Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery

The European Society for Vascular Surgery (ESVS) appointed the AAA Guidelines Committee to write the current clinical practice guidelines document for surgeons and physicians who are involved in the care of patients with abdominal aortic aneurysms (AAAs). Guideline development was recommended in 1990 by the Institute of Medicine to improve decision making for specific patients’ circumstances and to decrease the variability in appropriate and inappropriate health care between providers.1Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine Field M.J. Lohr K.N. Clinical practice guidelines: directions of a new program. National Academy Press, Washington, DC1990Google Scholar, 2Field M. Lohr K. Guidelines for clinical practice: from development to use. National Academy Press, Washington, DC1992Google Scholar Appropriate decision-making is critical to achieving excellent outcomes. Abdominal aortic aneurysm disease is complex and has significant clinical practice variability, although a valid evidence base is available to guide recommendations. The significant increase in the quantity of scientific literature concerning abdominal aortic aneurysmal disease published in recent years along with the number of technical and medical advances enables guideline recommendations with more certainty and supporting evidence than before. Potential increases in health care costs and risks due to industry and public-driven use of novel treatment options make the current guidelines increasingly important.3Dubois R.W. Dean B.B. Evolution of clinical practice guidelines: evidence supporting expanded use of medicines.Dis Manag. 2006; 9: 210-223Google Scholar, 4Sood R. Sood A. Ghosh A.K. Non–evidence-based variables affecting physicians’ test-ordering tendencies: a systematic review.Neth J Med. 2007; 65: 167-177Google Scholar, 5Manchanda P. Honka E. The effects and role of direct-to-physician marketing in the pharmaceutical industry: an integrative review.Yale J Health Policy Law Ethics. 2005; 5: 785-822Google Scholar, 6Win H.K. Caldera A.E. Maresh K. Lopez J. Rihal C.S. Parikh M.A. et al.EVENT Registry Investigators. Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents.JAMA. 2007; 297: 2001-2009Google Scholar Many clinical situations of patients with AAAs have not been the subject of randomised clinical trials. Patient care, however, needs to be delivered and decisions have to be made in these situations. Therefore, this document also provides guidance for decisions when extensive level I evidence is not available and recommendations are determined on the basis of the currently available best evidence for these situations. By providing information about the relevance and validity of the quality of evidence, the reader will be able to locate the most important and evidence-based information relevant to the individual patient.7Fonarow G.C. Abraham W.T. Albert N.M. Stough W.G. Gheorghiade M. Greenberg B.H. et al.OPTIMIZE-HF Investigators and Hospitals. Association between performance measures and clinical outcomes for patients hospitalized with heart failure.JAMA. 2007; 297: 61-70Google Scholar To optimise the implementation of the current document, the length of the guidelines has been kept as short as possible to enable prompt access to the guideline information. This clinical guidelines document is supposed to be a guide, not a document of rules, and allows flexibility for specific patients’ circumstances. This is the resulting clinical practice guidelines document and provides recommendations for clinical care of patients with abdominal aortic aneurysms including pre-operative, perioperative and post-operative care. Patients with AAAs are defined as male or female patients with asymptomatic, symptomatic or ruptured AAA with fusiform dilatation. This document does not cover patients with a saccular, infected or mycotic AAA or pseudoaneurysmal aortic dilatation. The AAA Guidelines Committee met in September 2009 for the first time to discuss the purpose and methods. The