
compare quality-of-life data points among patients
undergoing repair or medical management for AAA in
the United Kingdom from 2018 to 2021 for up to 5
years. The majority of ongoing trials related to AAA
repair are evaluating specific EVAR stent grafts
and techniques.54
ADVANCES IN PREVENTION AND MEDICAL
MANAGEMENT. There is currently no proven medical
therapy for prevention or treatment of AAAs.5 There
has been extensive research into possible therapeutic
targets for prevention of aortic aneurysms and miti-
gation of aneurysm growth. Although some targets
have shown promise in animal models, none have
been successfully translated into humans. This is
currently a very active area of AAA research. All tar-
geted clinical trials have had negative results,
although there are some ongoing trials. 55 There is
evidence that smoking cessation is associated with a
decreased incidence of AAA, reduced growth rate,
and decreased rupture risk, but smoking cessation is a
modification of a risk factor and not a targeted ther-
apy for AAA.56
Improved short-term survival of patients with AAA
undergoing endovascular repair has been well docu-
mented, but long-term relative survival of these pa-
tients remains a concern. Bulder et al57 evaluated all
patients who underwent elective AAA repair in
830 Hensley and Upchurch Jr. JACC VOL. 80, NO. 8, 2022

Abdominal Aortic Aneurysm Repair AUGUST 23, 2022:821–831

Sweden from 2001 to 2015. Notably, they compared CONCLUSIONS

outcomes among 3 time periods to account for ad-
vancements in AAA management: OSR-dominated Postoperative patients may benefit from more inten-
period (2001-2004), transition period (2005-2011), sive management of cardiovascular comorbidities to
and EVAR-first strategy (2012-2015). Similar to other improve their long-term relative survival disadvan-
studies, their findings showed statistically significant tage, as evidenced by a recent meta-analysis which
improvement in short-term (90 day) mortality in men showed that statin usage after AAA repair was asso-
from period 1 to period 3 for OSR and EVAR (4.1%- ciated with decreased short- and long-term
1.2% for OSR, 1.9%-0.9% for EVAR). Long-term sur- mortality. 58
vival of electively treated patients was stable across
FUNDING SUPPORT AND AUTHOR DISCLOSURES
the 3 time periods and remained lower relative to the
age- and sex-matched general population, more so for The authors have reported that they have no relationships relevant to
women. More interestingly, cardiovascular mortality the contents of this paper to disclose.

was the primary cause of death in this patient popu-

lation across all 3 time periods; cancer-related mor- ADDRESS FOR CORRESPONDENCE: Dr Sara E.
tality was the second most common cause of death. Hensley, University of Florida, Department of Sur-
Despite the short-term mortality benefits of elective gery, 1600 SW Archer Road, Gainesville, Florida
AAA repair, these patients are more likely to die of 32608, USA. E-mail: sara.hensley@surgery.ufl.edu.
complications of cardiovascular disease. Twitter: @gru6n.

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KEY WORDS AAA, abdominal aortic
aneurysm, aorta pathology, endovascular
aortic repair, EVAR