2026 KSVS临床实践指南：腹主动脉瘤的管理-重点关注18个关键临床问题

1) Surgical indications

Key question 1. Should aneurysmal repair be performed for fusiform degenerative abdominal aortic aneurysms (AAAs) measuring 5.5 cm or larger?

- Recommendation 1. Consider open surgical repair (OSR) or endovascular aneurysm repair (EVAR) for individuals with fusiform degenerative AAAs measuring 5.0-5.5 cm or larger.

- Grade of recommendation: Do, Conditional

- Level of evidence: High

$\bullet$ Key question 2. Should repair be performed for saccular AAAs regardless of size?

- Recommendation 2. Consider early OSR or EVAR for individuals with saccular AAAs.

- Grade of recommendation: Do, Conditional

- Level of evidence: Low

Key question 3. Is emergency surgery necessary for individuals presenting with abdominal pain associated with an AAA?

- Recommendation 3. Emergency surgery is not recommended for individuals with AAAs who present with abdominal, back, or radiating pain in the absence of definitive evidence of rupture.

- Grade of recommendation: Do not, Strong

- Level of evidence: Very low

2) Treatment strategies (EVAR vs. OSR)

$\bullet$ Key question 4. Is EVAR preferred over OSR in individuals with AAAs who meet the anatomical criteria for EVAR?

- Recommendation 4. Consider EVAR over OSR in individuals with AAAs who meet the anatomical criteria for EVAR.

- Grade of recommendation: Do, Conditional

- Level of evidence: High

Key question 5. Should OSR be considered before EVAR in individuals with AAAs who are expected to live more than 10 years?

- Recommendation 5. Consider OSR in individuals younger than 70 years with AAAs and an expected life expectancy greater than 10 years.

- Grade of recommendation: Do, Conditional

- Level of evidence: Very low

Key question 6. Is EVAR preferred over OSR in ruptured AAAs?

- Recommendation 6. Consider EVAR over OSR for ruptured AAAs when anatomically feasible.

- Grade of recommendation: Do, Conditional

- Level of evidence: Moderate

$\bullet$ Key question 7. Can EVAR be applied to infective native AAAs?

- Recommendation 7. EVAR may be considered for the treatment of infective native AAAs when anatomically and clinically feasible.

- Grade of recommendation: Do, Conditional

- Level of evidence: Low

3) Diagnosis of postoperative complications

$\bullet$ Key question 8. Can regular computed tomography (CT) or ultrasound surveillance after EVAR reduce mortality related to endoleak or aneurysm sac enlargement?

- Recommendation 8. Consider selective application of post-EVAR imaging intervals based on the operator's experience and the individual's risk of complications.

- Grade of recommendation: Do not, Conditional - Level of evidence: Very low

$\bullet$ Key question 9. Is regular sigmoidoscopy necessary after OSR of AAAs?

- Recommendation 9. Consider selective use of sigmoid-oscopy to diagnose intestinal ischemia following OSR of AAAs, guided by the individual's clinical course.

- Grade of recommendation: Do, Conditional

- Level of evidence: Very low

Kim et al.

Key question 10. Does regular imaging surveillance after OSR of AAAs reduce mortality due to graft- or aneurysm-related complications?

- Recommendation 10. Consider selective application of imaging surveillance after OSR of AAAs, based on the individual's clinical condition and the surgeon's experience.

- Grade of recommendation: Do, Conditional

- Level of evidence: Very low

4) Treatment of postoperative complications

Key question 11. Is removal of prosthetic graft necessary in cases of prosthetic graft infection following AAA repair?

- Recommendation 11. Graft removal may be considered in cases of prosthetic graft infection following AAA repair, with consideration of non-surgical or conservative management depending on the individual's clinical condition and the surgeon's experience.

- Grade of recommendation: Do, Conditional

- Level of evidence: Very low

Key question 12. Does reintervention or surgery reduce the risk of rupture in individuals with type 1 or type 3 endoleaks after EVAR of AAAs?

- Recommendation 12. Consider reintervention or surgery in individuals with type 1 or type 3 endoleaks following EVAR of AAAs.

- Grade of recommendation: Do, Conditional

- Level of evidence: Very low

Key question 13. Does reintervention or surgery reduce the risk of rupture in individuals with type 2 endoleaks accompanied by an increase in aneurysm size of 10 mm or more after EVAR?

- Recommendation 13. Consider treatment for type 2 endoleaks associated with aneurysm sac enlargement of 10 mm or more following EVAR of AAAs.

- Grade of recommendation: Do, Conditional

- Level of evidence: Very low

Key question 14. Should reintervention or surgery be performed in individuals with a continuous increase in aneurysm size after EVAR of AAAs in the absence of observed endoleaks?

- Recommendation 14. Consider reintervention or surgery in individuals with a continuous increase in aneurysm size after EVAR of AAAs without detectable endoleaks.

- Grade of recommendation: Do, Conditional - Level of evidence: Very low

5) Miscellaneous

$\bullet$ Key question 15. Should at least one internal iliac artery (IIA) be preserved during AAA repair?

- Recommendation 15. Consider preserving at least one IIA during OSR or EVAR of AAAs.

- Grade of recommendation: Do, Conditional

- Level of evidence: Low

$\bullet$ Key question 16. Is reimplantation of the inferior mesenteric artery (IMA) necessary to reduce the risk of bowel ischemia during OSR of AAAs?

- Recommendation 16. Consider reimplantation of the IMA during OSR of AAAs based on anatomical factors and surgeon preference.

- Grade of recommendation: Do, Conditional

- Level of evidence: Low

$\bullet$ Key question 17. Is a retroperitoneal approach recommended for surgery in cases of inflammatory AAA or complex abdominal pathology, such as horseshoe kidney (HK)?

- Recommendation 17. When performing OSR for inflammatory AAAs or those associated with complex abdominal pathology (e.g., HK), the surgical approach (reteroperitoneal or transperitoneal) should be determined based on anatomical factors and surgeon preference.

- Grade of recommendation: Do, Conditional - Level of evidence: Very low

$\bullet$ Key question 18. Is permissive hypotension recommended prior to surgery for ruptured AAAs?

- Recommendation 18. Consider permissive hypotension during resuscitation prior to surgery for ruptured AAAs.

- Grade of recommendation: Do, Conditional

- Level of evidence: Very low

Clinical Practice Guideline on AAA

INTRODUCTION AND GENERAL ASPECTS

1) Introduction and methods

The members of the Guideline Writing Committee (GWC) were appointed by the Korean Society for Vascular Surgery (KSVS), the Korean Society for Thoracic and Cardiovascular Surgery (KTCVS), and the Korean Society of Cardiology (KSC) to represent clinicians involved in the management of individuals with abdominal aortic aneurysms (AAAs).

Prior to initiating the literature review, GWC members submitted disclosure statements outlining any relationships that could be construed as actual or potential conflicts of interest. These statements are maintained at KSVS headquarters. The final document was approved by all GWC members and the external review committee. It underwent formal external peer review and was subsequently endorsed by the KSVS.

① The purpose of these guidelines

The KSVS developed clinical practice guidelines (CPGs) for the management of individuals with AAAs to support clinicians in selecting optimal therapeutic strategies. This document represents the first clinical guideline of AAAs issued by the KSVS and focuses on 18 key clinical questions.

In consideration of existing international AAA guidelines, redundant content was minimized, and emphasis was placed on issues particularly relevant to domestic contexts or insufficiently addressed in global recommendations. Authored and endorsed by the 16 GWC members, all of whom are KSVS members, these guidelines integrate the best available scientific evidence with clinical expertise. Through evidence synthesis and critical appraisal, recommendations were formulated for the evaluation and treatment of individuals with AAAs.

The primary goal of the KSVS in developing these guidelines is to standardize care and enhance clinical decision-making by presenting the most current and reliable evidence. However, individualized care must still be guided by

a range of factors, including symptomatology, comorbidities, age, functional status, care setting, procedural availability, and other clinical considerations.

② Methodology

(1) Strategy

The GWC convened on November 8, 2021, to formulate key questions for inclusion in the guidelines. In June 2023, GWC members reviewed and refined the phrasing and strength of each recommendation for the initial draft. When unanimous agreement could not be achieved, structured discussions were held to reach consensus. If consensus remained unattainable, decisions regarding phasing, grading, and evidence level were resolved through a majority vote among GWC members. A final hearing with KSVS members was held in December 2023, after which the finalized guidelines were submitted in March 2025. These guidelines will be subject to ongoing updates.

(2) Literature search and selection

Committee members, with support from clinical librarians, conducted systematic literature searches in MEDLINE (via PubMed), EMBASE, Cochrane Central, and KoreaMed up to February 3, 2022. Reference tracking and hand-searching by GWC members supplemented the search for additional relevant sources. A second search, focused on questions 17 and 18, was conducted in September 2022 and December 2023. Literature selection was based on information in study titles and abstracts.

The selection criteria were as follows: (1) Language: no restrictions; (2) Level of evidence: eligible studies included randomized controlled trials (RCTs), observational studies, case series, and case reports. The level of evidence assigned in each section corresponded to the strength of available data on the given topic; (3) Sample size: greater emphasis was placed on larger studies when available.

(3) Weighing the evidence

To develop the current guidelines, members of the GWC

|Recommendation rate|Strength|Direction|Definition| |---|---|---|---| |General usage|Strong|Do|When the benefits of treatment or examination clearly outweigh the risks, burdens, and costs associated with it.| |Selective usage|Conditional|Do|When the benefits of treatment or examination outweigh the associated risks, burdens, and costs, but uncertainty remains.| |Limited usage|Conditional|Do not|When the risks, burdens, and costs of treatment or examination outweigh the benefits, but uncertainty remains.| |No usage|Strong|Do not|When the risks, burdens, and costs of treatment or examination clearly outweigh its benefits.|

Kim et al.

reviewed and synthesized the selected literature. Conclusions were drawn based on the underlying scientific evidence. The recommendations provided in this document follow the Cochrane grading system. For each recommendation, both the direction and strength of the recommendation are indicated (Table 1). The quality of evidence supporting each recommendation is classified as high, moderate, low, or very low (Table 2).

