Endovascular and Open Repair of Abdominal Aortic Aneurysm

Abstract

Background

This review presents the surgical indications, surgical procedures, and results in the treatment of asymptomatic and ruptured abdominal aortic aneurysms (AAA).

Methods

An updated search of the literature on screening, diagnosis, treatment, and follow-up of AAA, based on the German clinical practice guideline published in 2018.

Results

Surgery is indicated in men with an asymptomatic AAA ≥ 5.5 cm and in women, ≥ 5.0 cm. The indication in men is based on four randomized trials, while in women the data are not conclusive. The majority of patients with AAA (around 80%) meanwhile receive endovascular treatment (endovascular aortic repair, EVAR). Open surgery (open aneurysm repair, OAR) is reserved for patients with longer life expectancy and lower morbidity. The pooled 30-day mortality is 1.16% (95% confidence interval [0.92; 1.39]) following EVAR, 3.27% [2.7; 3.83] after OAR. Women have higher operative/interventional mortality than men (odds ratio 1.67%). The mortality for ruptured AAA is extremely high: around 80% of women and 70% of men die after AAA rupture. Ruptured AAA should, if possible, be treated via the endovascular approach, ideally with the patient under local anesthesia. Treatment at specialized centers guarantees the required expertise and infrastructure. Long-term periodic monitoring by mean of imaging (duplex sonography, plus computed tomography if needed) is essential, particularly following EVAR, to detect and (if appropriate) treat endoleaks, to document stable diameter of the eliminated aneurysmal sac, and to determine whether reintervention is necessary (long-term reintervention rate circa 18%).

Conclusion

Vascular surgery now offers a high degree of safety in the treatment of patients with asymptomatic AAA. Endovascular intervention is preferred.

An abdominal aortic aneurysm (AAA) is an arterial wall weakness in the abdominal section of the aorta, resulting in changes in flow and pressure conditions in this area which ultimately lead to expansion and bulging of the weakened vessel wall.

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The prevalence of AAA is influenced by age and gender. A CT colonography study found that the prevalence of AAA—defined as an AAA diameter ≥ 30 mm—was 1.3% among male participants aged 55 to 64.9 years, 9.1% in the age group from 65.0 to 74.9 years, 16.8% in the age group 75.0 to 84.9 years, and 22.0% in the age group >85 years. The corresponding prevalence rates for women were 0.4%, 2.0%, 3.9%, and 6.2%, respectively (1). With increasing AAA diameter, the risk of rupture also increases: from approx. 0.3% per year for diameters ≤ 3.9 cm to 6.5% for diameters of 5.0 to 5.9 cm (2). Given the high mortality rate associated with this risk, prophylactic surgical repair of AAA should be recommended to symptom-free patients starting from a defined size of the aneurysm.

Under the leadership of the German Society for Vascular Surgery and Vascular Medicine (DGG e. V.), a clinical practice (S3) guideline of the Association of the Scientific Medical Societies in Germany (AWMF) was issued in 2018. This guideline addresses screening, diagnosis, therapy and follow-up of abdominal aortic aneurysms (3). This review article provides an update on the aspects of surgical repair. Please refer to the guideline for information about perioperative management and conservative treatment.

Method

This review is based on a literature search of the PubMed (Medline) database. Articles published in the last two years (January 2018 to March 2020) were searched using the following search terms: “abdominal aortic aneurysm [Title]“, “abdominal aortic aneurysm AND diameter threshold“, “abdominal aortic aneurysm AND outcome“, “abdominal aortic aneurysm AND mortality“, and “ruptured abdominal aortic aneurysm [Title]“. The method of this review follows the method of the 2018 clinical practice (S3) guideline (3). For the years before 2018, the systematic literature search of the 2018 guideline was relied on. All newly published guidelines, systematic reviews/meta-analyses, randomized trials, and registry studies were included.

Indication for surgery in asymptomatic patients

The indication for prophylactic elective surgery was very similar in all three guidelines on the management of AAA published in the last two years (3– 5). In the DGG guideline, it reads (3):

• “Patients with an infrarenal or juxtarenal AAA ≥ 5.5 cm are strongly recommended to undergo elective interventions.

• Patients with an infrarenal or juxtarenal AAA of 5.0 cm to 5.4 cm can be considered for elective intervention.

• Invasive interventions should be considered in women when the maximum AAA diameter has reached 5.0 cm.

