Aortic Aneurysm: Systematic Review with ☸️SAIMSARA.

• Generated: 2026-02-12 22:18:11 CET
• Plan: Pro (expanded craft tokens; source: Europe PMC)
• Source: Europe PMC
• Scope: Titles/Abstracts (tiab)
• Keyword Gate: Fuzzy (≥60% of required terms, minimum 2 terms matched in title/abstract)
• Total Abstracts/Papers: 45828
• Downloaded Abstracts/Papers: 45828
• Included original Abstracts/Papers: 24993
• Total study participants (naïve ΣN): 28210098

• Bias: Qualitatively inferred from study design fields.

• Risk Factors and Pathogenesis: Hypertension (HR 1.17 [1]), high diastolic blood pressure (HR 1.74 [1]), metabolic syndrome (MetS) (Odds Ratio [OR] 1.308 [364]), frailty (HR 1.82 [247]), current smoking (HR 17.68 [6008]), genetic liability to migraine (OR 1.18 [1721]), elevated apolipoprotein B (ApoB) (OR 1.34 [9784]), high total sitosterol (OR 1.74 [9547]), and fluoroquinolone use (OR 1.98 [5909]) are associated with increased AA risk. Longer diabetes duration and metformin use are associated with decreased thoracic aortic aneurysm and dissection (TAAD) risk [281].
• Diagnosis and Prognosis: Z-score-based approaches improve detection of TAA/dissection (57% detection rate at 3% false positive rate [FPR]) [38]. Deep learning models (TotalSegmentor) accurately segment AAAs on computed tomography (CT) (Sorensen-Dice 0.89) [134]. Retinal vascular features are associated with AA risk [539]. A multivariable risk model incorporating demographic and clinical factors predicts AAA onset with an area under the curve (AUC) of 0.807 [758].
• Surgical and Endovascular Repair: Open surgery is still necessary for some AAAs due to anatomical constraints [80]. Complex endovascular aneurysm repair (cEVAR) demonstrates fewer complications and more favorable perioperative outcomes compared to open surgical repair (OSR) in octogenarians for juxtarenal abdominal aortic aneurysm (JRAAA) [82]. The E-nside endograft shows good 2-year outcomes for complex abdominal and TAAA repair (90.3% overall survival) [189]. Surgeon volume is associated with increased technical success rates and improved outcomes in complex AAA repair [2610, 6163].
• Complications of Repair: Incisional hernias are common after open AAA/iliac artery aneurysm (IAA) repair (29%) [261]. Type II endoleaks (T2ELs) are frequently observed after endovascular aneurysm repair (EVAR) (16-35%) [20446, 1550, 5233, 13497], and sac prefilling with fibrin glue/coil can prevent them [319, 7150]. Aneurysm volume analysis is more sensitive than diameter for detecting sac enlargement post-EVAR [303]. Acute kidney injury (AKI) is a common complication (3.2-38.4%) [1683, 1702, 7732, 16134, 17944].
• Pharmacological Interventions: Statins prevent AAA progression [1213]. SGLT2 inhibitor (SGLT2i) therapy may be associated with a lower risk of AA [255]. Metformin is associated with decreased TAAD risk [281] but negatively impacts sac shrinkage after EVAR [3193]. Angiotensin-converting enzyme inhibitors (ACEi) are associated with a reduced risk of AAA rupture [6205]. Aged garlic extract attenuates AAA formation by inhibiting matrix metalloproteinase 9 (MMP9) [659].
• Emerging Technologies: Computational modeling integrated with clinical data evaluates genetic variants in TAA/dissection [16]. Patient-specific, non-invasive methods using 4D-CT angiography (CTA) and blood pressure data assess AAA wall integrity [31]. Deep learning-guided point-of-care ultrasound (POCUS) is effective for AAA screening (AUC 0.975) [5552]. Finite element modeling accurately predicts endoprosthesis deployment [1605] and rupture risk [441, 5807, 15528].
• Genetic and Molecular Mechanisms: Genome-wide association studies (GWAS) identified 24 susceptibility loci for AA/dissection (AAD) [657]. Dysregulation of the circ_0000006/miR-483-5p/KDM2B axis is observed in aortic dissection (AD) progression [618]. Zinc finger protein 36 (ZFP36) protects against AAA formation [54]. Calcineurin (Cn) in smooth muscle cells (SMCs) is required for Angiotensin-II (Ang-II)-induced AAA [3964, 8349]. Necroptosis is implicated in AAA pathogenesis [2649, 2888, 3068].
• Public Health and Screening: Population-based pilot screening programs for AAA have been launched in the Czech Republic [491] and evaluated in Sweden [1776]. Point-of-care ultrasound (POCUS) is highly accurate for diagnosing AAA in the emergency department (ED) (sensitivity 98.33%, specificity 99.84%) [3178]. The COVID-19 pandemic significantly reduced elective aortic aneurysm repairs [2951, 7009, 12887, 11378, 8346].
• Patient Outcomes and Disparities: Frailty is an independent risk factor for long-term AAA risk [247] and mortality after EVAR [731, 6401]. Chronic kidney disease (CKD) is a stronger predictor for mortality after AAA repair than the Charlson Comorbidity Index (CCI) [791]. Women have higher risk of death after AAA repair [2053] and worse long-term survival after open repair [948]. Patient-surgeon racial and ethnic concordance was associated with lower postoperative readmission and length of stay for Hispanic patients undergoing common surgical procedures, including AAA repair [5935].