SURGICAL INDICATION

1) Diameter

The decision regarding the appropriate diameter for aneurysm repair is based on weighing the risk of rupture against the operative mortality associated with repair procedures [1]. The most recent guidelines advise against elective repair of AAAs smaller than 55 mm in men and 50 mm in women, because of the very low rupture risk in this subgroup [1]. The lower threshold in women reflects the approximately fourfold higher rupture risk for small AAAs compared with men, which is partly attributed to smaller baseline aortic diameters in women [2]. Given that the aortic diameter in Korean individuals is generally smaller than in Western populations, racial differences should also be considered [3,4].

The GWC conducted a systematic review to synthesize current evidence objectively. The literature search on AAA

treatment outcomes revealed no direct comparative evidence identifying a specific diameter threshold for intervention. Therefore, indirect conclusions were drawn from studies involving individuals with AAAs smaller than the conventional intervention threshold. Of 261 studies, plus 5 additional studies identified through reference tracking, 4 RCTs were found to directly address the relevant key questions [5-8] (Table 3). Among the included studies, three applied an inclusion criterion of an aneurysm diameter less than 5.5 cm, while one used a threshold of 5.0 cm or less. Two studies evaluating open surgical repair (OSR) included only individuals with AAAs smaller than 5.5 cm. The remaining two studies assessed endovascular aneurysm repair (EVAR), with one study enrolling individuals with AAAs measuring 5 cm or less.

When overall survival was compared between the early intervention and surveillance groups, no significant difference was observed across all four studies. The meta-analysis showed that the risk ratios (RRs) for overall survival in the early intervention group compared with the surveillance group were 0.98 (95% confidence interval [CI], 0.97-0.99) at 1 year, 0.99 (95% CI, 0.98-1.01) at 2 years, 0.99 (95% CI, 0.97-1.02) at 3 years, and 1.01 (95% CI, 0.93-1.11) at 5 years (Fig. 1). Overall, these findings suggest no clinically meaningful long-term survival advantage with early repair compared with surveillance for small AAAs.

The studies reviewed were RCTs published between 1998 and 2011, all of which had a low risk of bias and were rated

|High|There is a lot of confidence that the true effect lies close to that of the estimated effect. There is moderate confidence in the estimated effect: The true effect is likely to be close to the estimated effect, but there is a possibility that it is substantially different. Low|There is moderate confidence in the estimated effect: The true effect is likely to be close to the estimated effect, but there is a possibility that it is substantially different. There is limited confidence in the estimated effect: The true effect might be substantially different from the estimated effect.| |---|---|---| |Low|There is very little confidence in the estimated effect: The true effect is likely to be substantially different from the estimated effect.|There is very little confidence in the estimated effect: The true effect is likely to be substantially different from the estimated effect.| |Very low|There is very little confidence in the estimated effect: The true effect is likely to be substantially different from the estimated effect.|Maximum AP diameter|

|Study|Country|Inclusion (cm)|Age (y)|Diagnostic tool|Number|Followed up|Male/female| |---|---|---|---|---|---|---|---| |CAESAR [5], 2011|Italy|4.1-5.4|50-79|CT|360|32.4 months (21.0-44.1) in early EVAR 30.9 months (18.3-45.3) in the surveillance|345/15| |PIVOTAL [8], 2010|USA|4.0-5.0|40-90|CT|728|20±12 months|631/97| |ADAM [7], 2002|USA|4.0-5.4|50-79|CT|1,136|4.9 years|1,027/109| |The UK Small Aneurysm|UK|4.0-5.5|60-76|Ultrasonography (maximum AP diameter)|1,090|4.6 years|902/188| |Trial [6], 1998||||||||

Values are presented as number only, range, mean±standard deviation, or median (interquartile range).

Clinical Practice Guideline on AAA

|Study|Experimental Events|Control Events|Total|Control Events|4|RR|95% CI| |---|---|---|---|---|---|---|---| |The UK Small Aneurysm Trial [6], 1998|511|563|502|527||0.95|[0.92; 0.98]| |ADAM [7], 2002|546|569|555|567||0.98|[0.96; 1.00]| |PIVOTAL [8], 2010|357|366|357|362||0.99|[0.97; 1.01]| |CAESAR [5], 2011|178|182|176|178||0.99|[0.96; 1.02]| |Common effect model||1,680||1,634||0.98|[0.97; 0.99]| |Random effects model||||||0.98|[0.97; 0.99]| |Heterogeneity: $I^{2}$=26%, $τ^{2}$<0.0001, P=0.25||||||1|| |B|||||||| |Study|Experimental Events|Total|Control|Control|||| |The UK Small Aneurysm Trial [6], 1998|490|563|474|527||0.97|95% CI| |ADAM [7], 2002|524|569|526|567||0.99|[0.96; 1.03]| |PIVOTAL [8], 2010|353|366|348|362||1.00|[0.98; 1.03]| |CAESAR [5], 2011|178|182|174|178||1.00|[0.97; 1.03]| |Common effect model||1,680||1,634||0.99|[0.98; 1.01]| |Random effects model||||||0.99|[0.98; 1.01]| |Heterogeneity: $I^{2}$=27%, $τ^{2}$=0, P=0.55||||||1|| |C|||||||| |Study|Experimental Events|Total|Control|Control|||| |The UK Small Aneurysm Trial [6], 1998|490|563|474|527||0.97|95% CI| |PAVOTAL [8], 2010|524|569|526|567||0.99|[0.95; 1.03]| |CAESAR [5], 2011|353|366|348|362||1.00|[0.97; 1.02]| |Favors surveillance ↔ Favors treatment||||||1.00|[0.97; 1.02]| |EX||||||1.00|[0.97; 1.03]| |EX||||||1.00|[0.98; 1.03]| |EX||||||1.00|[0.98; 1.01]| |EX||||||0.99|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |EX||||||1.00|[0.98; 1.01]| |||||||||

Kim et al.

2) Saccular aneurysm

Saccular AAAs are classified as a distinct subtype, characterized by focal, spherical dilations involving only a segment of the aortic circumference [9]. A widely accepted view holds that saccular AAAs may warrant earlier intervention due to their asymmetrical morphology, which is believed to increase rupture risk [10]. However, this remains debated, as the natural history and rupture risk of saccular aneurysms are poorly defined. The most recent ESVS guidelines suggest that early intervention via open or endovascular repair may be considered for saccular AAAs [1]. Although these guidelines imply a lower size threshold for elective repair compared to fusform AAAs, a specific diameter cutoff is not defined.

Given this uncertainty, the GWC sought to assess prognosis and treatment outcomes in individuals with saccular AAAs treated with EVAR or OSR. A literature search examining outcomes in these individuals yielded 261 studies. After full-text review, studies relevant to this question were identified, including 2 retrospective observational studies [11,12], 3 case series reporting clinical characteristics and/or outcomes (Table 4) [10,13,14], and 17 case reports detailing treatment outcomes (Supplementary Table 1) [15-31].

Karthaus et al. [11] analyzed 7,659 patients undergoing primary repair of degenerative AAAs in the Netherlands (2016-2018), among whom 471 (6.1%) had saccular AAAs. Saccular AAAs were treated at smaller diameters than fusiform AAAs in both elective and acute settings. Notably, 25.2% of acute saccular AAAs presented with a maximum diameter <55 mm and 8.4% with a maximum diameter <45 mm, supporting the concept that saccular AAAs may become acute at smaller diameters. The authors suggested that 45 mm may be an acceptable threshold for elective treatment.

Shang et al. [12] identified 322 saccular aortic aneurysms in 284 patients (2003-2011), including AAAs in 24.2%. Overall, 113 patients (39.8%) underwent repair (97 after the initial CTA and 16 during observation). Among 50 patients with CT follow-up at ≥3 months, 15 (30.0%) ultimately underwent intervention. Although the growth rate was

not higher than that reported for fusiform aneurysms, the authors emphasized the need for clinical and radiologic surveillance because a substantial proportion ultimately required intervention. Although this study included thoracic aortic aneurysms (TAAs) as well as AAAs, it was considered an important source for this key question, as it remains the only study describing the clinical progression of saccular aortic aneurysms. It has been cited as supporting evidence in both the SVS and ESVS guidelines [1,32].

Kristmundsson et al. [10] analyzed 206 individuals with ruptured AAAs diagnosed by CT between 2006 and 2013 and identified 9 cases of saccular AAAs. Notably, saccular AAAs were significantly more common among ruptures with a maximum diameter <55 mm than among those ≥55 mm (5/12 vs. 4/194, P<0.01).

Regarding post-treatment outcomes, the evidence is largely limited to small case series and case reports. Mizoguchi et al. [13] reported no mortality among six patients treated with EVAR for distal saccular AAAs. Yoshida et al. [14] reported one mortality due to acute myocardial infarction among nine individuals who received EVAR for saccular AAAs between 2010 and 2020.

Overall, no comparative studies have demonstrated the superiority of early intervention via surgery or EVAR over conservative management for saccular AAAs. The level of evidence remains low, as available studies only represent observational data from patient groups with this condition. Nevertheless, published case-based reports suggest low perioperative complication and mortality rates after intervention, while also highlighting instances of rapid aneurysm enlargement or rupture without treatment. These findings support early consideration of elective repair. Given the uncertainty surrounding rupture potential, intervention may be justified at a lower diameter threshold compared to fusion-form AAAs [12].

Recommendation 2. Consider early OSR or EVAR for individuals with saccular AAAs.

