Editor's Choice - Percutaneous Access Does Not Confer Superior Clinical Outcomes Over Cutdown Access for Endovascular Aneurysm Repair: Meta-Analysis and Trial Sequential Analysis of Randomised Controlled Trials

Comparison of percutaneous versus cutdown access in patients after endovascular abdominal aortic repair: a randomized controlled trial (SWEET-EVAR trial)

INTRODUCTION

The optimal choice of either percutaneous or cutdown access for endovascular abdominal aortic repair (EVAR) remains uncertain due to insufficient evidence, particularly regarding patient-centered outcomes (PCOs). This study aimed at comparing both clinician-reported outcomes (ClinROs) and PCOs of percutaneous versus cutdown access in patients after EVAR.

METHODS

The study was a single-blind, single-center, non-inferiority, randomized controlled trial. After eligibility screening, patients diagnosed with abdominal aortic diseases were randomly assigned to either the intervention group receiving percutaneous EVAR or the control group receiving cutdown EVAR. Primary ClinRO was access-related complications, and primary PCO was time return to normal life/work.

RESULTS

Overall, 120 patients (containing 240 accesses) were allocated to either intervention group ( n = 62) or control group ( n = 58). Percutaneous EVAR (10/124, 8.1%) was non-inferior and not superior to cutdown EVAR (17/116, 14.7%) regarding access-related complications ( P = 0.110; OR: 0.521, 95% CI: 0.225-1.157). As for PCOs, the recovery time back to normal life or work was superior in percutaneous EVAR compared to cutdown EVAR (16 vs. 28 days, P = 0.025; median difference: 7 days, 95% CI: 0-13 days). Moreover, percutaneous access did better in other PCOs, including a reduction in the duration of access-related pain (4 vs. 8 days, P = 0.001), decreased use of analgesics for access-related pain (0/61, 0% vs. 6/55, 10.9%; P = 0.026), and improved quality of life scores at 2 weeks following EVAR (0.876 vs. 0.782; P = 0.022). Prespecified subgroup analyses demonstrated percutaneous access significantly reduced the incidence of access-related complications compared to cutdown access in patients with thick subcutaneous tissue (1/42, 2.4% vs. 7/32, 21.9%; P = 0.026).

CONCLUSION

In patients without massive common femoral artery calcification, percutaneous access may accelerate postoperative recovery and enhance patient experience and quality of life following EVAR, but did not provide obvious advantages regarding access-related complications.

Utilization of percutaneous closure devices for large bore arterial access in patients with genetic aortopathy does not result in increased rates of access site complications

OBJECTIVE

Percutaneous closure devices for arterial sheaths of sufficient caliber to deliver aortic endografts have a published success rate of 90% to 95%. Despite this, they are frequently avoided in patients with genetic aortopathy due to concern for high failure rates and increased complications in the setting of compromised tissue integrity. This study aims to compare rates of access site complications after large bore percutaneous access among patients with and without confirmed genetic aortopathy.

METHODS

All patients undergoing endovascular aortic procedures requiring large bore (≥9F) femoral sheath access between 2019 and 2023 were identified. The specific mutation, demographics, comorbidities, and operative details including maximum sheath size were recorded. Outcomes including unplanned femoral cutdown, access site complications, and reinterventions were evaluated. These factors were then compared between patients with and without a laboratory-confirmed mutation associated with genetic aortopathy. A supplemental analysis was then performed on all patients with genetic aortopathy from 2014 to 2023.

RESULTS

Among the 404 patients identified, 33 (8%) had confirmed genetic aortopathy. Among these, 7 patients (21%) had Marfan syndrome, 7 (21%) had Loeys-Dietz syndrome, and 3 (9%) had vascular Ehlers-Danlos. Also represented were ACTA2, PRKG1, FOXE3, and LOX mutations. The genetic aortopathy group was significantly younger (median genetic aortopathy: median 52 years; nongenetic aortopathy: 71 years; P < .001). Thoracic endovascular aortic repair was most frequent in the genetic aortopathy group (52%), followed by zone II arch replacement with frozen elephant trunk (21%); the most frequent operation among the nongenetic aortopathy group was fenestrated/branched endovascular aortic repair (43%), followed by thoracic endovascular aortic repair (25%). Both groups had a median sheath size of 20F; the patients with genetic aortopathy had higher rates of both prior open (genetic aortopathy: 27%; nongenetic aortopathy: 12%; P = .015) and prior percutaneous ipsilateral access (genetic aortopathy: 58%; nongenetic aortopathy: 39%; P = .041). Rates of unplanned cutdowns (genetic aortopathy: 0%; nongenetic aortopathy: 6%) and access site complications (genetic aortopathy: 0%; nongenetic aortopathy: 8%) did not significantly differ between groups (P = .160 and P = .096, respectively). In supplementary analysis, there was one patient with genetic aortopathy who required unplanned cutdown, yielding an overall technical success rate of 97% for percutaneous closure over a 10-year period.

