Abdominal Aortic Aneurysm (AAA)


Article Author:
Palma Shaw
John Loree


Article Editor:
Ryan Gibbons


Editors In Chief:
Temekis Hampton


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
3/31/2019 6:38:17 PM

Introduction

Abdominal aortic aneurysm (AAA) is a life-threatening condition which requires monitoring or treatment depending upon the size of the aneurysm and/or symptomatology. AAA may be detected incidentally or at the time of rupture. An arterial aneurysm is defined as a permanent localized dilatation of the vessel at least 150% compared to a relative normal adjacent diameter of that artery [1]

Etiology

Risk factors for AAA include advanced age, tobacco use, hypertension, hypercholesterolemia, Chronic obstructive pulmonary disease, and male gender. Atherosclerosis is the most commonly associated pathology, but other causes such as cystic medial necrosis, dissection, syphilis, HIV and Ehlers-Danlos syndrome have been identified.

Aneurysm enlargement can be step-wise with the stability of the size for some time and then a more rapid enlargement. Rate of enlargement for small AAA (3-5 cm) is 0.2 to 0.3 cm/year and 0.3 to 0.5 cm/year for those > 5 cm [2].  The pressure on the aortic wall follows the Law of Laplace (wall stress is proportional to the radius of the aneurysm).  Because of this, larger aneurysms are at higher risk of rupture, and the presence of hypertension also increases this risk.  

Epidemiology

Based on autopsy studies, the frequency of these aneurysms varies from 0.5% to 3%. The incidence of abdominal aortic aneurysms increases after age 60 and peaks in the seventh and eighth decades of life. White men have the highest risk of developing abdominal aortic aneurysms. They are uncommon in Asian, African American, and Hispanic individuals [3]. Data derived from Lifeline AAA screening and National Health and Nutrition Examination Survey (NHANES, 2003-2006)database reveals a prevalence of 1.4% or 1.1 million AAAs in those studied aged 50 to 84 [4]. With the increased use of ultrasound, the diagnosis of abdominal aortic aneurysms is quite common. They tend to be more common in smokers and elderly white males. Although autopsy studies may under-represent the incidence of AAA, one study from Malmo Sweden found a prevalence of 4.3% in men and 2.1% in women detected on ultrasound [5].

Pathophysiology

Abdominal aortic aneurysms tend to occur when there is a failure of the structural proteins of the aorta. What causes these proteins to fail is not known, but it results in the gradual weakening of the aortic wall. The decrease in structural proteins of the aortic wall such as elastin and collagen has been identified [6][7][8]. The composition of the aortic wall is made of collagen lamellar units.  The number of lamellar units is lower in the infrarenal aorta than the thoracic aorta [8][9][10]. This is felt to contribute to the higher incidence of aneurysmal formation in the infrarenal aorta.  A chronic inflammatory process in the wall of the aorta has been identified but is of unclear etiology [11].

Other factors that may play a role in the development of these aneurysms include genetics, marked inflammation, and proteolytic degradation of the connective tissue in the aortic wall [12][13][14].

Histopathology

Autopsy studies usually show marked degeneration of the media. Examination of resected abdominal aortic aneurysms usually reveals a state of chronic inflammation with an infiltrate of neutrophils, macrophages, and lymphocytes. The media is often thin, and there is evidence of degeneration of the connective tissue.

History and Physical

The majority of abdominal aortic aneurysms are identified incidentally during an examination for another unrelated pathology. Most individuals are asymptomatic. Palpation of the abdomen usually reveals a pulsatile abdominal mass which is not tender. Enlarging aneurysms can cause symptoms of abdominal, flank or back pain.  Compression of adjacent viscera can cause gastrointestinal (GI) or renal manifestations.  Rupture of an abdominal aortic aneurysm is life-threatening. These patients may present in shock often with diffuse abdominal pain and distension. However, the presentation of patients with this type of ruptured aneurysm can vary from subtle to quite dramatic. Most patients with a ruptured abdominal aortic aneurysm die before hospital arrival. On physical exam, the patient may have tenderness over the aneurysm or demonstrate signs of embolization. The aneurysm may rupture into adjacent viscera or vessels presenting with GI bleeding or congestive heart failure due to the aortocaval fistula. Physical exam should also look for other associated aneurysms.  The most common associated aneurysm is an iliac artery aneurysm.  Peripheral aneurysms are also associated in approximately 5 % of patients, of which popliteal artery aneurysms are the most common.