Grade of recommendation: Do, Conditional

Level of evidence: Low

|Study|Study type|Population|Number|Age (y)|Male/Female|Intervention|Mortality| |---|---|---|---|---|---|---|---| |Shang et al. [12], 2013|Retrospective observational study|SAAA|113|NA|NA|EVAR or OSR|NA| |Karthaus et al. [11], 2019|Retrospective observational study|SAAA|471|NA|377/94|EVAR or OSR|8| |Kristmundsson et al. [10], 2016|Case series|SAAA|9|NA|NA|EVAR or OSR|NA| |Mizoguchi et al. [13], 2021|Case series|SAAA|6|NA|NA|EVAR|0| |Yoshida et al. [14], 2021|Case series|SAAA|9|74.3±10.6|6/3|EVAR|1|

Values are presented as number only or mean±standard deviation. Number indicates patients who underwent repair when applicable. SAAA: saccular abdominal aortic aneurysm; NA: not available; EVAR, endovascular aneurysm repair; OSR, open surgical repair.

Clinical Practice Guideline on AAA

3) Symptomatic non-ruptured AAA: emergent repair vs. deferred repair

The optimal timing for managing symptomatic but non-ruptured AAAs remains a subject of ongoing debate, as the balance between prompt intervention and deferred elective repair is still not clearly defined. Reflecting current literature, the ESVS guidelines recommend deferred urgent repair, ideally performed under elective conditions, to reduce operative risk and optimize outcomes [1].

To clarify this issue and generate objective evidence, the GWC conducted a systematic review. A literature search examining outcomes of emergency versus elective surgery for symptomatic, non-ruptured AAAs yielded 7,332 studies and 35 additional studies through reference screening. Eight relevant observational studies were identified through full-text review (Table 5) [33-40].

Despite decades of investigation, the timing of interven-

tion for symptomatic, non-ruptured AAAs remains clinically controversial. For symptomatic but non-ruptured AAAs, emergency surgery is often performed with limited preoperative optimization and is associated with a higher risk of intraoperative and postoperative complications, even though the rupture risk exceeds that of asymptomatic aneurysms [33,35,41,42]. A meta-analysis of eight studies demonstrated an odds ratio (OR) for mortality of 3.65 (95% CI, 2.17-6.13) for emergent repair compared with deferred treatment (Fig. 2).

Clinical studies to date have generally shown lower mortality with deferred treatment performed under elective conditions [33-39]. One single-center study reported a hospital mortality rate of 9% in the emergency surgery group and 12% in the group undergoing surgery after 24 hours, with no statistically significant difference (P=0.694); no significant differences were noted in postoperative complications or total hospital stay [40]. Overall, most included stud-

|Study|Country|Study type|Study period|Emergency|Emergency|Emergency|Elective|Elective|Elective| |---|---|---|---|---|---|---|---|---|---| |Study|Country|Study type|Study period|OP type|Number Mortality|OP type|Number Mortality|Number Mortality|Wortality| |Johnson et al. [36], 1980|USA|Retrospective|1952-1977|OSR|37|6 (16)|OSR|153|6 (4)| |Sullivan et al. [39], 1990|USA|Retrospective|1978-1989|OSR|19|5 (26)|OSR|117|6 (5)| |Cambria et al. [33], 1994|USA|Retrospective|1987-1992|OSR|14|4 (28.6)|OSR|22|0 (0)| |Soisalon-Soininen et al. [38], 1999|Finland|Retrospective|1970-1992|OSR|110|20 (18)|OSR|599|42 (7)| |Haug et al. [35], 2004|Norway|Retrospective|1983-1994|OSR|61|25 (40.9)|OSR|43|1 (2.3)| |Tambyraja et al. [40], 2004|UK|Retrospective|1995-2001|OSR|70|6 (9)|OSR|25|3 (12)| |Leo et al. [37], 2005|Finland|Retrospective|1972-2002|OSR|42|4 (9.5)|OSR|388|14 (3.6)| |Chandra et al. [34], 2017|USA|Retrospective|1995-2004|OSR+EVAR|81|7 (8.6)|OSR+EVAR|80|2 (2.5)|

Values are presented as number only or number (%).

OP, operation; OSR, open surgical repair; EVAR, endovascular aneurysm repair.

|Study|Experimental Events|Control Events|Control Events|OR|OR|95% CI| |---|---|---|---|---|---|---| |Johnson et al. [36], 1980|6|37|6|153|4.74|[1.43; 15.68]| |Sullivan et al. [39], 1990|5|19|6|117|6.61|[1.78; 24.50]| |Cambria et al. [33], 1994|4|14|0|22|19.29|[0.95; 392.11]| |Soisalon-Soininen et al. [38], 1999|20|110|42|599|2.95|[1.65; 5.25]| |Haug et al. [35], 2004|25|61|1|43|29.17|[3.76; 226.06]| |Tambyraja et al. [40], 2004|6|70|3|25|0.69|[0.16; 2.98]| |Leo et al. [37], 2005|4|42|14|388|2.81|[0.88; 8.97]| |Chandra et al. [34], 2017|7|81|2|80|3.69|[0.74; 18.33]| |Common effect model||434||1,427|3.42|[2.29; 5.11]| |Random effects model|||||3.65|[2.17; 6.13]| |Heterogeneity: $I^{2}$=40%, $τ^{2}$=0.1319, P=0.11||||0.01|0.1|[100]|

Kim et al.

ies were consistent with contemporary US and European clinical guidelines, which recommend semi-elective or preferably elective surgery for symptomatic but non-ruptured AAAs, following completion of appropriate diagnostic tests and patient optimization [1,32]. However, most studies were retrospective and conducted at a single center. Among the eight studies included, four were published prior to 2000 and focused specifically on AAA treatment. Additionally, seven studies involved fewer than 100 participants in either the intervention or control group, indicating a high risk of bias. As a result, the overall level of evidence was rated as very low.

Recommendation 3. Emergency surgery is not recommended for individuals with AAAs who present with abdominal, back, or radiating pain in the absence of definitive evidence of rupture.

Grade of recommendation: Do not, Strong

Level of evidence: Very low

4) Treatment method: EVAR vs. OSR

In Korea, the use of EVAR for AAAs has steadily increased since its introduction, while OSR has been performed at a relatively consistent annual rate [43]. To determine the preferred treatment method in anatomically suitable individuals, a literature search examining treatment outcomes in individuals with AAAs meeting anatomical criteria identified 1,484 studies from PubMed, EMBASE, Cochrane Central, and KoreaMed. Following full-text review, 12 studies derived from 5 RCTs were deemed relevant (Table 6) [44-55].

Meta-analysis results showed that the risk ratio (RR) for 30-day mortality after EVAR was 0.40 (95% CI, 0.22-0.74) (Fig. 3A). The RRs for mortality at 6 months, 4 years, and 8 years post-treatment were 0.60 (95% CI, 0.41-0.87), 0.93 (95% CI, 0.80-1.08), and 0.99 (95% CI, 0.91-1.09), respectively, indicating that the early survival advantage associated with EVAR diminished after 4 years (Fig. 3B-D).

In contrast, the RR for reintervention showed no significant difference at 4 years post-treatment (1.67; 95% Cl, 0.62-4.50), but was significantly higher at 8 years after EVAR (2.13; 95% Cl, 1.71-2.66) (Fig. 4).

The included studies had relatively large sample sizes, and the risk of bias was low in all but one trial. Therefore, the level of evidence was rated as high. Taking into account the short-term mortality benefit of EVAR, the lack of long-term survival advantage beyond 4 years, and the increased reintervention rate, the recommendation was graded as conditional (Do, Conditional).

Recommendation 4. Consider EVAR over OSR in individuals with AAAs who meet the anatomical criteria for EVAR. Grade of recommendation: Do, Conditional Level of evidence: High

5) Younger patients with long life expectancy: EVAR vs. OSR

A recent study on the long-term outcomes of AAA treatment demonstrated that the early survival benefit associated with EVAR diminishes during mid-term follow-up, with higher rates of intervention and secondary rupture compared with OSR [56]. Although EVAR is generally preferred in many individuals, these findings raise concerns about long-term complications and the burden of lifelong surveillance when applying EVAR in younger individuals with extended life expectancy.

The GWC sought to compare outcomes after EVAR and OSR in relation to life expectancy through a structured literature review. A search across PubMed, EMBASE, Cochrane Central, and KoreaMed yielded 1,484 studies, of which 28 observational studies were deemed relevant after full-text screening. As no studies directly compared outcomes by life expectancy, direct evidence on this question could not be obtained. Therefore, the mean age of the study population was used as an approximate surrogate for life expectancy. Based on this assumption and the average life expectancy in Korea, studies including participants

|Study|Country|Recruitment period|EVAR|OSR|Age (y)|Age (y)|Male sex|Male sex| |---|---|---|---|---|---|---|---|---| |Study|Country|Recruitment period|EVAR|OSR|EVAR|OSR|EVAR|OSR| |ACE [48], 2011|France|2003.03-2008.03|150|149|68.9±7.7|70±7.1|150 (100)|146 (98)| |DREAM [49], 2017|Netherlands|2000.11-2003.12|173|178|70.7±6.6|69.6±6.8|161 (93)|161 (90)| |EVAR 1 [50], 2016|UK|1999.09-2004.08|626|626|74.1±6.1|74.0±6.0|565 (90.3)|570 (91.1)| |Lottman et al. [45], 2004|Netherlands|1996.09-1999.10|57|19|69 (52-82)|68 (52-81)|54 (94.7)|16 (84.2)| |OVER [46], 2009|USA|2002.10-2008.04|444|437|69.6±7.8|70.5±7.8|441 (99.3)|435 (99.5)|

Values are presented as number only, mean±standard deviation, mean (range), or number (%). EVAR, endovascular aneurysm repair; OSR, open surgical repair.