• If the AAA growth rate is >10 mm/year, a conventional, open aneurysm repair (OAR [vascular graft via laparotomy]) or endovascular intervention (EVAR, interventional placement of a stent graft) is indicated, regardless of the AAA diameter.“

Neither the guidelines of the Society for Vascular Surgery (SVS) (4) nor those of the European Society for Vascular Surgery (ESVS) (5) state for men that an intervention can already be “considered” starting from an AAA diameter of 5.0 cm. It should be noted that these recommendations exclusively apply to the fusiform AAA (Figure 1). Due to the lack of data, no evidence-based statements can be made with regard to the indication for surgery in patients with eccentric saccular AAA. Saccular aneurysms are rare (5). In an analysis of 206 ruptured AAAs, saccular aneurysms were observed in 4.4% of cases (6). In general, however, the indication for interventional treatment is established earlier in patients with saccular AAA (Figure 2) compared to fusiform AAA because of the higher risk of rupture.

Figure 1:

Fusiform abdominal aortic aneurysm in an 85-year-old patient:

a) before; b) after endovascular repair

Figure 2:

Eccentric saccular abdominal aortic aneurysm in a 66-year-old patient: a) before; b) after endovascular repair

Yet, de facto these indication parameters are often not considered, possibly due to the fact that once an AAA has been detected patients are reluctant to wait until the intervention threshold has been reached, but also for economic reasons.

In an analysis of 44 089 patients with intact AAA (iAAA) in eleven countries (7), the percentages of men who underwent surgery for a small AAA<5,5 cm ranged from 6% (Iceland) and 16% (Sweden) up to 40% (USA) and 43% (Germany). Another cross-national study also reported significant differences in the indication for surgery. In this study, the rates of ruptured AAA repairs did not differ significantly between countries. The rate was also not influenced by the fact that the indication for repair of iAAA was established at an earlier or later point in the various countries. Consequently, repairing smaller iAAAs did not lower the rate of ruptured AAAs which were scheduled for treatment (8).

Selection of the surgical technique for intact abdominal aortic aneurysm

The German clinical practice (S3) guideline recommends for patients with acceptable periprocedural risk both EVAR and OAR to the same extent—provided the pathoanatomical feasibility of EVAR (3). Frequently, the decision is determined by patient preferences, depending on whether the patient prioritizes an early survival benefit (then EVAR) or the absence of later complications and follow-up examinations (then OAR) (box). Results of three new meta-analyses reported in the literature are listed in Table 1.

BOX. Cancer risk associated with endovascular repair.

Patients treated with endovascular aneurysm repair (EVAR) are exposed to a significantly higher radiation dose compared to patients treated with open repair (OAR). On the one hand, this is due to intraoperative fluoroscopic visualization of the endograft, and, on the other hand, it is a result of the subsequent CT scans which are regularly performed to monitor stent-graft positioning and aneurysm size. Using the English Hospital Episode Statistics (HES) from 2005 to 2013, Markar et al. (40) explored whether the higher exposure to radiation increases the cancer risk in patients treated with EVAR. They analyzed data from 14 150 patients with EVAR and 24 465 patients with OAR. Follow-up duration was up to seven years. In this cohort, EVAR was associated with an increased risk of postoperative abdominal tumor disease (hazard ratio [HR] 1.14; 95% confidence intervals: [1.03; 1.27]) and of cancer overall (HR 1.09; [1.02; 1.17]). With regard to the lung cancer risk, no statistically significant differences between EVAR and OAR were found (HR 1.04; [0.92; 1.18]). Follow-up with CT surveillance did not increase the tumor risk in the EVAR group. The authors concluded that the radiation exposure during the intervention may increase the radiation-related cancer risk and regarded intra-operative exposure to radiation and fluoroscopy time as important quality parameters for EVAR. However, the authors did not provide information about the overall mortality in this patient population.

Table 1. Endovascular repair (EVAR) versus open repair (OAR) of the intact abdominal aortic aneurysm (elective procedure), results of the meta-analyses.

Authors	Data source	Results
Bulder et al., 2019 (9)	51 studies/189 022 patients	30-day mortality after EVAR with 1.16%, 95% CI [0.92; 1.39] significantly lower than after OAR with 3.27% [2.71; 3.83] (p<0.001); no difference in long-term survival up to 10 years post-operatively
Li et al., 2019 (10)	54 studies/203 246 patients	Higher long-term mortality after 5–9 years with EVAR (27.3%) versus OAR (24.7%) (p = 0.03); higher rate of reintervention (OR 2.12 [1.67; 2.69]) and higher secondary rupture rate (OR 4.84 [2.63; 8.89]) with EVAR
Antoniou et al., 2020 (11)	Synthesis of 7 randomized trials; 2 983 patients	30-day case mortality for EVAR with 1.2% significantly lower compared to OAR with 3.1% (OR 0.36 [0.20; 0.66]), p = 0.001; over the long term, aneurysm-related mortality, rates of reintervention and rupture higher after EVAR compared to OAR.