AAA Guidelines Committee has been constituted with incorporation of members from different European countries, from academic and private hospitals, vascular and endovascular specialists and patients to maximise the support for the final guidelines document. Since Europe encompasses a variety of health care systems and political economies, health policy makers were not included.8The AGREE collaborationDevelopment and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project.Qual Saf Health Care. 2003; 12: 18-23Google Scholar The AAA Guidelines Committee performed a systematic literature search in MEDLINE, EMBASE and COCHRANE Library databases for each of the different topics that are discussed in this guidelines document. The Guidelines Committee used a grading schema based on levels of evidence and grades of recommendation according to the levels of evidence from the Oxford Centre For Evidence-Based Medicine.9Centre for Evidence-Based Medicine Levels of evidence.http://www.cebm.net/levels_of_evidence.aspGoogle Scholar The level of evidence classification provides information about the study characteristics supporting the recommendation and expert consensus, according to the categories shown in Table 1.Table 1Level of evidence classification. Open table in a new tab The recommendation grade indicates the strength of a recommendation. Definitions of the grades of recommendation are shown in Table 2.Table 2Grades of recommendationAConsistent level 1 studiesBConsistent level 2 or 3 studies or extrapolations from Level 1 studiesCLevel 4 studies or extrapolations from level 2 or 3 studiesDLevel 5 evidence or troublingly inconsistent or inconclusive studies of any level“Extrapolations" are where data are used in a situation that has potentially clinically important differences than the original study situation. Open table in a new tab “Extrapolations" are where data are used in a situation that has potentially clinically important differences than the original study situation. The AAA Guidelines Committee aimed to report as much as possible the calculated estimates of effects with their 95% confidence intervals. Every part of the guidelines document has been prepared by at least two members of the Committee and has been reviewed by the entire Committee. The initial guidelines document has been subsequently reviewed by the AAA Guidelines Review Committee. After incorporation of all comments and recommendations, the guidelines have been provided to the members of the ESVS. The final document has been approved by the ESVS. Abdominal aortic aneurysm (AAA), which comes from the Ancient Greek word ἀνεύρυσμα, means a dilatation or widening of the abdominal aorta. The most accepted definition of an AAA is based on the diameter of the abdominal aorta: an abdominal aortic diameter of 3.0 cm or more, which usually is more than 2 standard deviations above the mean diameter for both men and women, and is considered to be aneurysmal.10Steinberg I. Stein H.L. Arterosclerotic abdominal aortic aneurysms. report of 200 consecutive cases diagnosed by intravenous aortography.JAMA. 1966; 195: 1025Google Scholar, 11McGregor J.C. Pollock J.G. Anton H.C. The value of ultrasonography in the diagnosis of abdominal aortic aneurysm.Scott Med J. 1975; 20: 133-137Google Scholar, 12Wanhainen A. Thermudo R. Ahlström H. Lind L. Johansson L. Thoracic and abdominal aortic dimension in 70-years old men and women – a population-based whole-body MRI study.J Vasc Surg. 2008; 47: 504-512Google Scholar Other researchers have suggested defining abdominal aortic aneurysm as the maximum infra-renal aortic diameter being at least 1.5 times larger than the expected normal infra-renal aortic diameter to compensate for individual variation in the diameter of the adjacent aorta.13Sterpetti A. Schultz R. Feldhaus R. Cheng S. Peetz D. Factors influencing enlargement rate of small abdominal aortic aneurysms.J Surg Res. 1987; 43: 211-219Google Scholar, 14Collin J. Walton J. Araujo L. Lindsell D. Oxford screening programme for abdominal aortic aneurysm in men aged 65 to 74 years.Lancet. 