Clinical Practice Guideline on AAA

||Experimental Events|Experimental Events|Control Events|Control Events|Control Events|Control Events| |---|---|---|---|---|---|---| ||Events|Total|Events|Total|Recall|Recall| |At||||||| |Study|1|150|1|149||| |AEV 1 [50], 2016|11|614|26|602||| |Lottman et al. [45], 2004|1|57|1|19||| |OVER [46], 2009|1|444|10|437||| |Common effect model||1,265||1,207||| |Random effects model||||||| |Heterogeneity: $l^{2}$=16%, $τ^{2}$<0.0001, P=0.31||||||| |B||||||| |Study|Experimental Events|Total|Control|||| |DREAM [49], 2017|5|173|11|178|RR|95% CI| |EVAR 1 [50], 2016|26|626|45|626||| |OVER [46], 2009|11|444|14|437||| |Common effect model||1,243||1,241||| |Random effects model||||||| |Heterogeneity: $l^{2}$=0%, $τ^{2}$=0, P=0.72||||||| |C||||||| |Study|Experimental Events|Total|Control|||| |DREAM [49], 2017|39|173|36|178||| |EVAR 1 [50], 2016|152|626|161|626||| |OVER [46], 2009|70|444|84|437||| |Common effect model||1,243||1,241||| |Random effects model||||||| |Heterogeneity: $l^{2}$=0%, $τ^{2}$=0, P=0.46||||||| |D||Experimental Events|Control|||| |Study|Events|Total|Events|Total||| |DREAM [49], 2017|67|173|70|178||| |EVAR 1 [50], 2016|287|626|290|626||| |OVER [46], 2009|163|444|160|437||| |Common effect model||1,243||1,241||| |Random effects model||||||| |Heterogeneity: $l^{2}$=0%, $τ^{2}$=0, P=0.99||||||| |||||||| |Exper|Experimental Events|Total|Control|||| |DREAM [49], 2017|67|173|70|178||| |EVAR 1 [50], 2016|287|626|290|626||| |OVER [46], 2009|163|444|160|437||| |Common effect model||1,243||1,241||| |Random effects model||||||| |Heterogeneity: $l^{2}$=0%, $τ^{2}$=0, P=0.99||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| |||||||| ||<start||||||

Kim et al.

![|Study|Experimental Events|Total|Control Events|Total|RR|RR 95% CI|\n|:---:|:---:|:---:|:---:|:---:|:---:|:---:|\n|DREAM [49], 2017 EVAR 1 [50], 2016|30|173|31|178|1.00|[0.63; 1.57]|\n|DREAM [49], 2017 EVAR 1 [50], 2016|123|626|45|626|2.73|[1.98; 3.78]|\n|Common effect model|799|804|—|—|1.95|[1.50; 2.54]|\n|Random effects model|—|—|—|—|1.67|[0.62; 4.50]|\n|Heterogeneity: I²=92%, τ²=0.4692, P<0.01|—|—|—|—|—|—|\n|DREAM [49], 2017 EVAR 1 [50], 2016|55|173|32|178|1.77|[1.21; 2.59]|\n|DREAM [49], 2017 EVAR 1 [50], 2016|308|626|135|626|2.28|[1.93; 2.70]|\n|Common effect model|799|804|—|—|2.19|[1.87; 2.55]|\n|Random effects model|—|—|—|—|2.13|[1.71; 2.66]|\n|Heterogeneity: I²=30%, τ²=0.0097, P=0.23|—|—|—|—|—|—|\n](1/parseimages/figure4ed2307302934c14b26575bf1f3838d5_0_1.png) (Supplementary Fig. 1A). Similarly, in studies with a mean patient age ≥70 years, the pooled 10-year survival rate was 46.9% (95% CI, 31.8%~62.2%) for OSR and 40.7% (95% CI, 30.3%-51.5%) for EVAR, also without statistically significant difference (Supplementary Fig. 1B).

The pooled RRs for 10-year survival (OSR vs. EVAR) suggested numerically better outcomes with OSR in both the under-70 group (RR, 1.13; 95% CI, 0.95-1.34) (Fig. 5A) and the 70-and-older group (RR, 1.34; 95% CI, 0.98-1.82) (Fig. 5B). However, reintervention rates could not be pooled for meta-analysis because of heterogeneity in the observation periods across the included studies.

Although no statistically significant difference was observed in this systematic review, a previous meta-analysis that did not stratify by age reported that EVAR was associated with higher long-term mortality (OR, 1.19; 95% CI, 1.06-1.33), higher reintervention rates (OR, 2.12; 95% CI, 1.67-2.69), and an increased risk of post-treatment rupture (OR, 4.84; 95% CI, 2.63-8.89) compared to OSR [56]. Therefore, despite the absence of direct evidence specifically addressing individuals with long life expectancy, the available data raise concerns regarding the long-term durability of EVAR in this population.

Because few studies tracked individuals with a mean age <70 years for more than 10 years following EVAR, and most included studies were retrospective observational designs with a high risk of bias, the level of evidence was down-

graded accordingly. The final level of evidence for this recommendation was rated as very low.

Recommendation 5. Consider OSR in individuals young- er than 70 years with AAAs and an expected life expect- tancy greater than 10 years.

Grade of recommendation: Do, Conditional Level of evidence: Very low

6) Ruptured AAA: EVAR vs. OSR

Treatment outcomes for ruptured AAAs remain mixed, with some studies reporting similar long-term outcomes between OSR and EVAR, while others indicate lower mortality with EVAR [72-76]. A literature search on mortality and complication outcomes after repair of ruptured AAAs, either endovascular or open, yielded 1,484 papers from PubMed, EMBASE, Cochrane Central, and KoreaMed, of which 47 were deemed relevant after full-text review. Among these, 22 retrospective studies and four RCTs directly compared EVAR and OSR, and three RCTs along with 10 observational comparative studies were ultimately included in the meta-analysis (Table 8) [77-89]. Four studies reported reintervention rates; however, due to inconsistent study designs and differing follow-up durations, these were not included in the meta-analysis.

The studies selected for meta-analysis reported com-

Clinical Practice Guideline on AAA

|Study|Study type|Study period|Number|Mean age|10-year survival rate (%)| |---|---|---|---|---|---| |Under 70|||||| |Schmid et al. [61], 2020|Retrospective observational|1989-2013|OSR: 155|65.8|OSR: 92.3| |Gallitto et al. [59], 2020|Retrospective observational|2005-2013|EVAR: 58|60|EVAR: 79| |Lee et al. [60], 2015|Retrospective observational|2000-2013|OSR: 57||OSR: 70, P=0.94| |Arenas Azofra et al. [57], 2020|Retrospective observational|2003-2017|EVAR: 50|EVAR: 57.1|EVAR: 54| |Bae et al. [58], 2017|Retrospective observational|2007-2014|OSR: 91|OSR: 64.1|OSR: 57, P=0.195| |Reitz et al. [62], 2020|Retrospective observational|2003-2013|EVAR: 58|69.6|EVAR: 75.4| |70-and-older||||OSR: 40|OSR: 94| |Patel et al. [70], 2018|Randomized controlled|1999-2004|||| |Gennai et al. [67], 2022|Retrospective observational|1999-2016||EVAR: 626|EVAR: 14.9| |Abdulrasak et al. [63], 2020|Retrospective observational|1998-2012||OSR: 74.0|OSR: 23.8| |Oliveira-Pinto et al. [69], 2020|Retrospective observational|2000-2014||EVAR: 623|EVAR: 64.9| |Charbonneau et al. [66], 2019|Retrospective observational|2003-2016||EVAR: 543|EVAR: 32| |Salata et al. [71], 2019|Retrospective observational|2003-2016||OSR: 224|OSR: 70.9| |Iwakoshi et al. [68], 2014|Retrospective observational|2003-2016||EVAR: 6,100|EVAR: 75.0| |Bastos Gonçalves et al. [65], 2014|Retrospective observational|2000-2007||OSR: 11,583|OSR: 74.6| |Ballotta et al. [64], 2008|Retrospective observational|1992-2005||ASR: 127|EVAR: 39|

OSR, open surgical repair; EVAR, endovascular aneurysm repair.

plications, sequelae, and mortality among individuals who underwent EVAR or OSR for ruptured AAAs. Three RCTs provided data on 30-day mortality; two publications were derived from the Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) trial. Retrospective studies comparing 30-day mortality generally favored EVAR, although these findings did not consistently reach statistical significance. The meta-analysis showed an RR for 30-day mortality of 0.87 (95% CI, 0.74-1.02), suggesting a possible benefit of EVAR.

Comparative studies of intraoperative blood transfusion volume, operative time, and hospital length of stay also favored EVAR. Because randomized trials did not provide consistent data for postoperative morbidity, the meta-analysis for morbidity relied largely on retrospective data. Although follow-up durations varied and most studies reflected mid-term outcomes, the meta-analysis showed an RR for 30-day morbidity of 0.83 (95% CI, 0.78-0.88) and an RR for follow-up mortality of 0.66 (95% CI, 0.62-0.70). These findings suggest that EVAR may offer advantages in

early morbidity and overall survival.

In retrospective studies, OSR tended to be selected for individuals with short aneurysm necks, where securing a stent graft in the proximal aortic neck is technically challenging, introducing potential selection bias [90]. However, the impact of neck length on post-EVAR prognosis remains debated [81,90]. Prognosis in patients with ruptured AAAs may also vary depending on hemodynamic stability and the use of proximal aortic balloon occlusion [85,91].