CONCLUSIONS

Percutaneous access is safe and effective in patients with confirmed genetic aortopathy with similar rates of unplanned cutdown as those in patients without genetic aortopathy. Given the high rates of staged, repeat aortic procedures in this patient population, percutaneous closure should be attempted to avoid an obligate femoral incision, thereby reducing the potential for wound complications and increasing the ease of future procedures.

Early Results of Elective Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms With the MinosTM Stent-Graft System

PURPOSE

A variety of last-generation endografts are currently available for standard endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs). The purpose of this study is to report the preliminary clinical outcomes of the Minos trimodular stent-graft system, which was recently introduced to the European market.

MATERIALS AND METHODS

Between February 2020 and 2022, we treated 41 consecutive AAA patients (mean age 72.2±8.5, 37 males) with elective standard EVAR using the Minos. The mean maximum diameter of AAAs was 54.7±6.6 mm, the mean proximal neck's (PN) diameter was 24.8±2.7 mm, while the relevant length and angulation were 16.0 mm and 21.7°, respectively. Overall, 22 (53.6%) patients presented with shorter and angulated PN, according to the stent-graft's instructions of use, and in 6 (14.6%) patients the PN angulation >60° was combined with concomitant iliac angulation >60°. Eleven (26.8%) EVARs were performed with concomitant enormous iliac artery narrowing and tortuosity. Finally, in 19 (46.3%) AAAs, the distal iliac landing zone was aneurysmatic and they were treated with the bell-bottom technique in 17 patients and with limb extension to the external iliac artery in two cases. We evaluated technical and clinical success of the index procedures, which was based on the combination of five factors: freedom from EVAR-related mortality, from graft-related endoleak of any type, from migration at any part of graft as well the absence of notable increase AAA's sac maximum diameter and the patency of bifurcated stent-graft and of access vessels.

RESULTS

Primary technical and clinical success of index procedures was 100%. During a median 12-month radiological follow-up the clinical success remained 100%. No type I or III endoleak, stent-graft migration, EVAR-related death, AAA rupture, or graft-related adverse events or reinterventions were documented. Four (9.8%) type II endoleaks were detected with stable AAA sac diameter. The overall incidence of sac regression was 34.1% (n=14).

CONCLUSION

The preliminary results of our series showed that Minos provided excellent feasibility and safety features even through angulated and tortuous iliac vessels and in short and angulated PNs. The overall clinical success at 1 year suggests that performance of Minos follows very high standards. Further validation of these promising results with long-term data is acquired to complete the evaluation of this recently introduced stent-graft system.

CLINICAL IMPACT

The current study explored the clinical performance of a new in market ultra-low profile bifurcated abdominal aortic stent-graft, the MINOS. The early and 12-month results of study suggest that implantation of this stent-graft in standard EVAR, even in hostile proximal aortic neck and iliac vessels conditions, follows very high clinical standards and encourage the further clinical use of MINOS.

The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair

OBJECTIVE

Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs).

METHODS

Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation.

RESULTS

We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients.

CONCLUSIONS

Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Results of the Italian Collaborators for Evar Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm

OBJECTIVES

To analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort.

MATERIALS AND METHODS

This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal non-infected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (sCr) ≥0.3 mg/dL within 48 hours or an increase in sCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. Primary outcomes of interest were AKI incidence at 30 days and freedom from HD at 1-year follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year.

RESULTS

The final cohort analyzed 526 (29.8%). There were 489 (93%) males and 37 (7%) females: the median age was 76 years (interquartile range [IQR], 71-81). Chronic kidney disease (CKD) was present in 86 (16.3%) patients. Early mortality was observed in 8 (1.5%) patients, none was aorta-related. Complication rate was 17.1% (n=89). AKI was observed in 17 (3.2%). Renal replacement therapy was needed in 4 (0.8%). HD was transitory in 2 cases and definitive in 1. Binary logistic regression analysis identified CKD (odds ratio [OR]: 4.68, 95% confidence interval [CI]: 2.10-10.45, p<0.001), and the presence of renal artery stenosis (OR: 3.80, 95% CI: 1.35-10.66, p=0.011) to be associated with an increased risk of postoperative AKI. Estimated freedom from ARM was 94.9% at 1 year. Estimated freedom from HD rate at 1 year was 94%: This was significantly different between patients with preoperative CKD and those who did not have preoperative CKD (log-rank, p=0.042).