1988; 2: 613-615Google Scholar, 15Sonesson B. Lanne T. Hansen F. Sandgren T. Infrarenal aortic diameter in the healthy person.Eur J Vasc Surg. 1994; 8: 89-95Google Scholar AAA can be defined as an abdominal aortic diameter of 3.0 cm or more in either anterior-posterior or transverse planes. Level 2c, Grade B. Population screening studies offer the best evidence regarding the prevalence of AAA. Several of these have been conducted as randomised trials to assess the benefits of screening (MASS, Western Australia, Viborg and Chichester, the latter being the only one to include women).16Scott R.A. Wilson N.M. Ashton H.A. Kay D.N. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomised controlled study.Br J Surg. 1995; 82: 1066-1070Google Scholar, 17Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Screening for abdominal aortic aneurysms: single centre randomised controlled trial.BMJ. 2005; 330: 750-753Google Scholar, 18Norman P.E. Jamrozik K. Lawrence-Brown M.M. Le M.T. Spencer C.A. Tuohy R.J. et al.Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm.BMJ. 2004; 329: 1259-1262Google Scholar, 19Multicentre Aneurysm Screening Study GroupThe Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial.The Lancet. 2002; 360: 1531-1539Google Scholar Other evidence comes from the Rotterdam, Tromsø and other large epidemiological screening studies.20Pleumeekers H.J. Hoes A.W. van der Does E. van Urk H. de Jong P.T. Grobbee D.E. Aneurysms of the abdominal aorta in older adults. The Rotterdam Study.Am J Epidemiol. 1995; 142: 1291-1299Google Scholar, 21Singh K. Bonaa K.H. Jacobsen B.K. Bjork L. Solberg S. Prevalence and risk factors for abdominal aortic aneurysms in a population-based study: the Tromsø Study.Am J Epidemiol. 2001; 154: 236-244Google Scholar Prevalence rates vary according to age, gender and geographical location (Table 3). Level 1a. In keeping with ethnic and environmental risk factors, a screening study of US veterans (between 50 and 79 years old, n = 73,451) showed the highest prevalence of AAA ≥3.0 cm was 5.9% and was found in white male smokers between 50 and 79 years.22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar All the aneurysm population screening data (Table 3) are now dated and there is little contemporary information for 21st century prevalence, although there are some indications, at least in the USA, that the admission rate for aneurysm repair is declining.23Levin D.C. Rao V.M. Frangos A.J. Sunshine J.H. Endovascular repair vs open surgical repair of abdominal aortic aneurysms: comparative utilization trends from 2001 to 2006.J Am Coll Radiol. 2009; 6: 506-509Google Scholar Important risk factors for AAA are advanced age, male gender and smoking.20Pleumeekers H.J. Hoes A.W. van der Does E. van Urk H. de Jong P.T. Grobbee D.E. Aneurysms of the abdominal aorta in older adults. The Rotterdam Study.Am J Epidemiol. 1995; 142: 1291-1299Google Scholar, 21Singh K. Bonaa K.H. Jacobsen B.K. Bjork L. Solberg S. Prevalence and risk factors for abdominal aortic aneurysms in a population-based study: the Tromsø Study.Am J Epidemiol. 2001; 154: 236-244Google Scholar, 22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar, 23Levin D.C. Rao V.M. Frangos A.J. Sunshine J.H. Endovascular repair vs open surgical repair of abdominal aortic aneurysms: comparative utilization trends from 2001 to 2006.J Am Coll Radiol. 2009; 6: 506-509Google Scholar, 24Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Hye R.J. Makaroun M.S. et al.The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.Arch Intern Med. 2000; 160: 1425-1430Google Scholar, 25Vardulaki K.A. Walker N.M. Day N.E. Duffy S.W. Ashton H.A. Scott R.A. Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm.Br J Surg. 2000; 87: 195-200Google Scholar, 26Steickmeier B. Epidemiology of aortic disease: aneurysm, dissection, occlusion.Radiologe. 