CI, confidence interval; OR, odds ratio

The SVS guideline (4) emphasizes the endovascular approach—provided it is technically and pathoanatomically feasible—as the single standard of care and considers OAR only as an alternative surgical procedure for special situations, as it is associated with higher perioperative morbidity and mortality. The ESVS guideline (5) recommends OAR for patients with longer life expectancy because of its slightly better long-term outcomes compared to EVAR. Conversely, the guideline’s view on EVAR is that it offers clear advantages for patients with limited life expectancy or with an above-average operative risk. We recommend to use the DIGG risk score of the German Institute for Vascular Health Research (DIGG) to preoperatively estimate the operative risk (12).

Gender differences in the management of the intact abdominal aortic aneurysm

Liu et al. (13) found in a meta-analysis (32 cohort studies, 74 969 patients) in women who underwent EVAR a significantly higher 30-day mortality compared to men (odds ratio 1.67; 95% confidence interval [1.50; 1.87]; p<0.001). Likewise, the rates of further complications, such as ischemia of the lower extremities as well as renal and cardiac complications after EVAR were higher in women compared to men. In addition, the long-term survival was found reduced in women (hazard ratio 1.23; [1.09; 1.38]; p = 0.001). By contrast, no significant gender differences were identified in respect to early and late re-interventions or endoleaks. The authors mentioned as reasons for the more unfavorable outcomes after EVAR in women compared to men the relatively larger AAA diameter in women at the time of intervention if the indication for intervention was based on an AAA diameter of 5.5 cm as in men (the aortic diameters in women are smaller), as well as the older age among women compared to men and the less favorable anatomical situation with smaller access vessels for endovascular intervention and a more hostile aneurysmal neck anatomy. Thus, these findings confirm the results of an earlier meta-analysis (14) which also showed that the morphology of AAA in women is less favorable for EVAR that that in men. Furthermore, the 30-day mortality rate is almost twice as high in women as it is in men, both after EVAR and after OAR.

As a consequence it has been suggested to set the limit indicator for intervention in women at a smaller AAA diameter, to develop better endografts and, given the increased risk among women, to preferentially treat female patients in specialized centers with adequate experience in both EVAR and open repair.

Complex abdominal aortic aneurysms

Being technically challenging, the repair of complex AAAs is associated with an increased rate of complications. It is distinguished between juxtarenal, pararenal and suprarenal AAAs. Doonan et al. (15) compared the outcomes achieved with EVAR versus OAR in patients with complex AAAs in a meta-analysis of 15 non-randomized studies including 5121 patients (1506 EVAR, 3615 OAR). EVAR was associated with a significantly lower 30-day case fatality rate compared to OAR (odds Ratio [OR] 0.50; [0.34; 0.74]; p<0.001) and a lower rate of acute post-operative renal failure (OR 0.50; [0.28; 0.89]; p = 0.02), but with a higher rate of spinal cord ischemia. Here, however, the absolute differences were small (EVAR 1.23%; OAR 0.31%). Likewise, the rate of intestinal ischemia and the length of hospital stay was shorter after EVAR compared to OAR. The limited available long-term outcome data showed no significant differences between the two approaches; however, the rate of reintervention was higher after EVAR. The available evidence indicates that patients with comorbidity may benefit from the endovascular strategy.

Symptomatic abdominal aortic aneurysm

A symptomatic AAA is defined as an AAA which causes symptoms such as pain without having developed a gap in the aortic wall. Diagnostic investigations show no retroperitoneal hematoma. In patients with symptomatic AAA, the perioperative risk is higher compared to patients with asymptomatic AAA.

Soden et al. (16) identified 4495 asymptomatic AAAs in their search of the database of the National Surgical Quality Improvement Program (NSQIP) and compared these cases with 455 cases of symptomatic AAA. They found no significant difference between the two groups with regard to AAA diameter; however, in a multivariable model, the postoperative 30-day mortality after data adjustment was twice as high among patients with symptomatic AAA compared to asymptomatic patients (OR 2,1; [1.3; 3,5]). While this applied to both OAR and EVAR, the hospital mortality rate of symptomatic AAA was lower with EVAR compared to OAR (3.8% vs 7.7%). In a Dutch registry, too, a significantly higher 30-day mortality rate was observed among patients treated for symptomatic AAA compared asymptomatic AAA. This analysis also found better outcomes after EVAR compared to OAR (17).