CONCLUSION

AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative CKD is the most important predictor for postoperative AKI, which was not associated with the need for HD at 1-year follow-up but with a higher propensity of mortality.

CLINICAL IMPACT

This "real world" experience confirm that EVAR performed with standard contrats agent protocol remains safe for acute kidney injury development. Therefore, only patients presenting with preoperative borderline or ascertained chronic kidney disease will take the most advantage from the use of carbon dioxide contrast.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. Therefore, it is critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This Cochrane Review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. However, the technique may be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the previous Cochrane Review published in 2017.

OBJECTIVES

To evaluate the benefits and harms of totally percutaneous access compared to cut-down femoral artery access in people undergoing elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

We used standard, extensive Cochrane search methods The latest search was 8 April 2022.

SELECTION CRITERIA

We included randomised controlled trials in people diagnosed with an AAA comparing totally percutaneous versus surgical cut-down access endovascular repair. We considered all device types. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for ruptured AAAs and those reporting aorto-uni-iliac repairs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. short-term mortality, 2. failure of aneurysm exclusion and 3. wound infection. Secondary outcomes were 4. major complications (30-day or in-hospital); 5. medium- to long-term (6 and 12 months) complications and mortality; 6. bleeding complications and haematoma; and 7. operating time, duration of intensive treatment unit (ITU) stay and hospital stay. We used GRADE to assess the certainty of evidence for the seven most clinically relevant primary and secondary outcomes.

MAIN RESULTS

Three studies with 318 participants met the inclusion criteria, 189 undergoing the percutaneous technique and 129 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report the method of randomisation, allocation concealment or preselected outcomes. The other two larger studies had few sources of bias and good methodology; although one study had a high risk of bias in selective reporting. We observed no clear difference in short-term mortality between groups, with only one death occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.06 to 36.18; 2 studies, 181 participants; low-certainty evidence). One study reported failure of aneurysm exclusion. There was one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 1 study, 151 participants; moderate-certainty evidence). For wound infection, there was no clear difference between groups (RR 0.18, 95% CI 0.01 to 3.59; 3 studies, 318 participants; moderate-certainty evidence). There was no clear difference between percutaneous and cut-down femoral artery access groups in major complications (RR 1.21, 95% CI 0.61 to 2.41; 3 studies, 318 participants; moderate-certainty evidence), bleeding complications (RR 1.02, 95% CI 0.29 to 3.64; 2 studies, 181 participants; moderate-certainty evidence) or haematoma (RR 0.88, 95% CI 0.13 to 6.05; 2 studies, 288 participants). One study reported medium- to long-term complications at six months, with no clear differences between the percutaneous and cut-down femoral artery access groups (RR 0.82, 95% CI 0.25 to 2.65; 1 study, 135 participants; moderate-certainty evidence). We detected differences in operating time, with the percutaneous approach being faster than cut-down femoral artery access (mean difference (MD) -21.13 minutes, 95% CI -41.74 to -0.53 minutes; 3 studies, 318 participants; low-certainty evidence). One study reported the duration of ITU stay and hospital stay, with no clear difference between groups.

AUTHORS' CONCLUSIONS

Skin puncture may make little to no difference to short-term mortality. There is probably little or no difference in failure of aneurysm exclusion (failure to seal the aneurysms), wound infection, major complications within 30 days or while in hospital, medium- to long-term (six months) complications and bleeding complications between the two groups. Compared with exposing the femoral artery, skin puncture may reduce the operating time slightly. We downgraded the certainty of the evidence to moderate and low as a result of imprecision due to the small number of participants, low event rates and wide CIs, and inconsistency due to clinical heterogeneity. As the number of included studies was limited, further research into this technique would be beneficial.

Percutaneous Approach in Endovascular Aortic Procedures Using a Suture-Mediated Closure Device

BACKGROUND

The purpose of this study is to assess the efficacy of a suture-mediated closure device during percutaneous endovascular aortic repair.

METHODS

A single-center, retrospective analysis of patients undergoing endovascular repair for infrarenal, thoracic and thoracoabdominal aortic aneurysms and aortic dissections via percutaneous femoral access between April 2017 and June 2021 was performed. The primary endpoint of the study was the efficacy and technical success of the Perclose ProGlide closure device during percutaneous endovascular procedures. The secondary endpoints were intraoperative and postoperative inguinal and vascular complications during and after device use.

