THE ABDOMINAL AORTIC ANEURYSM FROM PATHOGENESIS TO MODERN TREATMENT APPROACHES – OPEN SURGERY VERSUS EVAR

Hubert Kostka; Damian Dolata; Adrian Zagórski; Jadwiga Kleinrok; Anna Bereta-Kostaś; Rafał Kuśmider; Małgorzata Leśnik; Patrycja Wierzbowska

doi:10.31435/ijitss.4(48).2025.4331

Authors

Hubert Kostka 5 Military Clinical Hospital with Polyclinic SPZOZ, Kraków, Poland https://orcid.org/0009-0003-4419-5364
Damian Dolata Independent Public Healthcare Institution of the Ministry of the Interior and Administration in Kraków, Kraków, Poland https://orcid.org/0009-0006-9165-8212
Adrian Zagórski 5 Military Clinical Hospital with Polyclinic SPZOZ, Kraków, Poland https://orcid.org/0000-0002-5420-8101
Jadwiga Kleinrok University Hospital in Kraków, Kraków, Poland https://orcid.org/0009-0005-2132-9299
Anna Bereta-Kostaś University Hospital in Kraków, Kraków, Poland https://orcid.org/0009-0007-5664-3119
Rafał Kuśmider Medical University of Silesia Medyków 18, 40-752 Katowice https://orcid.org/0009-0003-3580-3495
Małgorzata Leśnik Medical University of Silesia, Katowice, Poland https://orcid.org/0009-0004-4798-6302
Patrycja Wierzbowska Gabriel Narutowicz Municipal Specialist Hospital, Kraków, Poland https://orcid.org/0009-0005-5201-0512

DOI:

https://doi.org/10.31435/ijitss.4(48).2025.4331

Keywords:

Abdominal Aortic Aneurysm, EVAR, Stent-Graft, OAR, Aneurysm Rupture

Abstract

Introduction and Purpose: Abdominal aortic aneurysm (AAA) is a serious vascular condition with a high risk of rupture and associated mortality. It most commonly affects older males with cardiovascular risk factors such as smoking, hypertension, and atherosclerosis. With the advancement of surgical techniques, two primary treatment strategies have emerged: open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR). This paper aims to review and compare both approaches in terms of clinical effectiveness, safety profile, indications, complications, and long-term outcomes, while also considering molecular, biomechanical, and economic aspects.

Materials and Methods: A thorough analysis of contemporary clinical evidence was performed, emphasizing both surgical and endovascular treatment modalities' strengths, limitations, and clinical outcomes. The analysis also included pathophysiological mechanisms underlying AAA development.

State of Knowledge: OAR remains the treatment of choice in younger patients and in cases with complex aneurysm anatomy, connective tissue disorders, infection, or unfavorable vascular morphology. Despite being more invasive, OAR offers long-term durability and lower rates of secondary interventions. EVAR, in contrast, is associated with lower perioperative mortality, shorter hospitalization, and faster recovery, but requires lifelong imaging surveillance and carries a higher risk of reintervention due to complications such as endoleaks or graft migration. Long-term survival appears comparable between both methods, though some studies suggest a potential advantage of OAR in certain subgroups. Ongoing research into fenestrated and branched endografts, microRNA modulation and epigenetic enzyme targeting may pave the way for more personalized and non-surgical treatment options.

Conclusions: Both OAR and EVAR have specific indications and limitations, and the choice of therapy should be individualized based on patient characteristics, anatomy, and institutional expertise. Further multicenter, long-term studies are needed to evaluate overall survival, complication rates, cost-effectiveness, and quality of life in patients undergoing AAA repair.