Given the relatively consistent 30-day mortality findings from randomized trials and their lower risk of bias, the level of evidence was rated as moderate. For 30-day morbidity and overall mortality, despite variability in morbidity definitions and follow-up periods, consistency across studies and a relatively low risk of bias supported a moderate-to-high level of evidence. However, as most mortality outcomes were limited to less than one year [78,90], further data on long-term prognosis are needed. Based on this, the final level of evidence was classified as moderate. Although statistical significance varied, most studies favored EVAR,

Kim et al.

 |Study|Study design|Country|Population (EVAR:OSR)|Result| |---|---|---|---|---| |Anjum et al. [77], 2015|RCT|Multi|458 (177:281)|No significant difference| |Powell et al. [78], 2014|RCT|Multi|502 (259:243)|No significant difference| |Reimerink et al. [79], 2013|RCT|Netherlands|106 (57:59)|No significant difference| |Giles et al. [80], 2009|Retrospective|USA|567(121:446)|Recommend EVAR| |Schechter et al. [81], 2017|Retrospective|USA|99 (25:74)|No significant difference| |Speicher et al. [82], 2014|Retrospective|USA|1,997 (614:1,383)|Recommend EVAR| |Davenport et al. [83], 2010|Retrospective|USA|427 (99:328)|Recommend EVAR| |Lyons et al. [84], 2010|Retrospective|UK|37 (18:19)|Recommend EVAR| |Wang et al. [85], 2018|Retrospective|China|4,929 (2,749:2,180)|No significant difference| |Guo et al. [86], 2016|Retrospective|China|59 (36:23)|Recommend EVAR| |Noorani et al. [87], 2012|Retrospective|UK|102 (52:50)|Recommend EVAR| |Wu et al. [88], 2014|Retrospective|Taiwan|35 (15:20)|No significant difference| |Gupta et al. [89], 2018|Retrospective|USA|3,164 (1,614:1,550)|Recommend EVAR|

RCT, randomized controlled trial; EVAR, endovascular aneurysm repair; OSR, open surgical repair.

justifying a conditional recommendation.

Recommendation 6. Consider EVAR over OSR for ruptured AAAs when anatomically feasible.

Grade of recommendation: Do, Conditional Level of evidence: Moderate

7) Infective native AAA: EVAR vs. OSR

Infective native AAA As arise from septic emboli infiltrat-ing the vasa vasorum, hematogenous dissemination during bacteremia, or contiguous spread from adjacent infections, leading to infectious arterial wall degeneration and aneurysm formation [1,92]. The term “mycotic aneurysm,” originally

Clinical Practice Guideline on AAA

introduced by Osler in 1885 to describe fungus-like vegetations in endocarditis-associated aneurysms [93,94], has recently been reconsidered. The proposed term “infective native aortic aneurysm” is now favored, as “mycotic” misleadingly implies a fungal etiology [95].

Historically, OSR followed by either extra-anatomic bypass or in-situ reconstruction has been regarded as the standard treatment. However, growing evidence supports EVAR as a viable alternative, with successful outcomes increasingly reported. The GWC conducted a comprehensive literature search on outcomes following EVAR or OSR for infective native AAA. This search retrieved 1,484 articles from PubMed, EMBASE, Cochrane Central, and KoreaMed, with an additional 42 papers identified through reference screening. Thirteen retrospective studies were deemed relevant upon full-text review (Table 9) [96-108]. Among these, four studies directly comparing EVAR and OSR were included in the meta-analysis [96,101,103,104]. Although follow-up periods for mortality and survival varied, the meta-analysis included studies reporting 1-year mortality rates. The 1-year mortality

rate was 17.3% (19/110) in the EVAR group and 26.9% (39/145) in the OSR group, yielding an OR of 0.52 (95% CI, 0.27-0.99), suggesting lower 1-year mortality after EVAR (Fig. 6).

Reinfection and reintervention were reported in individual studies; however, studies directly comparing EVAR and OSR were limited. Even among studies reporting outcomes, inconsistent data formats rendered most data unsuitable for meta-analysis [102,107]. Although higher reintervention frequencies were reported after EVAR in some reports, interpretation is limited, in part due to planned OSR following EVAR in selected cases, precluding definitive conclusions regarding the inferiority of EVAR.

Traditionally, early-stage infective native aortic aneurysms were managed by complete excision of infected arterial segments with extra-anatomical reconstruction to avoid the infected field [97,98]. Subsequent studies suggested that in-situ graft reconstruction may offer outcomes comparable or superior to extra-anatomic bypass, especially when combined with prolonged antibiotic therapy and adjunctive measures such as omental wrapping [109]. Initially, EVAR

|Study|Study design|Total number|EVAR|OSR|Combine|Age, mean (y)|Age, mean (y)|Patients/male sex|Patients/male sex|1 year mortality (%)|1 year mortality (%)| |---|---|---|---|---|---|---|---|---|---|---|---| |Study|Study design|Total number|EVAR|OSR|Combine|EVAR|OSR|EVAR|OSR|EVAR|OSR| |Kan et al. [96], 2010|Retrospective|41|20|21|0|61|62|20/14|21/17|30|43| |Dubois et al. [97], 2010|Retrospective|44|1|43|0|-|-|-|-|-|-| |Lai et al. [98], 2011|Retrospective|34|2|32|0|69|-|-|34/28|0|17| |Yu et al. [99], 2011|Retrospective|56|1|41|0|-|-|-|-|-|-| |Sedivy et al. [100], 2012|Retrospective|32|32|0|0|67|-|32/25|-|41|-| |Yamanaka et al. [101], 2014|Retrospective|70|18|52|0|70|-|-|70/50|11|13| |Sörelius et al. [102], 2014|Retrospective|123|123|0|0|69|-|123/87|-|24|-| |Youn et al. [103], 2015|Retrospective|13|2|10|1|43|67|2/1|10/10|50|30| |Sörelius et al. [104], 2016|Retrospective|132|70|62|0|71|68|70/49|62/42|14|28| |Luo et al. [105], 2017|Retrospective|40|40|0|0|73|-|40/31|-|29|-| |Zhu et al. [106], 2020|Retrospective|16|16|0|0|58|-|16/12|-|13|-| |Di et al. [107], 2020|Retrospective|19|16|3|0|71|60|16/13|3/3|32|0| |Tshomba et al. [108], 2020|Retrospective|23|3|17|3|-|-|-|-|-|-|

EVAR, endovascular aneurysm repair; OSR, open surgical repair; -, not available.

Kim et al.

|Study|Experimental Events|Total|Control Events|Total|OR|OR|95% CI| |---|---|---|---|---|---|---|---| |Kan et al. [96], 2010|6|20|9|21||0.57|[0.16; 2.07]| |Yamanaka et al. [101], 2014|2|18|10|52||0.52|[0.10; 2.66]| |Sorelius et al. [104], 2016|10|70|17|62||0.44|[0.18; 1.05]| |Youn et al. [103], 2015|1|2|3|10||2.33|[0.11; 50.98]| |Common effect model||110||145||0.52|[0.27; 0.99]| |Random effects model||||||0.52|[0.27; 0.99]| |Heterogeneity: $I^{2}$=0%, $τ^{2}$=0, P=0.78|||||0.1|0.5 1 2 10||

use in infective native AAAs was constrained by concerns regarding persistent infection and the potential need for prolonged, and sometimes lifelong, antibiotic therapy due to retained infected tissue. However, accumulating reports have suggested that EVAR may reduce early mortality in selected high-risk or emergent presentations. Moreover, EVAR has been proposed as a bridging strategy to stabilize patients and reduce perioperative risk before definitive surgical debridement and reconstruction, when required [97,110].

In this systematic review, multiple reports demonstrated favorable initial outcomes after EVAR. Recent systematic reviews, including those addressing infective thoracic aortic aneurysms, have also indicated that endovascular treatment may not be demonstrably inferior to OSR [111]. Although all studies included in the meta-analysis were retrospective and carried a high risk of bias, current evidence suggests that EVAR is not inferior to OSR. Moreover, given its association with improved 1-year mortality rates, EVAR may be considered as a treatment option for infective native AAAs when anatomically feasible, particularly in patients with high risk of early mortality.

Recommendation 7. EVAR may be considered for the treatment of infective native AAAs when anatomically and clinically feasible.

Grade of recommendation: Do, Conditional

Level of evidence: Low

DIAGNOSIS OF POSTOPERATIVE COMPLICATIONS

1) Regular imaging surveillance after EVAR

The risk of graft-related complications necessitates imaging follow-up after EVAR. However, recent guidelines do not provide a single standardized protocol applicable to all patients and recommend individualized surveillance strat-

egies [1,32]. The GWC conducted a systematic review to evaluate the association between regular imaging follow-up and clinical outcomes after EVAR. A literature search on imaging surveillance after EVAR in patients with AAA yielded 1,090 papers from PubMed, EMBASE, Cochrane Central, and KoreaMed, with seven additional studies identified through reference screening. Of these, eight observational cohort studies directly comparing regular versus irregular follow-up were included and analyzed (Table 10) [112-119]. Meta-analysis demonstrated that the RR for all-cause mortality in the regular follow-up group after EVAR was 1.57 (95% CI, 1.06-2.31), and the RR for reintervention was 1.32 (95% CI, 1.14-1.52) (Fig. 7).

These observational findings should not be interpreted as evidence that irregular follow-up is beneficial. The studies included in the meta-analysis did not consistently report adherence to EVAR device instructions for use, and early post-EVAR outcomes such as endoleak were not accounted for. As retrospective cohort studies, variations existed in follow-up protocols, and the rationale for irregular follow-up in the control groups remained unclear. In addition, confounding and selection bias are likely, as higher-risk patients may undergo more intensive surveillance and undergo more reinterventions because complications are detected more frequently. Given the presence of confounding variables, selection biases, and variation in outcome assessments, the recommendation grade was assigned as conditional, and the level of evidence was rated very low.