2001; 41: 624-632Google Scholar, 27Scott R.A. Bridgewater S.G. Ashton H.A. Randomised clinical trial of screening for abdominal aortic aneurysm in women.Br J Surg. 2002; 89: 283-285Google Scholar, 28Wilmink T.B. Quick C.R. Day N.E. The association between cigarette smoking and abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 1099-1105Google Scholar, 29Johansen K. Koepsell T. Familial tendency for abdominal aortic aneurysms.JAMA. 1986; 256: 1934-1936Google Scholar, 30van Vlijmen-van Keulen C.J. Pals G. Rauwerda J.A. Familial abdominal aortic aneurysm: a systematic review of a genetic background.Eur J Vasc Endovasc Surg. 2002; 24: 105-116Google Scholar, 31Larsson E. Granath F. Swedenborg J. Hultgren R. A population-based case-control study of the familial risk of abdominal aortic aneurysm.J Vasc Surg. 2009; 49: 47-50Google Scholar A positive family history for AAA especially in male first-degree relatives, is also associated with increased risk for AAA.29Johansen K. Koepsell T. Familial tendency for abdominal aortic aneurysms.JAMA. 1986; 256: 1934-1936Google Scholar, 30van Vlijmen-van Keulen C.J. Pals G. Rauwerda J.A. Familial abdominal aortic aneurysm: a systematic review of a genetic background.Eur J Vasc Endovasc Surg. 2002; 24: 105-116Google Scholar, 31Larsson E. Granath F. Swedenborg J. Hultgren R. A population-based case-control study of the familial risk of abdominal aortic aneurysm.J Vasc Surg. 2009; 49: 47-50Google Scholar Smoking is a strong risk factor (odds ratio >3.0 in all studies), the associated risk being much higher than for either coronary artery disease or stroke.20Pleumeekers H.J. Hoes A.W. van der Does E. van Urk H. de Jong P.T. Grobbee D.E. Aneurysms of the abdominal aorta in older adults. The Rotterdam Study.Am J Epidemiol. 1995; 142: 1291-1299Google Scholar, 21Singh K. Bonaa K.H. Jacobsen B.K. Bjork L. Solberg S. Prevalence and risk factors for abdominal aortic aneurysms in a population-based study: the Tromsø Study.Am J Epidemiol. 2001; 154: 236-244Google Scholar, 22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar, 24Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Hye R.J. Makaroun M.S. et al.The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.Arch Intern Med. 2000; 160: 1425-1430Google Scholar, 28Wilmink T.B. Quick C.R. Day N.E. The association between cigarette smoking and abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 1099-1105Google Scholar Level 2a. Additionally, the following factors have been associated with AAA development: history of other vascular aneurysms,32Allardice J.T. Allwright G.J. Wafula J.M. Wyatt A.P. High prevalence of abdominal aortic aneurysm in men with peripheral vascular disease: screening by ultrasonography.Br J Surg. 1988; 75: 240-242Google Scholar, 33Shapira O.M. Pasik S. Wassermann J.P. Barzilai N. Mashiah A. Ultrasound screening for abdominal aortic aneurysms in patients with atherosclerotic peripheral vascular disease.J Cardiovasc Surg (Torino). 1990; 31: 170-172Google Scholar, 34MacSweeney S.T. O’Meara M. Alexander C. O’Malley M.K. Powell J.T. Greenhalgh R.M. High prevalence of unsuspected abdominal aortic aneurysm in patients with confirmed symptomatic peripheral or cerebral arterial disease.Br J Surg. 1993; 80: 582-584Google Scholar, 35Graham L.M. Zelenock G.B. Whitehouse Jr., W.M. Erlandson E.E. Dent T.L. Lindenauer S.M. et al.Clinical significance of arteriosclerotic femoral artery aneurysms.Arch Surg. 1980; 115: 502-507Google Scholar greater height,22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar coronary artery disease,22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar, 33Shapira O.M. Pasik S. Wassermann J.P. Barzilai N. Mashiah A. Ultrasound screening for abdominal aortic aneurysms in patients with atherosclerotic peripheral vascular disease.J Cardiovasc Surg (Torino). 1990; 31: 170-172Google Scholar cerebrovascular disease,34MacSweeney S.T. O’Meara M. Alexander C. O’Malley M.K. Powell J.T. Greenhalgh R.M. High prevalence of unsuspected abdominal aortic aneurysm in patients with confirmed symptomatic peripheral or cerebral arterial disease.Br J Surg. 1993; 80: 582-584Google Scholar atherosclerosis,22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar hypercholesterolemia,20Pleumeekers H.J. Hoes A.W. van der Does E. van Urk H. de Jong P.T. Grobbee D.E. Aneurysms of the abdominal aorta in older adults. The Rotterdam Study.Am J Epidemiol. 