Abdominal aortic aneurysms

Abstract

An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage — the mortality for patients with ruptured AAA is 65–85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.

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Fig. 1: AAAs.
Fig. 2: A speculative model of AAA progression.
Fig. 3: Conventional imaging of AAA.
Fig. 4: Functional imaging of AAA.
Fig. 5: Finite element analysis of AAA.
Fig. 6: Proposed surveillance protocol for patients with AAAs.
Fig. 7: History of the treatment of AAA.
Fig. 8: Open AAA repair surgery.
Fig. 9: Endovascular aortic repair.

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Acknowledgements

The authors thank A. Courtois for her help during the preparation of this manuscript, J. Roy, M. L. Liljeqvist and C. Gasser for their contribution to Fig. 5 and P. Bonnet for providing the figure on the surgical management of AAAs.

Reviewer information

Nature Reviews Disease Primers thank H.-H. Eckstein, S. Haulon, F. Moll, C. A. Nienaber, P. Norman, C. Zarins and the other anonymous reviewer(s) for their contribution to the peer review of this work.

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Introduction (N.S. and J.T.P.); Epidemiology (R.H. and H.K.); Mechanisms/pathophysiology (J.-O.D., H.K. and J.-B.M.); Diagnosis, screening and prevention (N.S., A.N. and R.H.); Management (N.S., A.K., K.Y. and R.H.); Quality of life (A.K. and J.T.P.); Outlook (N.S., H.K. and J.T.P.); Overview of Primer (N.S. and R.H.).

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Correspondence to Natzi Sakalihasan.

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UK Office for National Statistics: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath

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Sakalihasan, N., Michel, JB., Katsargyris, A. et al. Abdominal aortic aneurysms. Nat Rev Dis Primers 4, 34 (2018). https://doi.org/10.1038/s41572-018-0030-7

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