RESULTS

A total of 376 punctures were performed in 263 patients with the deployment of the ProGlide vascular closure system. Twenty-two cases involved percutaneous re-puncture as part of a staged procedure. The primary and secondary technical success rates were 93.1% (350/376) and 94.7% (356/376), respectively. In 20 patients (5.3%), intraoperative femoral exposure due to complications was required. Postoperative complications occurred in 13 cases (3.5%), 2 of which required surgical reintervention. There was no statistical significance between the type of endovascular procedure and primary technical success (p = 0.56). The introduction of larger-diameter sheaths was not associated with increased intraoperative and postoperative complication rates (p = 0.75 and p = 0.78, respectively). Percutaneous re-puncture of the vascular access site did not result in a lower overall technical success rate (20/22, 90.9% primary technical success rate, p = 0.67; 21/22, 95.5% secondary technical success rate, p = 0.86) or an increased number of perioperative complications (1/22, 4.5% intraoperative complications, p = 0.86; 2/22, 9.1% postoperative complications, p = 0.13).

CONCLUSION

The application of the ProGlide closure system is a safe and efficient method to achieve hemostasis during percutaneous endovascular aortic repair. Complex aortic pathologies, which often require a staged approach with re-puncture, can also be successfully treated with this closure system.

The effect of percutaneouS vs. cutdoWn accEss in patients after Endovascular aorTic repair (SWEET): Study protocol for a single-blind, single-center, randomized controlled trial

Background

Endovascular abdominal aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) have become the first-line treatment for aortic diseases, but current evidence is uncertain regarding whether a percutaneous approach has better outcomes than cutdown access, especially for patient-centered outcomes (PCOs). This study is designed to compare these outcomes of percutaneous access vs. cutdown access after endovascular aortic repair.

Method

The SWEET study is a randomized, controlled, single-blind, single-center non-inferiority trial with two parallel groups in two cohorts respectively. After eligibility screening, subjects who meet the inclusion criteria will be divided into Cohort EVAR or Cohort TEVAR according to clinic interviews. And then participants in two cohorts will be randomly allocated to either intervention groups receiving percutaneous access endovascular repair or controlled groups receiving cutdown access endovascular repair separately. Primary clinician-reported outcome (ClinRO) is access-related complication, and primary patient-centered outcome (PCO) is time back to normal life. Follow-up will be conducted at 2 weeks, 1 month, 3 months postoperatively.

Discussion

The choice of either percutaneous or cutdown access may not greatly affect the success of EVAR or TEVAR procedures, but can influence the quality of life and patient-centered experience. Given the very low evidence for ClinROs and few data for PCOs, comparison of the percutaneous vs. cutdown access EVAR and TEVAR is essential for both patient-centered care and clinical decision making in endovascular aortic repair.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100053161 (registered on 13th November, 2021).

Predictors of percutaneous access-related complications in aortic endovascular procedures - 'real-world' insights and a comparison to open access

BACKGROUND

Percutaneous endovascular aneurysm repair (PEVAR) is becoming increasingly popular due to fewer access-related complications, shorter procedural times and length of stay (LOS). Our aim was to explore factors associated with access-related complications and their impact on procedural time and LOS.

METHODS

We retrospectively analysed consecutive aorto-iliac endovascular procedures in a tertiary hub comprising 2 institutions and 18 consultant vascular surgeons and interventional radiologists between 2016 - 2017. Access-related complications were defined as: bleeding requiring cutdown or return to theatre, acute limb ischaemia or common femoral artery (CFA) pseudoaneurysm requiring intervention and wound infection or dehiscence needing hospitalization.

RESULTS

Of 511 patients, 354 (69%) had a percutaneous approach via 589 CFA access sites. In this percutaneous group, access-related complications occurred in 11% of sites (65/589); Their rate varied with procedure type ranging between 3.6% to 17.6%. The most common complication was bleeding due to closure device failure in 8.5% (50/589) of access sites. When uncomplicated, percutaneous interventions were faster compared to open surgical access (p<0.0001). Operation time and median LOS (3 vs. 2 days) were longer for elective standard EVAR patients experiencing access-related complications (p=0.033). In the percutaneous group, multivariate regression analysis demonstrated significant associations between accessrelated complications and eGFR (odds ratio (OR) 0.984 [0.972-0.997], p=0.014), CFA depth (OR 1.026 [1.008-1.045], p=0.005), device used (Prostar vs. Proglide (OR 2.177 [1.236-3.832], p=0.007) and procedural type (complex vs. standard EVAR) (OR 2.017 [1.122-3.627], p=0.019). We developed a risk score which had reasonably good predictive power (C-statistic 0.716 [0.646-0.787],p<0.0001) for avoiding access complications.

CONCLUSIONS

Physiological (low eGFR level), anatomical (increased CFA depth) and technical factors (choice of device and complex procedures) were identified as predictors of access-related complications in this large retrospective series. These are important for safe selection of patients that would benefit from percutaneous access.

AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis

Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.