Recommendation 8. Consider selective application of post-EVAR imaging intervals based on the operator's experience and the individual's risk of complications. Grade of recommendation: Do not, Conditional Level of evidence: Very low

Clinical Practice Guideline on AAA

Table 10. Observational cohort studies comparing regular and irregular imaging follow-up after endovascular aneurysm repair for abdominal aortic aneurysms

|Study|Design|Number (C, NC)|Surveillance|Definition of regular surveillance|Reintervention|C|Norality|C|Mean duration|Mean duration of follow-up (mo)| |---|---|---|---|---|---|---|---|---|---|---| |Leurs et al. [112, 2005]|Retrospective observational 4,433 (1,538, 2895)|4,334 (1,538, 2895)|CTA, angogram, 1,433 (1,538, 2895)|1,3, 6, 12, 18, and 24 months then 111 (17, 119)|117 (7, 152)|15.5(5, 4)|182 (11, 8) 252 (8,7)|NC|C|NC| |Jones et al. [113, 2007]|Retrospective observational 302 (2003, 99)|302 (2003, 99)|DUS, CTA, X-ray 1|1,6, 12, and 18 months|45 (22.2) 11 (11, 11) 1|75 (36.9) 36 (36.4)|29.6|29.6|-|-| |Sarangarn et al. [115, 2010]|Retrospective observational 569 (301, 268)|126 (107, 19)|CTA, X-ray 1|1,6, 12, and 24 months then 24 months then 11, 18, and 24 months then 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 months then 11, 18, and 24 mo|||||||

Values are presented as number only or number (%)

Clinical Practice Guideline on AAA

Kim et al.

![|Study|Experimental Events|Experimental Total|Control Events|Control Total|RR|95% CI|\n|:---:|:---:|:---:|:---:|:---:|:---:|:---:|\n|Leurs et al. [112], 2005|182|1,538|252|2,895|1.36|[1.14; 1.63]|\n|Jones et al. [113], 2007|75|203|36|99|1.02|[0.74; 1.39]|\n|Sarangarm et al. [114], 2010|48|107|5|19|1.70|[0.78; 3.72]|\n|Waduud et al. [115], 2015|150|301|57|268|2.34|[1.81; 3.03]|\n|Godfrey et al. [116], 2015|11|129|6|50|0.71|[0.28; 1.82]|\n|Wu et al. [117], 2015|29|89|26|99|1.24|[0.79; 1.94]|\n|AbuRahma et al. [118], 2016|43|242|12|284|4.21|[2.27; 7.79]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al. [114], 2010|34|107|2|19|3.02|[0.79; 11.53]|\n|Waduud et al. [115], 2015|3|129|0|50|2.73|[0.14; 51.91]|\n|Godfrey et al. [116], 2015|19|89|13|99|1.63|[0.85; 3.10]|\n|Wu et al. [117], 2015|7|242|16|284|0.51|[0.21; 1.23]|\n|AbuRahma et al. [118], 2016|251|963|94|451|1.25|[1.01; 1.54]|\n|Leurs et al. [112], 2005|111|1,538|156|2,895|1.34|[1.06; 1.69]|\n|Jones et al. [113], 2007|45|203|11|99|2.00|[1.08; 3.69]|\n|Sarangarm et al.\n](1/parseimages/figurea5411a82e82b4723a4609996b36e2459_0_1.png)

2) Sigmoidoscopy

Colon ischemia is a severe early complication following EVAR or OSR and is associated with high morbidity and mortality [120]. Reported prevalence varies widely and ranges from 0.5% to nearly 40% depending on rupture status and detection strategy [120]. Because delayed detection may worsen outcomes, the GWC performed a literature review to evaluate whether routine sigmoidoscopy could reduce related morbidity or mortality. The literature search on complications after AAA repair, including colon ischemia, yielded 1,031 papers from PubMed, EMBASE, Cochrane Central, and KoreaMed, with 15 additional articles identified through reference screening. Among these, eight observational studies were deemed relevant based on full-text review (Table 11) [121-128].

Three of the included studies were prospective [121,122, 127]. In each study, endoscopic evaluation was performed in all patients who survived to the scheduled assessment time (100/107, 105/105, and 41/41, respectively). The reported prevalence of colon ischemia was 9.0% (9 cases), 11.4%

(12 cases), and 22.0% (9 cases). Surgical intervention was required in 3, 0, and 2 patients, respectively. However, none of the studies reported data on overall or disease-specific mortality.

The remaining five studies were retrospective [123-126,128]. Nonetheless, endoscopic examinations were performed in all eligible patients at predefined time points, based on institutional surveillance protocols. The timing varied: four studies performed endoscopy within 24 hours; one study performed endoscopy within 72 hours; one study performed repeat examinations every 12 hours within 2 days; one study performed examinations on postoperative days 2 and 4; and one study performed endoscopy at 3-6 days postoperatively. Repeat examinations were conducted in 2 studies [121,125].

No studies directly compared routine versus symptom-triggered sigmoidoscopy. The reported prevalence of colon ischemia was 13.0% in studies evaluating only OSR (excluding ruptured AAA), 9.0% in studies including some ruptured AAA with OSR only, and 11.4% in studies involving EVAR with some ruptured cases. Among studies restricted

Clinical Practice Guideline on AAA

to ruptured AAA, the prevalence of ischemia varied: 22.0%, 32.8%, and 38.7% in OSR-only studies; 22.2% in EVAR-only cohorts; and 32.3% in studies primarily using EVAR with some OSR cases.

The meta-analysis estimated an overall prevalence of colon ischemia after AAA repair of 21.3% (95% CI, 13.6-30.2%), with 30.7% (95% CI, 25.1-36.6%) in ruptured AAA and 13.0% in non-ruptured AAA (Supplementary Fig. 2). The overall prevalence of ischemia requiring open surgery was 5.5% (95% CI, 1.6-11.1%), including 11.0% (95% CI, 7.3-15.3%) in ruptured AAA and 1.0% in non-ruptured cases.

Given the absence of controlled comparisons, there is insufficient evidence that routine sigmoidoscopy improves overall morbidity or mortality. Therefore, selective sigmoidoscopy guided by the individual's clinical course and symptoms is reasonable. In ruptured AAA, because the risk of colon ischemia is substantially higher, vigilant monitoring and a lower threshold for endoscopic evaluation are warranted.

The level of evidence was rated very low due to the absence of controlled or randomized studies and the potential for bias related to rupture status and baseline patient characteristics.

Recommendation 9. Consider selective use of sigmoid-oscopy to diagnose colon ischemia following OSR of AAAs, guided by the individual's clinical course.

Grade of recommendation: Do, Conditional Level of evidence: Very low

3) Regular imaging surveillance after OSR

Imaging surveillance after OSR aims to detect asymptomatic complications such as para-anastomotic aneurysms (PAA), recurrent aneurysm, late synchronous aneurysms, or disease progression. To date, no high-level evidence supports specific time intervals for surveillance.

A literature search on late complications after abdominal aortic surgery yielded 4,618 papers from major databases, of which 21 relevant observational studies were reviewed (Supplementary Table 2) [51,129-148]. Among these, four retrospective studies reporting the incidence and timing of PAA following OSR were included in the meta-analysis [130,140,141,144]. The estimated cumulative detection rates of PAA through regular imaging surveillance were 0.6% at 5 years (95% CI, 0.2-4%), 2.2% at 10 years (95% CI, 0.1-6.3%), and 4.7% at 15 years (95% CI, 0.6-12.1%) (Supplementary Fig. 3).

Because all included studies were retrospective and generally lacked a comparator group with irregular imaging

|Table 11. Studies reporting the prevalence of colonic ischemia detected by postoperative signoidoscopy after OSR or EVAR or EVAR drombimal aortic aneurysms|Number of VAR|Signoido-Positive colon scopy|Surveillance ischemia sky|Laparotomy time|30-day fortension ischemia sky|NA (%)|NA (%)| |---|---|---|---|---|---|---|---| |Bast et al. [121], 1990|Study type|Study period|107|None|3(3.0)|NA (%)|NA (%)| |Fanti et al. [122], 1997|Prospective|1991-1994|105|17|105(100)|12(11.4)|0(0)| |Champagne et al. [123], 2004|Retrospective Observational|2002-2006|1995-2002|88|88(aill)|62(70.5)|24(38.7) 24(24.0)| |Megalopoulos et al. [125], 2007|Retrospective Observational|1999-2005|44|44|44(aill)|8(22.2)|19(32.2)| |Tottrup et al. [127], 2013|Retrospective Observational|2001-2003|55|55|55|62(all)|3(8.3)| |Uborovius et al. [128], 2020|Denmark Denmark|2010-2011|2010-2011|2010-2011|59(95.2)|3(32.2)|6(10.2)| |Valence are presented as number only or number (%)|Retrospective Observational|2014-2017|2014-2017|None|None|None|1(1.0)| |Variables are presented as number only or number (%)|Retrospective Observational|2014-2017|2014-2017|None|None|None|1(1.0)| |EVAR, endovascular arreunys repair; OSR, OSR, opp, sorg; surgical repair; NA, not assessed; -; not available.||||||||

NA

Kim et al.

intervals, they provide limited evidence for evaluating the true utility of routine surveillance. Accordingly, the level of evidence was rated as very low. CT was the most commonly used follow-up imaging modality, which carries risks such as contrast-induced nephropathy and cumulative radiation exposure. Therefore, imaging surveillance after OSR should be selectively applied based on patient-specific risk factors and surgeon judgment.

Recommendation 10. Consider selective application of imaging surveillance after OSR of AAAs, based on the individual's clinical condition and the surgeon's experience.