References

Sakalihasan, N., Limet, R., & Defawe, O. D. (2005). Abdominal aortic aneurysm. Lancet (London, England), 365(9470), 1577–1589. https://doi.org/10.1016/S0140-6736(05)66459-8

Nordon, I. M., Hinchliffe, R. J., Loftus, I. M., & Thompson, M. M. (2011). Pathophysiology and epidemiology of abdominal aortic aneurysms. Nature reviews. Cardiology, 8(2), 92–102. https://doi.org/10.1038/nrcardio.2010.180

Baxter, B. T., Terrin, M. C., & Dalman, R. L. (2008). Medical management of small abdominal aortic aneurysms. Circulation, 117(14), 1883–1889. https://doi.org/10.1161/CIRCULATIONAHA.107.735274

Wanhainen, A., Van Herzeele, I., Bastos Goncalves, F., Bellmunt Montoya, S., Berard, X., Boyle, J. R., D'Oria, M., Prendes, C. F., Karkos, C. D., Kazimierczak, A., Koelemay, M. J. W., Kölbel, T., Mani, K., Melissano, G., Powell, J. T., Trimarchi, S., Tsilimparis, N., ESVS Guidelines Committee, Antoniou, G. A., Björck, M., … Yeung, K. K. (2024). Editor's Choice — European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery, 67(2), 192–331. https://doi.org/10.1016/j.ejvs.2023.11.002

Chaikof, E. L., Dalman, R. L., Eskandari, M. K., Jackson, B. M., Lee, W. A., Mansour, M. A., Mastracci, T. M., Mell, M., Murad, M. H., Nguyen, L. L., Oderich, G. S., Patel, M. S., Schermerhorn, M. L., & Starnes, B. W. (2018). The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Journal of vascular surgery, 67(1), 2–77.e2. https://doi.org/10.1016/j.jvs.2017.10.044

Greenhalgh, R. M., Brown, L. C., Kwong, G. P., Powell, J. T., Thompson, S. G., & EVAR trial participants (2004). Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet (London, England), 364(9437), 843–848. https://doi.org/10.1016/S0140-6736(04)16979-1

De Bruin, J. L., Baas, A. F., Buth, J., Prinssen, M., Verhoeven, E. L., Cuypers, P. W., van Sambeek, M. R., Balm, R., Grobbee, D. E., Blankensteijn, J. D., & DREAM Study Group (2010). Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. The New England journal of medicine, 362(20), 1881–1889. https://doi.org/10.1056/NEJMoa0909499

IMPROVE Trial Investigators, Powell, J. T., Sweeting, M. J., Thompson, M. M., Ashleigh, R., Bell, R., Gomes, M., Greenhalgh, R. M., Grieve, R., Heatley, F., Hinchliffe, R. J., Thompson, S. G., & Ulug, P. (2014). Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ (Clinical research ed.), 348, f7661. https://doi.org/10.1136/bmj.f7661

Lederle, F. A., Freischlag, J. A., Kyriakides, T. C., Matsumura, J. S., Padberg, F. T., Jr, Kohler, T. R., Kougias, P., Jean-Claude, J. M., Cikrit, D. F., Swanson, K. M., & OVER Veterans Affairs Cooperative Study Group (2012). Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. The New England journal of medicine, 367(21), 1988–1997. https://doi.org/10.1056/NEJMoa1207481

Li, B., Khan, S., Salata, K., Hussain, M. A., de Mestral, C., Greco, E., Aljabri, B. A., Forbes, T. L., Verma, S., & Al-Omran, M. (2019). A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm. Journal of vascular surgery, 70(3), 954–969.e30. https://doi.org/10.1016/j.jvs.2019.01.076

DeRoo, E., Stranz, A., Yang, H., Hsieh, M., Se, C., & Zhou, T. (2022). Endothelial Dysfunction in the Pathogenesis of Abdominal Aortic Aneurysm. Biomolecules, 12(4), 509. https://doi.org/10.3390/biom12040509

Maegdefessel, L., Azuma, J., Toh, R., Merk, D. R., Deng, A., Chin, J. T., Raaz, U., Schoelmerich, A. M., Raiesdana, A., Leeper, N. J., McConnell, M. V., Dalman, R. L., Spin, J. M., & Tsao, P. S. (2012). Inhibition of microRNA-29b reduces murine abdominal aortic aneurysm development. The Journal of clinical investigation, 122(2), 497–506. https://doi.org/10.1172/JCI61598

Puchenkova, O. A., Soldatov, V. O., Belykh, A. E., Bushueva, O., Piavchenko, G. A., Venediktov, A. A., Shakhpazyan, N. K., Deykin, A. V., Korokin, M. V., & Pokrovskiy, M. V. (2022). Cytokines in Abdominal Aortic Aneurysm: Master Regulators With Clinical Application. Biomarker insights, 17, 11772719221095676. https://doi.org/10.1177/11772719221095676