Ruptured abdominal aortic aneurysm – prognosis

A ruptured abdominal aortic aneurysm (rAAA) is a surgical emergency requiring immediate treatment. A population-based survey (10 724 persons, of these 24.4% women) in Sweden covering the period from 2001 to 2015 shows the problem of treatment delay analyzed by gender (18). Women with rAAA were with a mean age of 79.7 years significantly older than men (mean age 76.1 years). The mortality rates for all patients with rAAA (with and without hospital admission) were 81.1% and 68.5% for women and men, respectively. Of all patients with rAAA admitted to hospital, only about half (52.7%) were treated in the hospital and women significantly less frequently than men (table 2). The mortality among women treated for rAAA remained significantly higher up to one year after the intervention compared to that of men. However, the postoperative complication rates of women and men did not differ significantly (35.1% vs 33.1%).

Table 2. Gender-specific prognosis of patients with ruptured abdominal aortic aneurysm after hospital admission (Sweden 2001 – 2015, population-based study [18]).

Parameter	Women n (%)	Men n (%)	p
Hospital admissions (rAAA)	2 032	6 466	–
Treated – OAR – EVAR	820 (40.4) 691 (84.3) 129 (15.7)	3 660 (56.6) 3 067 (83.8) 593 (16.2)	<0.001 – –
30-day mortality	325 (39.6)	1 107 (30.2)	<0.001
90-day mortality	367 (44.8)	1 274 (34.8)	<0.001
1-year mortality	426 (52.0)	1 496 (40.9)	<0.001

EVAR, endovascular aneurysm repair; OAR, open aneurysm repair; rAAA, ruptured abdominal aortic aneurysm

A comparative analysis of rAAA mortality in England and the USA confirms the large number of patients with rAAA who only received non-corrective treatment after hospital admission. In England, this applied to 41.6% of patients, in the USA to 19.6% (p<0.0001) (19). The rate of patients with rAAA in whom the indication for intervention was established in the hospital was significantly higher, both in England and the USA, if the patients were admitted to an academic teaching hospital. This finding supports the approach to admit these patients to tertiary care hospitals. In this comparative study, the hospitals were also classified by bed capacity. Both in the USA and in England, the best outcomes were achieved in the hospitals with the highest capacity. The same observation was made by Fierro et al. (20) in Catalonia where 69.2% of the patients admitted to a tertiary care hospital underwent an intervention compared to only 29.5% of patients admitted to local hospitals.

Selection of the surgical technique for ruptured abdominal aortic aneurysms

Both the SVS (4) and ESVS (5) guidelines strongly recommend endovascular treatment of ruptured AAA, if technically feasible; the levels of evidence of this recommendation are set as C and B, respectively. Whether endovascular repair or open repair is the better approach to treat a ruptured aneurysm was recently evaluated by Kontopodis et al. (21) in a meta-analysis of 136 studies (267 259 patients; EVAR: 58 273, OAR: 208 986). Among these studies were 109 comparative investigations, including four randomized trials. In the meta-regression model, the pooled perioperative mortality accounted for 0.245 [0.234; 0.257] and 0.378 [0.364; 0.392] after EVAR and OAR, respectively. Thus, EVAR was associated with significantly lower perioperative mortality (OR 0.54 [0.51; 0.57], p<0.001). In addition, with OAR, but not with EVAR a significant inverse association between hospital mortality and hospital case load was found, with better outcomes in high-volume hospitals. Overall, the outcomes had improved over the period from 2002 to 2019, both after EVAR and OAR, and the difference between EVAR and OAR had increased in favor of EVAR.

Varkevisser et al. (22) also investigated whether the 5-year survival rates after endovascular and open repair of rAAA had changed over the last 14 years. They found a change for EVAR, but not for OAR. In the late cohort (interventions performed between 2014 and 2018), EVAR was associated with a significantly higher survival rate compared to OAR—a result that supports the use of EVAR in patients with rAAA. Additional results on the management of rAAA are listed in Table 3.

Table 3. Results after endovascular repair (EVAR) and open repair (OAR) of the ruptured abdominal aortic aneurysm.