Grade of recommendation: Do, Conditional

Level of evidence: Very low

TREATMENT OF POSTOPERATIVE COMPLICATIONS

1) Prosthetic graft infection

Prosthetic graft infection following OSR or EVAR is a serious postoperative complication associated with poor outcomes, including pseudoaneurysm formation, aorto-enteric fistula, septic shock, life-threatening hemorrhage, and death [149,150]. A broad spectrum of bacterial and fungal organisms can cause graft infections, although Gram-positive cocci and enterococci are the most frequently isolated pathogens. Highly virulent organisms, such as Staphylococcus aureus or Pseudomonas aeruginosa, are associated with worse prognosis and higher reinfection rates. In contrast, less virulent skin flora, including Staphylococcus epidermis-dis and corynebacteria, are typically linked to milder clinical courses [151,152]. Diagnosis should follow the Management of Aortic Graft Infection Collaboration (MAGIC) criteria, and microbiologic confirmation of the causative pathogen should be pursued whenever possible [153].

Historically, total graft explanation followed by extra-anatomic bypass was considered the standard treatment due to concerns about persistent infection [154,155]. This approach was supplemented by long-term systemic antibiotic therapy, typically at least 6 weeks but often extended to 3 to 6 months, with some patients requiring lifelong oral antibiotic suppression [154-157]. However, given the high mortality and amputation rates associated with total graft excision and extra-anatomic bypass, there has been a paradigm shift toward alternative strategies, including in situ revascularization, graft excision without revascularization, and partial graft resection [158]. In individuals with high operative risk, conservative approaches with graft pres-ervation and adjunctive procedures such as percutaneous drainage, or omentopexy may be appropriate [159].

The GWC conducted a systematic review to compare mortality outcomes between graft removal and conservative management with graft preservation. The search identified 6,719 publications from PubMed, EMBASE, Cochrane Central, and KoreaMed. After full-text screening, 22 relevant observational studies and one case series were included (Supplementary Table 3) [158,160-181]. Among these, four retrospective studies reporting outcomes for both graft excision and conservative management were included in the meta-analysis (Supplementary Table 3) [162,167,172,179]. It should be noted that the included cohorts were heterogeneous, and some studies also included non-AAA indications (e.g., AIOD) and complex presentations (e.g., aorto-enteric fistula), limiting direct generalizability to all patients after AAA repair.

The meta-analysis showed that within 30 days postoperatively, the pooled RR for mortality in patients undergoing graft removal compared with those managed with graft preservation and antibiotic therapy was 0.98 (95% CI, 0.40-2.38). At 1 year, the RR increased to 3.44 (95% CI, 1.60-7.42) (Fig. 8). Due to the small sample sizes across included studies, pooled mortality estimates were also calculated. Within 30 days, the estimated mortality was 17.4% (95% CI, 12.9%-22.3%) in the graft removal group and 7.1% (95% CI, 0.3%-31.5%) in the graft-preservation with antibiotic therapy group. The estimated cumulative mortality at 1, 2, and 5 years was 28.7%, 36.6%, and 51.8%, respectively, for the graft removal group, and 16.1%, 18.5%, and 50.0%, respectively, for the graft-preservation with antibiotic therapy group (Supplementary Fig. 4). These trends were generally consistent with the direction of effect observed in the meta-analysis, although estimates were imprecise.

Given potential differences in baseline characteristics and center-specific outcomes between treatment strategies, studies were stratified into Group A (reporting outcomes for graft removal only) and Group B (reporting outcomes for both graft removal and graft preservation). The 30-day mortality was 18.1% (95% CI, 14.0%-22.6%) in Group A and 33.5% (95% CI, 12.5%-55.4%) in Group B. One-year mortality was 27.3% (95% CI, 18.4%-37.1%) in Group A and 71.1% (95% CI, 28.1%-99.9%) in Group B. These differences may reflect case-mix severity and/or center-level variation. However, as some studies reported no mortality in either treatment arm and CIs were wide in two studies, it is difficult to determine a consistent effect direction. Therefore, these findings do not provide strong evidence for the superiority of graft removal. Furthermore, due to the small sample sizes and retrospective design of the included studies, the overall quality of evidence was downgraded to very low.

In prosthetic aortic graft infections, the general principle

Clinical Practice Guideline on AAA

![|Study|Experimental Events|Experimental Total|Control Events|Control Total|RR|95% CI|Weight (common)|Weight (random)|\n|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|\n|Cappocci et al. (162), 2016|7|20|3|6|0.70|[0.26; 1.90]|79.4%|63.1%|\n|Dominguez-Cainzos et al. (167), 2023|4|6|0|4|6.23|[0.43; 89.35]|11.2%|19.7%|\n|Maze et al. (172), 2013|0|0|0|17|1.80|[0.10; 32.79]|0.0%|0.0%|\n|Shukuzawa et al. (179), 2019|0|2|1|13|0.98|[0.40; 2.38]|9.4%|17.1%|\n|Common effect model|29|40|0|40|0.98|[0.40; 2.38]|100.0%|--|\n|Random effects model| | | | |1.27|[0.34; 4.75]|--|100.0%|\n|Heterogeneity²: I² = 0.4609, P = 0.29| | | | | | | | |\n|Favors removal ← → Favors conservative treatment| | | | | | | | |\n|Dominguez-Cainzos et al. (167), 2023|4|6|2|4|2.67|[0.45; 15.96]|18.4%|18.4%|\n|Maze et al. (172), 2013|0|0|1|17|2.33|[0.18; 29.51]|9.1%|9.1%|\n|Shukuzawa et al. (179), 2019|2|2|3|13|3.86|[1.57; 9.50]|72.5%|72.5%|\n|Common effect model|9|34|0|34|3.44|[1.60; 7.42]|100.0%|--|\n|Random effects model| | | | |3.44|[1.60; 7.42]|--|100.0%|\n|Heterogeneity²: I² = 0.00, P = 0.89| | | | | | | | |\n](1/parseimages/figuref022458ad3194fd5a539ecf6bf69afbe_0_1.png) of foreign body infection management—device removal—carries substantial operative risk. As such, a patient-centered strategy is essential, considering clinical status, anatomical factors, and infection extent (e.g., graft-enteric fistula), along with institutional experience. If the graft is retained, prolonged antibiotic therapy is necessary, and adjunctive procedures such as drainage should be considered when indicated. As a result, the recommendation strength was rated as Conditional.

Recommendation 11. Graft removal may be considered in cases of prosthetic graft infection following AAA repair, with consideration of non-surgical or conservative management depending on the individual's clinical condition and the surgeon's experience.

Grade of recommendation: Do, Conditional Level of evidence: Very low

2) Type 1 or 3 endoleaks

Endoleaks are defined as persistent blood flow within the aneurysm sac following EVAR [182]. Management should be guided by the endoleak type and its associated risk of sac rupture. Type 1 endoleak represents direct presurization of the aneurysm sac due to an inadequate seal at

the proximal (type 1a) or distal (type 1b) attachment zone of the stent graft. Type 3 endoleak results from component separation or fabric disruption of the endograft. Type 1 and type 3 endoleaks are considered the most dangerous, as they allow systemic pressure to act directly on the aneurosmys wall, increasing the risk of secondary rupture.

The GWC aimed to identify direct evidence regarding the need for reintervention or surgical repair in patients with type 1 or type 3 endoleaks. The available evidence consisted predominantly of small retrospective series, most lacking control groups. Several studies reported favorable outcomes following intervention (endovascular or open repair), but no RCTs compared intervention versus conservative follow-up in these cases.

Some retrospective studies described patients who did not undergo intervention, excluding those whose endoleaks resolved spontaneously. However, most individuals with persistent endoleaks eventually required intervention. The rationale for non-intervention was often unclear, limiting interpretability. Reported reasons included patient refusal, clinical judgment by the treating physician, or minimal endoleak volume.

The literature search on type 1 and type 3 endoleaks following EVAR yielded 5,212 articles from PubMed, EM-BASE, Cochrane Central, and KoreaMed. Among these, 27

Kim et al.

retrospective studies were deemed relevant (Supplementary Table 4) [64,161,183-207]. Of these, 11 studies provided extractable data on rupture, aneurysm sac size, or mortality and were included in the meta-analysis [64,183,184,188,191,192,194,201,202,205,206]. Most were non-comparative studies without control groups and were used to estimate the pooled event rates among cohorts managed with intervention versus observation.

Pooled estimates showed an all-cause mortality rate of 3.6% (95% CI, 0.5-8.6%) in the intervention group (endovascular or surgical treatment) and 36.7% (95% CI, 4.1-76.2%) in the non-intervention group (Supplementary Fig. 5). Aneurysm-related mortality was 3.6% (95% CI, 0.5-8.6%) in the intervention group and 1.1% (95% CI, 0.23.3%) in the non-intervention group. Aneurysm sac enlargement occurred in 13.2% (95% CI, 3.6-26.4%) of individuals receiving intervention and in 28.2% (95% CI, 8.9-51.2%) of those not treated. Rupture was observed in 3.2% (95% CI, 0-9.1%) of the intervention group and 4.4% (95% CI, 0-45.9%) of the non-intervention group.

According to published reviews and expert consensus, persistent type 1 endoleak increases the risk of aneurysm rupture [208]. Therefore, reintervention (endovascular or surgical) is generally advised. Endovascular options include balloon angioplasty, graft extension, intravascular stapling, and embolization, with conversion to open repair considered when endovascular correction is unsuccessful. Type 3 endoleaks result from defects at modular junctions or fabric disruption, typically caused by deployment errors, inadequate overlap, stent migration, or device fatigue. Similar to type 1 endoleaks, they increase intra-aneurysmal pressure and rupture risk. Prompt endovascular repair is advised, with open conversion considered if endovascular correction fails.

Because no randomized or case-control studies were available and the evidence consisted primarily of retrospective series, the recommendation was rated as conditional. The quality of evidence was downgraded to very low, primarily due to potential biases, including variability in intervention timing and inconsistent reporting of endoleak volume across studies.