Evaluation

The diagnosis of an abdominal aortic aneurysm is usually made with ultrasound (US), but a CT scan is needed to determine the exact location, size, and involvement of other vessels. The US can be used for screening purposes but is less accurate for aneurysms above the renal arteries because of the overlying air-containing lung and viscera. CTA requires the use of ionizing radiation and intravenous contrast. Magnetic resonance angiography can be used as well to delineate the anatomy and does not require ionizing radiation.

Most of these aneurysms are located below the origin of the renal arteries. They may be classified as saccular (localized) or fusiform (circumferential). Some people may develop an inflammatory abdominal aortic aneurysm which is characterized by intense inflammation, a thickened peel, and adhesions to adjacent structures. Angiography is now rarely done to make the diagnosis because of the superior images obtained with CT scans [15].

Treatment / Management

The treatment of unruptured abdominal aortic aneurysm has changed over time. Treatment is recommended when it reaches 5 cm to 5.5 cm, is demonstrated as rapidly enlarging > 0.5 cm over 6 months or becomes symptomatic.  Open surgical repair via transabdominal or retroperitoneal approach has been the gold standard.  Endovascular repair from a femoral arterial approach is now applied for a majority of repairs, especially in older and higher risk patients.  Endovascular therapy is recommended in patients who are not candidates for open surgery. This includes patients with severe heart disease, and/or other comorbidities that preclude open repair. A ruptured abdominal aortic aneurysm warrants emergency repair.  Endovascular approach for ruptured AAA has demonstrated superior results and survival compared to open repair if the anatomy is suitable, but the mortality rates remain high. The risk of surgery is influenced by the age of the patient, the presence of renal failure, and the status of the cardiopulmonary system [16][17].

Data show that for unruptured abdominal aortic aneurysms, endovascular repair has no long-term differences in outcomes compared to open repair. All patients with small abdominal aortic aneurysms who do not undergo repair need periodic follow up with an ultrasound every 6 to 12 months to ensure that the aneurysm is not expanding[18].

Prognosis

Once an abdominal aortic aneurysm ruptures, the prognosis is grim. More than 50% of patients die before they reach the emergency room. Those who survive have very high morbidity. Predictors of mortality include preoperative cardiac arrest, age >80, female gender, massive blood loss and ongoing transfusion [19].  For those undergoing elective repair, the prognosis is good to excellent. However, long-term survival depends on other comorbidities like chronic obstructive pulmonary disease, heart disease, and peripheral vascular disease. It is estimated that 70% of patients after repair will survive for 5 years.

Complications

  • Bleeding
  • Limb ischemia
  • Delayed rupture secondary to endoleak
  • Abdominal compartment syndrome
  • Myocardial infarction
  • Pneumonia
  • Graft infection
  • Colon ischemia
  • Renal failure
  • Bowel obstruction
  • Blue toe syndrome
  • Amputation
  • Impotence
  • Lymphocele
  • Death

Postoperative and Rehabilitation Care

After repair, it is essential that the patient discontinue smoking, eat a healthy diet, and maintain a healthy weight. Physical and/or occupational therapy may be necessary.

Consultations

Once an abdominal aortic aneurysm is diagnosed, the patient should be referred to a vascular surgeon. Surveillance imaging at 12-month intervals is recommended or patients with an AAA of 4.0 to 4.9 cm in diameter [20].

To ensure that the patient is fit for surgery, cardiology and pulmonology as indicated is recommended.

Pearls and Other Issues

  • Patients with abdominal aortic aneurysms should quit smoking is to reduce the risk of enlargement.
  • Medical optimization of hypertension, hyperlipidemia, diabetes, and other atherosclerotic risk factors.
  • Moderate exercise does not cause rupture or AAA expansion [21].
  • The Society for Vascular Surgery Guidelines recommends ultrasound screening for all men and woman 65 years of age or older who have smoked or have a family history of AAA(20).
  • Surveillance Guidelines for AAA per the Society for Vascular Surgery using duplex US are the following:
    • 3-year intervals for patients with an AAA between 3.0 and 3.9 cm
    • 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter.
    • 6-month intervals for patients with an AAA between 5.0 and 5.4 cm in diameter
  • Those patients with an initial aortic diameter <3 cm have a low risk for rupture. At this time there are no recommendations for surveillance; however, it should be noted that gradual expansion in these patients has been noted over time.
  • Patients presenting with a symptomatic AAA should be considered for urgent repair.
  • Asymptomatic patients with AAA demonstrating an aortic diameter > 5.4 cm or those with the rapid expansion of small AAA should be evaluated for repair.
  • The goal of AAA repair is to increase survival. Consideration of quality of life after the repair is important; particularly in those with shortened life expectancy due to medical co-morbidities or cancer.
  • Endovascular repair may offer fewer complications and better quality of life in those at high risk for open repair up to 1-year post-intervention [22].