• Enhanced Risk Stratification: The strong association of hypertension, frailty, and metabolic syndrome with AA risk [1, 247, 364] necessitates systematic assessment of these factors in clinical practice to identify high-risk individuals for targeted screening and preventive strategies.
• Improved Diagnostic Tools: Z-score-based approaches for TAA/dissection detection [38] and deep learning-guided POCUS for AAA screening [5552] offer more accurate and accessible methods for early diagnosis.
• Personalized Treatment and Surveillance: Aneurysm volume analysis is more sensitive than diameter for detecting sac enlargement post-EVAR [303], and specific endograft designs (e.g., Gore C3 Excluder [600]) demonstrate long-term durability, informing tailored surveillance protocols.
• Perioperative Optimization: Preoperative comprehensive geriatric assessment [17767] and exercise training [10800, 943] can reduce complications and improve hospital length of stay in older patients undergoing vascular surgery, highlighting the importance of multidisciplinary care.
• Management of Endoleaks: Sac prefilling with fibrin glue and/or coil can effectively prevent Type II endoleaks (T2ELs) [319], and diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping combined with noncontrast magnetic resonance angiography (NC-MRA) is accurate for detecting endoleaks [162], guiding timely interventions to prevent aneurysm growth.

• Long-Term Efficacy of Novel Therapeutics: Further randomized controlled trials (RCTs) are needed to confirm the long-term efficacy and safety of emerging pharmacological interventions, such as SGLT2 inhibitors [255] or metformin [1456, 3193], in preventing AA progression or improving outcomes after repair.
• Standardization of AI/ML Models: While deep learning shows promise for diagnosis and risk prediction [134, 1690, 5552], robust, multicenter validation studies are required to standardize models and establish their generalizability across diverse patient populations and imaging modalities.
• Understanding Sex and Racial Disparities: Research should investigate the underlying biological and socioeconomic factors contributing to observed disparities in AAA incidence, rupture risk (e.g., higher in women [2940]), and postoperative outcomes (e.g., worse long-term survival in women after open repair [948], higher mortality in Black men [10367]).
• Biomechanical Rupture Prediction: Advanced computational models incorporating geometry, wall stiffness, and intraluminal thrombus characteristics [441, 5807, 15528] need further prospective validation to improve personalized rupture risk assessment beyond current diameter-based guidelines.
• Mechanisms of Post-EVAR Complications: Studies are needed to elucidate the precise mechanisms driving post-EVAR complications like T2ELs [2630] and iliac limb occlusion (ILO) [3158], and to develop targeted prevention strategies, potentially leveraging biomarkers like D-dimer [5010, 5901].

• Heterogeneous Study Designs — The diverse range of study designs (cohort, mixed, experimental, case reports) limits direct comparison and meta-analysis of outcomes.
• Varied Follow-up Durations — Follow-up periods varied significantly, from days to over a decade, making it challenging to draw consistent conclusions about long-term outcomes for all interventions and risk factors.
• Population Specificity

• Population Specificity — Many studies focused on specific populations (e.g., UK Biobank participants, octogenarians, patients with specific comorbidities), potentially limiting the generalizability of findings to broader patient demographics [1, 82, 247].
• Variability in Definitions — Definitions of outcomes, particularly for endoleaks or aneurysm growth, varied across studies, complicating direct comparisons and synthesis of evidence [303, 13497].
• Qualitative Bias Assessment — Bias was qualitatively inferred from study design, and formal risk of bias assessment was not performed, which might affect the certainty of the evidence.
• Limited Long-Term Data — While some studies offered long-term follow-up, many interventions, particularly novel endovascular techniques or pharmacological agents, still lack extensive long-term data on durability and patient-centered outcomes [600, 189].
• Lack of Mechanistic Detail — While many studies identified associations or potential targets, the precise molecular and cellular mechanisms underlying some observed phenomena (e.g., the protective effect of SGLT2i [255]) often require further elucidation.

• Comparative Effectiveness Research — Conduct large-scale, prospective comparative effectiveness studies to directly compare different surgical and endovascular repair techniques (e.g., OSR vs. FEVAR in specific patient subgroups) on long-term patient-reported outcomes and cost-effectiveness [1165, 235].
• Biomarker Validation Trials — Validate promising diagnostic and prognostic biomarkers (e.g., plasma proteins [41], ATG4B [4735], D-dimer [5010]) in diverse, independent cohorts to integrate them into clinical decision-making algorithms.
• AI-Driven Personalized Medicine — Develop and rigorously validate AI/machine learning models for personalized risk prediction of aneurysm growth and rupture, treatment selection, and complication management, using multimodal data (imaging, genomics, clinical) [1690, 2765, 3483].
• Genetic and Molecular Pathway Targeting — Further investigate the therapeutic potential of targeting identified molecular pathways (e.g., NF-κB pathway [204, 3917], SIRT3 activation [2747], calcineurin inhibition [3964]) in preclinical models and early-phase clinical trials.
• Optimizing Screening Programs — Evaluate the cost-effectiveness and impact of expanding population-based AAA screening programs to broader demographics, potentially incorporating polygenic risk scores (PRS) to refine screening eligibility and timing [491, 1776, 2765].