Davis, F. M., Melvin, W. J., Mangum, K., Tsoi, L. C., Joshi, A. D., Cai, Q., Henke, P. K., Gudjonsson, J. E., & Gallagher, K. A. (2023). The Histone Methyltransferase SETDB2 Modulates Tissue Inhibitors of Metalloproteinase-Matrix Metalloproteinase Activity During Abdominal Aortic Aneurysm Development. Annals of surgery, 278(3), 426–440. https://doi.org/10.1097/SLA.0000000000005963

Jafar Moradicheghamahi (2024) The Role of Wall Mechanics in the Hemodynamics of a Realistic Abdominal Aortic Aneurysm: A Fluid-Structure Interaction Study. Journal of EngineeringVolume 2024, Issue 1 3280563 https://doi.org/10.1155/2024/3280563

Yuan, Z., Lu, Y., Wei, J., Wu, J., Yang, J., & Cai, Z. (2021). Abdominal Aortic Aneurysm: Roles of Inflammatory Cells. Frontiers in immunology, 11, 609161. https://doi.org/10.3389/fimmu.2020.609161

Bailey, D. M., Rose, G. A., O'Donovan, D., Locker, D., Appadurai, I. R., Davies, R. G., Whiston, R. J., Bashir, M., Lewis, M. H., & Williams, I. M. (2022). Retroperitoneal Compared to Transperitoneal Approach for Open Abdominal Aortic Aneurysm Repair Is Associated with Reduced Systemic Inflammation and Postoperative Morbidity. Aorta (Stamford, Conn.), 10(5), 225–234. https://doi.org/10.1055/s-0042-1749173

Rastogi, V., Kim, N. H., Marcaccio, C. L., Patel, P. B., Varkevisser, R. R. B., de Bruin, J. L., Verhagen, H. J. M., & Schermerhorn, M. L. (2022). Retroperitoneal versus Transperitoneal Approach for Open Repair of Complex Abdominal Aortic Aneurysms. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery, 64(1), 23–31. https://doi.org/10.1016/j.ejvs.2022.05.030

Bakewell, R., Krokidis, M., & Winterbottom, A. (2022). Endovascular Abdominal Aortic Aneurysm Repair: Overview of Current Guidance, Strategies, and New Technologies, Perspectives from the United Kingdom. Journal of clinical medicine, 11(18), 5415. https://doi.org/10.3390/jcm11185415

Malkawi, A. H., Hinchliffe, R. J., Holt, P. J., Loftus, I. M., & Thompson, M. M. (2010). Percutaneous access for endovascular aneurysm repair: a systematic review. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery, 39(6), 676–682. https://doi.org/10.1016/j.ejvs.2010.02.001

Martin Czerny, MD, Martin Funovics, MD (2013) Endovascular Aortic Repair. Cardiac surgeryVolume 18, Issue 1p65-72 https://doi.org/10.1053/j.optechstcvs.2013.01.003

Kim, H. O., Yim, N. Y., Kim, J. K., Kang, Y. J., & Lee, B. C. (2019). Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Comprehensive Review. Korean journal of radiology, 20(8), 1247–1265. https://doi.org/10.3348/kjr.2018.0927

Figueroa, A. V., Tanenbaum, M. T., Costa-Filho, J. E., Gonzalez, M. S., Baig, M. S., & Timaran, C. H. (2024). Up and over staged endoconduit technique for endovascular aortic aneurysm repair. Journal of vascular surgery cases and innovative techniques, 10(3), 101449. https://doi.org/10.1016/j.jvscit.2024.101449

Steffen, M., Schmitz-Rixen, T., Böckler, D., Grundmann, R. T., & DIGG gGmbH (2020). Comparison of open and endovascular repair of juxtarenal abdominal aortic aneurysms. Langenbeck's archives of surgery, 405(2), 207–213. https://doi.org/10.1007/s00423-020-01865-4

Prateek K. Gupta, Bala Natarajan (2011) Contemporary Outcomes following Endovascular versus Open Repair of Abdominal Aortic Aneurysm. Journal of Vascular Surgery, Volume 53, Issue 6, 33S - 34S https://doi.org/10.1016/j.jvs.2011.03.072