1995; 142: 1291-1299Google Scholar, 22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar and hypertension,21Singh K. Bonaa K.H. Jacobsen B.K. Bjork L. Solberg S. Prevalence and risk factors for abdominal aortic aneurysms in a population-based study: the Tromsø Study.Am J Epidemiol. 2001; 154: 236-244Google Scholar, 22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar, 35Graham L.M. Zelenock G.B. Whitehouse Jr., W.M. Erlandson E.E. Dent T.L. Lindenauer S.M. et al.Clinical significance of arteriosclerotic femoral artery aneurysms.Arch Surg. 1980; 115: 502-507Google Scholar, 36Baxter B.T. Terrin M.C. Dalman R.L. Medical management of small abdominal aortic aneurysms.Circulation. 2008; 117: 1883-1889Google Scholar although the data for some of these factors are inconsistent and studies may not have been subject to multivariate adjustment, so that spurious associations may have been reported. More recently, genome-wide association studies have demonstrated the association with variants on chromosome 9p21. The presence of rs7025486[A] in the DAB21P gene is associated with a 20% increased risk of developing AAA, odds ratio 1.21 [95%CI 1.14–1.28].37Helgadottir A. Thorleifsson G. Magnusson K.P. Grétarsdottir S. Steinthorsdottir V. Manolescu A. et al.The same sequence variant on 9p21 associates with myocardial infarction, abdominal aortic aneurysm and intracranial aneurysm.Nat Genet. 2008; 40: 217-224Google Scholar Black or Asian race and diabetes mellitus are negatively associated with AAA development.22Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Littooy F.N. Bandyk D. et al.Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group.Ann Intern Med. 1997; 126: 441-449Google Scholar, 38Salem M.K. Rayt H.S. Hussey G. Rafelt S. Nelson C.P. Sayers R.D. et al.Should Asian men be included in abdominal aortic aneurysm screening programmes?.Eur J Vasc Endovasc Surg. 2009; 38: 748-749Google Scholar Level 2a-3b. The evidence for other risk factors including homocysteinemia, high levels of lipoprotein (a) and plasminogen activator inhibitor-1 is very weak.39Sofi F. Marcucci R. Giusti B. Pratesi G. Lari B. Sestini I. et al.High levels of homocysteine, lipoprotein (a) and plasminogen activator inhibitor-1 are present in patients with abdominal aortic aneurysm.Thromb Haemost. 2005; 94: 1094-1098Google Scholar Level 4b. The reported average growth rate of AAAs between 30 and 55 mm ranges from 0.2 to 0.3 cm per year. Larger AAA diameters are associated with higher AAA growth rates. A wide variation between patients has been reported consistently.40Thompson A.R. Cooper J.A. Ashton H.A. Hafez H. Growth rates of small abdominal aortic aneurysms correlate with clinical events.Br J Surg. 2010; 97: 37-44Google Scholar, 41Brady A.R. Thompson S.G. Fowkes F.G. Greenhalgh R.M. Powell J.T. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance.Circulation. 2004; 110: 16-21Google Scholar, 42Schouten O. van Laanen J.H. Boersma E. Vidakovic R. Feringa H.H. Dunkelgrun M. et al.Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth.Eur J Vasc Endovasc Surg. 2006; 32: 21-26Google Scholar, 43Brown P.M. Sobolev B. Zelt D.T. Selective management of abdominal aortic aneurysms smaller than 5.0 cm in a prospective sizing program with gender-specific analysis.J Vasc Surg. 2003; 38: 762-765Google Scholar, 44McCarthy R.J. Shaw E. Whyman M.R. Earnshaw J.J. Poskitt K.R. Heather B.P. Recommendations for screening intervals for small aortic aneurysms.Br J Surg. 2003; 90: 821-826Google Scholar, 45Santilli S.M. Littooy F.N. Cambria R.A. Rapp J.H. Tretinyak A.S. d’Audiffret A.C. et al.Expansion rates and outcomes for the 3.0-cm to the 3.9-cm infrarenal abdominal aortic aneurysm.J Vasc Surg. 2002; 35: 666-671Google Scholar, 46Lindholt J.S. Heegaard N.H. Vammen S. Fasting H. Henneberg E.W. Heickendorff L. Smoking, but not lipids, lipoprotein(a) and antibodies against oxidized LDL, is correlated