Factors that increase the operative risk for abdominal aortic aneurysm repair include:

  • Severe heart disease.
  • Severe chronic obstructive pulmonary disease.
  • Poor renal function
  • Comorbidities such as stroke, diabetes, hypertension, and advanced age can increase open surgical risk. These individuals should be considered for endovascular stenting of the aneurysm if the aortic anatomy permits.

Infrarenal Aortic Aneurysm Repair

Consideration for repair is appropriate for all symptomatic aneurysms.  Aortic anatomy and device availability can dictate the approach.  Open aneurysm repair had been the gold standard but carries increased risk and potential complications which may be acceptable in a younger good surgical risk patient.  This is still the more durable procedure. Endovascular repair is now an established technique for repairing an abdominal aortic aneurysm. This minimally invasive procedure can also be offered but has better outcomes and durability when the anatomy meets device specific recommendations. This is the preferred approach in cases of rupture and in patients with multiple risk factors or shortened life expectancy.  Intervention or surgical treatment risks versus benefits of repair in patients at increased risk for open surgery should be considered, and no intervention may be appropriate in some cases.  Patients should be well informed regarding their options, risks of repair and potential post-operative complications.  Endovascular repair requires life-long follow up with imaging as early, or late endoleaks may develop causing aortic sac pressurization and rupture.  Secondary interventions may be necessary the majority of which are minimally invasive, but there is a small chance that open conversion with the removal of the stent graft may be required when these secondary endovascular interventions fail.

 

Enhancing Healthcare Team Outcomes

Infrarenal abdominal aortic aneurysms are the most common aneurysm of the aorta.  Screening ultrasound has helped detect AAA and allow for surveillance in asymptomatic patients with a diameter < 5 cm.  In females, the repair should be considered at 5 cm and in males at 5.5 cm.  If rapid enlargement is demonstrated (>5 mm over 6 months) repair should be considered.  Education of first responders, primary care physicians, and emergency department physicians can facilitate diagnosis and reduce delays in treatment. A team approach of emergency nurses, emergency physicians, and a vascular surgeon will facilitate rapid evaluation and treatment and improve outcomes. Referral to a vascular center that can provide a standard of care management is appropriate.  Once the decision for repair has been made, cardiology workup and clearance and optimization of other medical co-morbidities can improve outcomes. If the aneurysm is small, the patient and family should be educated regarding compliance with blood pressure control, a healthy diet, exercise, cessation of smoking, and follow up.


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Abdominal Aortic Aneurysm (AAA) - Questions

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Which statement about abdominal aortic aneurysms (AAAs) is false?



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In a patient with a leaking abdominal aortic aneurysm, what is the most frequent finding on physical exam?



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In a 65 year old suspected of having an abdominal aortic aneurysm, what is the diagnostic test of choice?



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What should be done for a patient with a 3.5 cm abdominal aortic aneurysm?



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Of the following measurements, which would be considered the threshold for surgical intervention in treating a man with an abdominal aortic aneurysm?



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Which of the following is not true regarding abdominal aortic aneurysms (AAA)?



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Where are atherosclerotic aneurysms most often located?



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Which of the following laboratory studies is usually not required preoperatively in a patient undergoing abdominal aortic aneurysm surgery?



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A 65-year-old male is found to have an asymptomatic, 6 cm abdominal aortic aneurysm. Which of the following is the best option for the treatment of this patient?



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A 71-year-old presents with a pulsatile abdominal mass, hypotension, and pain. He is rushed to the operating room. Which of the following is the one factor that determines his mortality?



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What is the best advice for an elderly male with history of hypertension and cigarette smoking who is diagnosed with an abdominal aortic aneurysm (AAA) measuring 3.0 cm?



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A 65-year-old male with a history of hypertension and smoking is taking hydrochlorothiazide, has a blood pressure of 132/78 mmHg, and the physical exam is normal. Which of the following is an appropriate recommendation?



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Where are atherosclerotic aneurysms most often located?