JJ Syrakuzy, ML Schermerhorn, AJ Meltzer (2016). Comparisons of Outcomes After Endovascular and Open Repair of Abdominal Aortic Aneurysms in Low-Risk Patients. Journal of Vascular Surgery, Volume 64, Issue 5, 1526 https://doi.org/10.1016/j.jvs.2016.09.011

Alnefaie, S. A., Alzahrani, Y. A., & Alzahrani, B. S. (2022). A Comparison of Endovascular Aneurysm Repair and Open Repair for Ruptured Aortic Abdominal Aneurysms. Cureus, 14(6), e25672. https://doi.org/10.7759/cureus.25672

Chinsakchai, K., Khunprasert, P., Ruangsetakit, C., Wongwanit, C., Hongku, K., Tongsai, S., Sermsathanasawadi, N., Hahtapornsawan, S., Puangpunngam, N., Prapassaro, T., & Pruekprasert, K. (2025). A 10-Year Retrospective Comparison of Endovascular and Open Aneurysm Repair for Infective Native Abdominal Aortic Aneurysm. Annals of vascular surgery, 111, 131–142. https://doi.org/10.1016/j.avsg.2024.10.010

Nadin Elsayed, Claire B. Janssen Long (2021). Term Outcomes After Open Conversion of Endovascular Aneurysm Repair Versus Primary Aortic Repair. Journal of Vascular Surgery, Volume 74, Issue 3, e129 - e130 https://doi.org/10.1016/j.jvs.2021.06.199

Gormley, S., Bernau, O., Xu, W., & Khashram, M. (2024). Propensity score analysis demonstrates no long term survival benefit from contemporary endovascular aneurysm repair compared to open in Aotearoa New Zealand. ANZ journal of surgery, 94(5), 819–825. https://doi.org/10.1111/ans.18815

Siracuse, J. J., Schermerhorn, M. L., Meltzer, A. J., Eslami, M. H., Kalish, J. A., Rybin, D., Doros, G., Farber, A., & Vascular Study Group of New England (2016). Comparison of outcomes after endovascular and open repair of abdominal aortic aneurysms in low-risk patients. The British journal of surgery, 103(8), 989–994. https://doi.org/10.1002/bjs.10139

Loftus, I. M., Haulon, S., & Boyle, J. R. (2020). NICE Abdominal Aortic Aneurysm Guidelines Finally Published: How Will They Influence Aortic Practice in the UK and Beyond?. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery, 59(5), 697–698. https://doi.org/10.1016/j.ejvs.2020.04.001

Aburahma, A. F., Campbell, J. E., Mousa, A. Y., Hass, S. M., Stone, P. A., Jain, A., Nanjundappa, A., Dean, L. S., Keiffer, T., & Habib, J. (2011). Clinical outcomes for hostile versus favorable aortic neck anatomy in endovascular aortic aneurysm repair using modular devices. Journal of vascular surgery, 54(1), 13–21. https://doi.org/10.1016/j.jvs.2010.12.010

Ho, P., Ting, A. C., & Cheng, S. W. (2004). Blood loss and transfusion in elective abdominal aortic aneurysm surgery. ANZ journal of surgery, 74(8), 631–634. https://doi.org/10.1111/j.1445-1433.2004.03117.x

Ettengruber, A., Epple, J., Schmitz-Rixen, T., Böckler, D., Grundmann, R. T., & DIGG gGmbH (2022). Long-term outcome and cancer incidence after abdominal aortic aneurysm repair. Langenbeck's archives of surgery, 407(8), 3691–3699. https://doi.org/10.1007/s00423-022-02670-x

Markar, S. R., Vidal-Diez, A., Sounderajah, V., Mackenzie, H., Hanna, G. B., Thompson, M., Holt, P., Lagergren, J., & Karthikesalingam, A. (2019). A population-based cohort study examining the risk of abdominal cancer after endovascular abdominal aortic aneurysm repair. Journal of vascular surgery, 69(6), 1776–1785.e2. https://doi.org/10.1016/j.jvs.2018.09.058