Authors	Data source	Results
IMPROVE Trial Investigators 2014 BMJ (23)	Randomized trial (n = 613)	30-day mortality: EVAR 35.4%, 95% CI: [112; 316], OAR 37.4% [111; 297]; p = 0.62; women benefit significantly more from EVAR than men (p = 0.02). 30-day mortality: women EVAR 37%, OAR 57%; men EVAR 35%, OAR 32%
IMPROVE Trial Investigators 2017 BMJ (24)	Randomized trial	After three years, 48% of patients in the EVAR group and 56% in the OAR group had died (p = 0.053). Mortality after seven years about 60% in both groups.
Wang et al.2019 (25)	VQI cohort, n = 3 719 (2 922 men; 797 women)	30-day mortality women 32.8%; men 25.5% (p<0.001); in both men and women, oar is associated with higher mortality compared to evar (or 1.69 [1.29; 2.22]; p<0.001)
Melillo et al. 2020 (26)	NSQIP database (n = 3 806)	30-day mortality: men EVAR 17.7%, OAR 28.2% (p<0.001)) women evar 22.4%; oar 32.8% (p<0.001)
D’Oria et al. 2020 (27)	VQI database, EVAR n = 2 389; OAR n = 1 868	OAR is associated with significantly increased hospital mortality compared to EVAR (OR 2.08 [1.76; 2.45]; p<0.001). the survival benefit of evar is maintained over a period of five years postoperatively.
Varkevisser et al. 2020 (22)	VQI cohort; N = 1 177 matched pairs	5-year survival after EVAR 63%, after OAR 54% (HR 0.69, [0.60; 0.79]; p<0.001)
Kontopodis et al. 2020 (21)	Meta-analysis; 136 studies, 267 259 patients	EVAR is associated with significantly lower perioperative mortality compared to OAR (OR 0.54 [0.51; 0.57], p<0.001).

HR, hazard ratio; CI, confidence interval; NSQIP, National Surgical Quality Improvement Program (USA); OR, odds ratio; VQI, Vascular Quality Initiative (USA)

In the randomized IMPROVE study, patients with rAAA who were treated with EVAR under local anesthesia had a significantly lower 30-day mortality rate compared to patients treated with EVAR under general anesthesia (28). In the meantime, these results have been confirmed in registry studies (29– 31). EVAR should be performed in patients with rAAA under local anesthesia, if possible.

Treatment in centers,minimum volume

In Germany, there are no minimum case volume requirements for elective AAA treatment in place. So far, no generally binding minimum volumes have been defined in the literature (32). When analyzing 22 227 elective OARs (German DRG data [DRG, diagnose-related case groups]), Nimptsch and Mansky (33) calculated a limit of at least 18 OARs per year needed to reduce hospital mortality associated with open treatment below the average. Likewise, Trenner et al. (34) found in their analysis of DRG data of the period from 2012 to 2016 a significant correlation between high annual procedure numbers and low hospital mortality. They regarded the call for a minimum volume of 30 AAAs/year as useful and feasible.

Follow-up after endovascular aneurysm repair

The German clinical practice (S3) guideline (3) and other guidelines (4, 5) recommend long-term (lifelong) periodic imaging surveillance for patients with EVAR, preferably using Duplex ultrasonography as the most cost-effective strategy (35). It is intended to monitor endoleaks, to document the stability or shrinking of the excluded aneurysm sac and to plan re-interventions where necessary.

The extent to which these recommendations are actually implemented in daily practice and the consequences of non-compliance was assessed by Grima et al. (36) in a systematic review (7 studies, 14 311 patients). They concluded that approximately 42% of patients did not comply with the recommendations. There was no difference in overall mortality after five years between the compliance and non-compliance patient groups. However, long-term imaging surveillance is indispensable, especially after EVAR. Given the large number of patients who do not comply with the recommended monitoring intervals after EVAR, there is a demand for personalizing the follow-up programs to a greater extent. Based on the data of the EVAR 1 and EVAR 2 trials (38, 39), Grootes et al. (37) designed a Cox regression model addressing this issue. They arrived at the conclusion that only patients showing an aneurysm growth of more than 1 mm per year required intensive follow-up. Five years after the intervention, aneurysm growth of more the 1 mm per year was observed in 85% of patients who either had experienced aneurysm rupture or required a rupture-preventing intervention within the next two years (37). Conversely, in the presence of aneurysm growth of less than 1 mm/year, about half of all cases could be categorized as low-risk and the number of further follow-ups could be reduced.

Key Messages.

• Patients with an asymptomatic infrarenal abdominal aortic aneurysm (AAA) ≥ 5.5 cm are strongly recommended to undergo elective AAA repair. In women, invasive treatment should already be considered if the aortic diameter is 5.0 cm.