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A 68-year-old male presents with sudden onset of back pain. He says he has never had back pain before and denies any trauma. He says he just does not feel good and feels like he is going to die. On examination, he looks ill with a blood pressure of 70/54 mmHg, a pulse of 110 beats/min, and respirations 18. His abdomen is tender to palpation. There is a large pulsatile mass. What is the next step in his management?



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A 78-year-old is found to have an asymptomatic pulsatile abdominal mass. The ultrasound shows an abdominal aortic aneurysm measuring 5.5 cm. Which of the following statements concerning this patient's condition is correct?



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A patient with an Oliver sign will have which of the following?



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Which is NOT a risk factor for an abdominal aortic aneurysm?



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Which of the following is the strongest predictor for abdominal aortic aneurysm rupture?



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Which is TRUE about management of an abdominal aortic aneurysm (AAA) in a 67-year-old male?



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Which diagnostic test should be ordered first in the case of a female who is status post abdominal aortic aneurysm repair with foley catheter in place, a blood pressure of 110/75 and pulse of 115 whose urine output drops to 40 cc/hour and creatinine rises to 2.5 mg/dL?



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What is the best advice for a 68-year-old male with a history of hypertension and cigarette smoking who is diagnosed with an abdominal aortic aneurysm measuring 3.0 cm?



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Why is the inclusion technique for the repair of aneurysms NOT used?



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What is the best advice for a 68-year-old male with a history of hypertension and cigarette smoking who is diagnosed with an abdominal aortic aneurysm measuring 3.0 cm?



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A 70-year-old man has sudden onset of abdominal pain which is constant and radiates to the right flank and groin. Past medical history is significant for hypertension with poor compliance, smoking, and coronary artery disease. The patient is diaphoretic and uncomfortable. Blood pressure is 180/115, pulse 100, and he is afebrile. The abdomen shows diffuse tenderness without rebound, hepatomegaly, or masses but is limited by obesity. Which of the following is the most likely diagnosis?



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A 70-year-old male with a history of hyperlipidemia and hypertension is on metoprolol, simvastatin, and hydrochlorothiazide. Blood pressure and lipids are well controlled. Ultrasound shows an infrarenal abdominal aortic aneurysm measuring 4 cm. Select the incorrect statement.



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Which statement regarding abdominal aortic aneurysm is correct?



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A 69-year-old female is found to have a 6 cm abdominal aortic aneurysm (AAA). Select the correct statement.



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According to the United States Preventive Services Task Force, who should be screened for abdominal aortic aneurysms?



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What risk factor is most strongly associated with an abdominal aortic aneurysm?



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Compared to normal arteries, what is the percentage increase in diameter of an abdominal aortic aneurysm?



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At what interval should a patient with an abdominal aortic aneurysm (AAA) of 4 to 4.5 cm receive serial ultrasounds?



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Who is predominantly affected by abdominal aortic aneurysms (AAAs)?



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A patient complaining of tearing back pain has a pulsatile abdominal mass on physical exam. What is the most likely diagnosis?



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A 70-year-old female with a history of hyperlipidemia and hypertension dies suddenly secondary to rupture of an abdominal aortic aneurysm. Select the most probable event that initiated this pathology.



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Which of the followings is not true with regards to abdominal aortic aneurysms?



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Which statement about a ruptured abdominal aortic aneurysm is false?



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Which of the following statements is false with respect to dissecting aortic aneurysms?



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What are the current United States Preventive Task Force (USPSTF) recommendations on screening for abdominal aortic aneurysm?



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A 70-year-old obese male with a history of hypertension presents with low back pain and a blood pressure of 80/60 mmHg and a heart rate of 120 mmHg. Which of the following would be an incorrect action?



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Which of the following is the most common type of aortic aneurysm?



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Which of the following is not a risk factor for an aortic aneurysm?



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A 62-year-old man with a history of hypertension and tobacco use presents to the emergency department with a 2.5-day history of constant hypogastric pain, that has been steadily worsening. The emergency department determines that the man has a AAA or abdominal aortic aneurism. What could be heard upon auscultation at the midline 2 inches cephalad to the umbilicus?