to the expansion of abdominal aortic aneurysms.Eur J Vasc Endovasc Surg. 2001; 21: 51-56Google Scholar, 47Lindholt J.S. Juul S. Vammen S. Lind I. Fasting H. Henneberg E.W. Immunoglobulin A antibodies against Chlamydia pneumoniae are associated with expansion of abdominal aortic aneurysm.Br J Surg. 1999; 86: 634-638Google Scholar, 48Lindholt J.S. Heickendorff L. Antonsen S. Fasting H. Henneberg E.W. Natural history of abdominal aortic aneurysm with and without coexisting chronic obstructive pulmonary disease.J Vasc Surg. 1998; 28: 226-233Google Scholar, 49Stonebridge P.A. Draper T. Kelman J. Howlett J. Allan P.L. Prescott R. et al.Growth rate of infrarenal aortic aneurysms.Eur J Vasc Endovasc Surg. 1996; 11: 70-73Google Scholar Level 1b-2b. Several cohort studies have implicated that statins are associated with lower AAA growth rates.42Schouten O. van Laanen J.H. Boersma E. Vidakovic R. Feringa H.H. Dunkelgrun M. et al.Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth.Eur J Vasc Endovasc Surg. 2006; 32: 21-26Google Scholar, 50Sukhija R. Aronow W.S. Sandhu R. Kakar P. Babu S. Mortality and size of abdominal aortic aneurysm at long-term follow-up of patients not treated surgically and treated with and without statins.Am J Cardiol. 2006; 97: 279-280Google Scholar, 51Schlösser F.J. Tangelder M.J. Verhagen H.J. van der Heijden G.J. Muhs B.E. van der Graaf Y. et al.SMART study groupGrowth predictors and prognosis of small abdominal aortic aneurysms.J Vasc Surg. 2008; 47: 1127-1133Google Scholar However, the largest and most carefully conducted study has not demonstrated any association between statins and AAA growth.52Ferguson C.D. Clancy P. Bourke B. Walker P.J. Dear A. Buckenham T. et al.Association of statin prescription with small abdominal aortic aneurysm progression.Am Heart J. 2010; 159: 307-313Google Scholar Smoking has been associated with aneurysm expansion.40Thompson A.R. Cooper J.A. Ashton H.A. Hafez H. Growth rates of small abdominal aortic aneurysms correlate with clinical events.Br J Surg. 2010; 97: 37-44Google Scholar, 46Lindholt J.S. Heegaard N.H. Vammen S. Fasting H. Henneberg E.W. Heickendorff L. Smoking, but not lipids, lipoprotein(a) and antibodies against oxidized LDL, is correlated to the expansion of abdominal aortic aneurysms.Eur J Vasc Endovasc Surg. 2001; 21: 51-56Google Scholar, 47Lindholt J.S. Juul S. Vammen S. Lind I. Fasting H. Henneberg E.W. Immunoglobulin A antibodies against Chlamydia pneumoniae are associated with expansion of abdominal aortic aneurysm.Br J Surg. 1999; 86: 634-638Google Scholar, 53Brady A.R. Thompson S.G. Greenhalgh R.M. Powell J.T. Cardiovascular risk factors and abdominal aortic aneurysm expansion: only smoking counts. US small aneurysm trial participants.Br J Surg. 2003; 90: 491-492Google Scholar, 54Chang J.B. Stein T.A. Liu J.P. Dunn M.E. Risk factors associated with rapid growth of small abdominal aortic aneurysms.Surgery. 1997; 121: 117-122Google Scholar, 55Vega de C.M. Gomez R. Estallo L. Rodriguez L. Baquer M. Barba A. 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Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance.Circulation. 2004; 110: 16-21Google Scholar, 42Schouten O. van Laanen J.H. Boersma E. Vidakovic R. Feringa H.H. Dunkelgrun M. et al.Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth.Eur J Vasc Endovasc Surg. 2006; 32: 21-26Google Scholar, 47Lindholt J.S. Juul S. Vammen S. Lind I. Fasting H. Henneberg E.W. Immunoglobulin A antibodies against Chlamydia pneumoniae are associated with expansion of abdominal aortic aneurysm.Br J Surg. 1999; 86: 634-638Google Scholar, 54Chang J.B. Stein T.A. Liu J.P. Dunn M.E. Risk factors associated with rapid growth of small abdominal aortic aneurysms.Surgery. 1997; 121: 117-122Google Scholar, 59Wilmink A.B. Hubbard C.S. Day N.E. Quick C.R. The incidence of small abdominal aortic aneurysms and the change in normal infrarenal aortic diameter: implications for screening.Eur J Vasc Endovasc Surg. 2001; 21: 165-170Google Scholar, 61Solberg S. 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