• For patients with acceptable periprocedural risk, EVAR or OAR are equally recommendable, assuming anatomical feasibility for EVAR. Patients with longer life expectancy benefit from OAR, while limited life expectancy of the patient or increased operative risk would support EVAR.

• Patients with complex AAA or with symptomatic AAA should preferably be offered EVAR.

• These patients should only be treated in high-volume centers with constant intervention readiness and adequate experience in OAR and EVAR.

• The results of the last five years show superiority of the endovascular repair over the open repair of the ruptured AAA. In these patients, EVAR should ideally be performed under local anesthesia.

• In Germany, no minimum annual case volume requirements for AAA repairs are in place. Nevertheless, published data clearly show that AAA repair outcomes significantly improve with increasing case volume of the hospital.

Questions on the article in issue 22–23/2020: Endovascular and Open Repair of Abdominal Aortic Aneurysm.

The submission deadline is 26 November 2021. Only one answer is possible per question. Please select the answer that is most appropriate.

Question no. 1

What is the prevalence of abdominal aortic aneurysm (AAA) – defined by a AAA diameter ≥ 30 mm – in the age group 65 to 75 years?

1. 22% in men and 3.9% in women

2. 9.1% in men and 6.2% in women

3. 16.8% in men and 0.4% in women

4. 22% in men and 6.2% in women

5. 9.1% in men and 2.0% in women

Question no. 2

What statement applies to the saccular abdominal aortic aneurysm (AAA)?

1. It is less common than the fusiform AAA.

2. It is associated with a lower risk of rupture compared to the fusiform AAA.

3. The decision to operate should be made with caution.

4. High-quality evidence is available with regard to the indication to operate a saccular AAA.

5. The saccular AAA should be regarded as physiological in men.

Question no. 3

Starting from what maximum aortic diameter, one should consider a prophylactic elective intervention to treat an abdominal aortic aneurysm in women according to the DGG guideline?

1. from a maximum aortic diameter of 6.0 cm

2. from a maximum aortic diameter of 4.5 cm

3. from a maximum aortic diameter of 5.5 cm

4. from a maximum aortic diameter of 5.0 cm

5. from a maximum aortic diameter of 5.7 cm

Question no. 4

The use of which score is recommended by the authors to preoperatively estimate the surgical risk associated with EVAR and OAR?

1. ASCVD risk score

2. MICA risk score

3. HRQoL score

4. QoL score

5. DIGG risk score

Question no. 5

What minimum volume requirements are in place for centers providing elective AAA repair in Germany?

1. 30 per year

2. There is no minimum volume requirement.

3. 20 per year

4. 70 per year

5. 15 per year

Question no. 6

With regard to endovascular repair (EVAR), which were the areas where gender differences were found?

1. Early re-interventions and long-term survival

2. Ischemia of the lower extremities and late re-interventions

3. Renal complications and endoleaks

4. Ischemia of the lower extremities and 30-day mortality

5. Late re-intervention and cardiac complications

Question no. 7

According to a population-based survey in Sweden, what is the mortality rate in patients (with or without hospitalization) with ruptured abdominal aortic aneurysm (rAAA)?

1. Approx. 50% in women and approx. 80% in men

2. approx. 80% in women and approx. 70% in men

3. approx. 30% in women and approx. 10% in men

4. approx. 25% in women and approx. 50% in men

5. approx. 70% in women and approx. 90% in men

Question no. 8.

Which type of intervention is recommended as the treatment of choice for ruptured abdominal aortic aneurysm (rAAA)?

1. Endovascular repair (EVAR) under regional anesthesia

2. Endovascular repair (EVAR) under local anesthesia

3. Endovascular repair (EVAR) under general anesthesia

4. Open surgery (OAR) under local anesthesia

5. Open surgery (OAR) under general anesthesia

Question no. 9

In Germany, what percentage of men with intact abdominal aortic aneurysm (iAAA) with a diameter <5.5 cm were surgically treated according to an international study?

1. 7%

2. 14%

3. 23%

4. 43%

5. 65%

Question no. 10

What type of follow-up is recommended by the German clinical practice (S3) guideline for patients after endovascular repair (EVAR) of an aneurysm?

1. Imaging surveillance in the first three years after the intervention

2. Imaging surveillance for one to two years after the intervention

3. Lifelong periodic surveillance using Duplex ultrasonography

4. Abdominal CT scan at least every six months

5. Abdominal CT scan at least once a year