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Abdominal Aortic Aneurysm (AAA) - References

References

Johnston KW,Rutherford RB,Tilson MD,Shah DM,Hollier L,Stanley JC, Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. Journal of vascular surgery. 1991 Mar;     [PubMed]
Powell JT,Sweeting MJ,Brown LC,Gotensparre SM,Fowkes FG,Thompson SG, Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. The British journal of surgery. 2011 May;     [PubMed]
Zommorodi S,Leander K,Roy J,Steuer J,Hultgren R, Understanding abdominal aortic aneurysm epidemiology: socioeconomic position affects outcome. Journal of epidemiology and community health. 2018 Oct;     [PubMed]
Kent KC,Zwolak RM,Egorova NN,Riles TS,Manganaro A,Moskowitz AJ,Gelijns AC,Greco G, Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. Journal of vascular surgery. 2010 Sep;     [PubMed]
Bengtsson H,Bergqvist D,Ekberg O,Janzon L, A population based screening of abdominal aortic aneurysms (AAA). European journal of vascular surgery. 1991 Feb;     [PubMed]
Xu C,Zarins CK,Glagov S, Aneurysmal and occlusive atherosclerosis of the human abdominal aorta. Journal of vascular surgery. 2001 Jan;     [PubMed]
Busuttil RW,Abou-Zamzam AM,Machleder HI, Collagenase activity of the human aorta. A comparison of patients with and without abdominal aortic aneurysms. Archives of surgery (Chicago, Ill. : 1960). 1980 Nov;     [PubMed]
Busuttil RW,Rinderbriecht H,Flesher A,Carmack C, Elastase activity: the role of elastase in aortic aneurysm formation. The Journal of surgical research. 1982 Mar;     [PubMed]
Dobrin PB,Baumgartner N,Anidjar S,Chejfec G,Mrkvicka R, Inflammatory aspects of experimental aneurysms. Effect of methylprednisolone and cyclosporine. Annals of the New York Academy of Sciences. 1996 Nov 18;     [PubMed]
Cohen JR,Mandell C,Chang JB,Wise L, Elastin metabolism of the infrarenal aorta. Journal of vascular surgery. 1988 Feb;     [PubMed]
Parry DJ,Al-Barjas HS,Chappell L,Rashid ST,Ariëns RA,Scott DJ, Markers of inflammation in men with small abdominal aortic aneurysm. Journal of vascular surgery. 2010 Jul;     [PubMed]
Jiang H,Sasaki T,Jin E,Kuzuya M,Cheng XW, Inflammatory Cells and Proteases in Abdominal Aortic Aneurysm and its Complications. Current drug targets. 2018;     [PubMed]
Majumder PP,St Jean PL,Ferrell RE,Webster MW,Steed DL, On the inheritance of abdominal aortic aneurysm. American journal of human genetics. 1991 Jan;     [PubMed]
Tilson MD,Seashore MR, Human genetics of the abdominal aortic aneurysm. Surgery, gynecology     [PubMed]
Gibbons RC,Young M, Aneurysm, Abdominal Aortic (AAA), Imaging 2019 Jan;     [PubMed]
Jonker LT,de Niet A,Reijnen MMPJ,Tielliu IFJ,Zeebregts CJ, Mid- and Long-Term Outcome of Currently Available Endografts for the Treatment of Infrarenal Abdominal Aortic Aneurysm. Surgical technology international. 2018 Nov 11;     [PubMed]
Wang LJ,Prabhakar AM,Kwolek CJ, Current status of the treatment of infrarenal abdominal aortic aneurysms. Cardiovascular diagnosis and therapy. 2018 Apr;     [PubMed]
Amin S,Schnabel J,Eldergash O,Chavan A, [Endovascular aneurysm repair (EVAR) : Complication management]. Der Radiologe. 2018 Sep;     [PubMed]
Johansen K,Kohler TR,Nicholls SC,Zierler RE,Clowes AW,Kazmers A, Ruptured abdominal aortic aneurysm: the Harborview experience. Journal of vascular surgery. 1991 Feb;     [PubMed]
Chaikof EL,Dalman RL,Eskandari MK,Jackson BM,Lee WA,Mansour MA,Mastracci TM,Mell M,Murad MH,Nguyen LL,Oderich GS,Patel MS,Schermerhorn ML,Starnes BW, The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Journal of vascular surgery. 2018 Jan;     [PubMed]
Myers J,McElrath M,Jaffe A,Smith K,Fonda H,Vu A,Hill B,Dalman R, A randomized trial of exercise training in abdominal aortic aneurysm disease. Medicine and science in sports and exercise. 2014 Jan;     [PubMed]
Kayssi A,DeBord Smith A,Roche-Nagle G,Nguyen LL, Health-related quality-of-life outcomes after open versus endovascular abdominal aortic aneurysm repair. Journal of vascular surgery. 2015 Aug;     [PubMed]

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