Recommendation 12. Consider reintervention or surgery in individuals with type 1 or type 3 endoleaks following EVAR of AAAs.

Grade of recommendation: Do, Conditional

Level of evidence: Very low

3) Type 2 endoleak

Type 2 endoleaks, which arise from retrograde flow through collateral vessels, are the most frequently encoun-

tered endoleak following EVAR. Although they are generally considered benign compared to other endoleak types, their clinical relevance remains debated. Some practitioners favor a conservative approach, recommending intervention only when there is clear evidence of aneurysm sac expansion, whereas others advocate earlier treatment to prevent potential complications, including rupture. Spontaneous resolution is common: approximately 60% of early postoperative type 2 endoleaks resolve within six months, and many of the remainder regress over time [209]. Although the relationship between sac enlargement and rupture risk in type 2 endoleaks remains inconclusive, sac rupture has been reported [210]. The decision to intervene for persistent type 2 endoleaks is typically based on diameter increase and growth rate (e.g., ≥5 mm per SVS guidelines; ≥10 mm per ESVS guidelines), as well as inflow and outflow vessel size, patency, and symptom presence [1,182].

The GWC evaluated whether reintervention or surgery could reduce rupture risk in patients with type 2 endoleaks associated with ≥10 mm of aneurysm sac enlargement. The literature search on type 2 endoleaks following EVAR yielded 5,170 articles from PubMed, EMBASE, Cochrane Central, and KoreaMed, with an additional 50 articles identified through reference screening. From these, 172 studies were evaluated for eligibility based on predefined criteria. A total of 40 studies met inclusion criteria, all of which were retrospective observational studies (Supplementary Table 5) [204,207,209,211-247]. None of these studies directly compared aneurysm sac number or rupture risk between patients managed with surveillance alone and those undergoing reintervention, making it difficult to robustly evaluate the RRs and benefits of conservative monitoring versus intervention.

Nonetheless, rupture events associated with sac enlarge-ment due to type 2 endoleaks have been documented. Given the high mortality rate associated with aneurysm rupture, treatment can be considered for type 2 endoleaks accompanied by sac growth. Although not formally included in the analysis, literature reviews examining post-EVAR aortic rupture have reported high mortality (119 deaths among 231 cases, 51.5%).

Evidence regarding the timing of treatment for type 2 endoleaks with aneurysm sac enlargement remains limited. Most studies defined sac enlargement as an increase of ≥5 mm, and data are sparse regarding outcomes using larger thresholds (e.g., ≥10 mm) or absolute sac diameter criteria. Similarly, the optimal treatment strategy remains uncertain. The 40 studies included for analysis were exclusively retrospective, each reporting on different embolization techniques and materials; therefore no single approach could be recommended based on comparative evidence.

Meta-analysis showed that sac enlargement persisted in

Clinical Practice Guideline on AAA

22.6% (95% CI, 13.6%-33.0%) after embolization, with additional endovascular procedures required in 20.9% (95% CI, 13.8%-28.8%), surgical reintervention in 6.1% (95% CI, 2.7%-10.4%), rupture in 0.5% (95% CI, 0%-1.7%), and aneurysm-related mortality in 0.3% (95% CI, 0%-1.6%) (Supplementary Fig. 6). These findings underscore the limitations of current procedural treatments and emphasize the importance of long-term imaging surveillance after intervention.

Reports on surgical treatment for type 2 endoleaks were limited to four studies describing vessel ligation without stent graft exploration. The pooled incidence of aneurysm sac enlargement and additional intervention was 3.8% (95% CI, 0%-13.3%) and 0.1% (95% CI, 0%-5.2%), respectively. However, although only two studies reported major surgical complications, the pooled estimate of major complications was relatively high at 18.0% (95% CI, 5.5%-34.4%). Given the rupture risk associated with type 2 endoleaks and the observation that further sac enlargement was not reported in 77.4% of patients after embolization and 96.2% after surgical vessel closure, treatment can be considered for clinically meaningful sac growth, including growth ≥10 mm, after EVAR.

Because no RCTs or comparative studies were available and the evidence consisted only of retrospective data, the recommendation was graded as conditional. The level of evidence was rated as very low due to concerns about bias, including variability in treatment timing, endoleak volume, and baseline aneurysm size across studies.

Recommendation 13. Consider treatment for type 2 endoleaks associated with aneurysm sac enlargement of 10 mm or more following EVAR of AAAs. Grade of recommendation: Do, Conditional Level of evidence: Very low

4) Type 5 endoleak

Type 5 endoleak, also known as endotension, refers to progressive aneurysm sac enlargement without any demonstrable endokak on imaging. The underlying mechanism is poorly understood; one proposed explanation is increased graft permeability, which permits transmission of systemic pressure to the aneurysm sac wall and results in continued sac pressurization and expansion. It is important to exclude other types of endoleak, as the source may not be detectable using conventional imaging modalities [1]. Similar to type 2 endoleaks, a selective treatment strategy is advised for patients with type 5 endoleak exhibiting significant sac enlargement (ESVS guideline: ≥10 mm) [1].

A literature search was conducted to evaluate whether

reintervention or surgery is warranted in such cases. The search included PubMed, EMBASE, Cochrane Central, and KoreaMed and yielded 5,215 articles. An additional 10 articles were identified through reference screening, of which seven observational studies met inclusion criteria (Supplementary Table 6) [161,180,248-252]. Four studies were single-center reports, with reported rates of type 5 endoleak ranging from 1% to 12% among patients undergoing EVAR depending on definitions, devices, and follow-up duration [161,180,248,250]. One study investigating ruptured aneurysms identified nine cases of type 5 endoleak among 270 patients (3.3%) [252].

In a large cohort study involving 14,817 patients, individuals without detectable endoleaks but with aneurysm sac enlargement had significantly lower survival compared to those without sac growth (HR, 1.6; 95% CI, 1.3-2.1; P<0.001). Among patients without endoleaks, 5-year and 10-year survival rates were 87% and 78%, respectively, for those with sac regression, 86% and 69% for those with stable sac size, and 79% and 61% for those with sac enlargement [251]. Another large cohort study of 6,337 patients without endoleaks stratified individuals by changes in an-eurysm sac size during follow-up compared with baseline preoperative measurements. Freedom from rupture at 7 years was significantly lower in patients with sac enlarge-ment ≥8 mm. While the risk of rupture in this group was <1% during the first 4 years, it increased to 7.5% at 5 years and 13.6% at 7 years [249].

In a single-institution series of 97 endovascular repairs, 12 cases of type 5 endoleak were reported. Three patients were managed conservatively, and nine underwent relining. Notably, no deaths or aneurysm ruptures occurred in either group during follow-up [248].

Among the seven identified studies, six did not directly compare outcomes between conservative management and intervention/surgery for type 5 endoleak. One single-center study divided patients by treatment strategy, but because no deaths or ruptures were observed, meta-analysis was not feasible, and the level of evidence was assessed as very low.

Overall, available evidence suggests that patients with aneurysm sac enlargement without a visible endoleak may have worse survival and a higher risk of rupture than those without sac growth. Therefore, continued imaging surveil-lance is warranted in patients with sac enlargement without a demonstrable endoleak, and individualized reintervention or surgical repair should be considered when rupture risk is judged to be clinically significant. In a survey of external experts, 96.6% (28/29) supported these CPGs, and 100% (29/29) endorsed the assigned recommendation grade. Nevertheless, objective criteria for determining when to initiate reintervention or surgery in cases of aneurysm sac enlarge-

Kim et al.

ment remain insufficiently defined.

Recommendation 14. Consider reintervention or surgery in individuals with a continuous increase in aneurysm size after EVAR of AAAs without detectable endoleaks. Grade of recommendation: Do, Conditional Level of evidence: Very low

MISCELLANEOUS

1) Preservation of internal iliac artery (IIA)

The IIA provides critical blood supply to pelvic structures, including the sigmoid colon, rectum, ovaries, uterus, sacrum, and gluteal muscles. It consists of multiple branches, and collateral circulation is maintained via an extensive pelvic arterial network, which includes contributions from the IMA and the deep femoral artery [253]. Depending on the status of this pelvic collateral network, sacrifice of one or both IIAs can result in varying degrees of ischemic complications, such as buttock claudication, colonic ischemia, pelvic necrosis, or erectile dysfunction [254,255].

A literature review was performed to determine whether preservation of at least one IIA is necessary during AAA repair. The search identified 1,822 articles across PubMed, EMBASE, Cochrane Central, and KoreaMed, focusing on outcomes following IIA embolization or ligation during EVAR or OSR. Among these, 12 observational studies reporting complications from unilateral or bilateral IIA occlusion were included in the meta-analysis (Table 12) [256-267].

The meta-analysis demonstrated that the risk of buttock claudication was higher after bilateral IIA occlusion than after unilateral occlusion (RR, 190; 95% CI, 1.52–2.38). The

RR for ischemic colitis was markedly elevated (RR, 16.81; 95% CI, 4.31-65.53), and the RR for erectile dysfunction was 2.43 (95% CI, 1.72-3.42) (Fig. 9). Additionally, neurological deficits suggestive in spinal cord ischemia were observed in two patients across the included studies, both of whom had bilateral IIA occlusion [256].

In the early 2000s, studies primarily focused the safety of IIA occlusion during EVAR or OSR, regardless of laterality [256-259]. From the late 2000s onward, research increasingly examined outcomes based on occlusion techniques (e.g., Amplatzer plug or coil embolization) and timing, including preoperative versus intraoperative occlusion [260-264]. One study directly compared unilateral and bilateral IIA occlusion [256]. In that study, no cases of buttock ne-crosis or ischemic colitis requiring abdominal surgery were reported in either group. However, persistent buttock claudication occurred in 12% of patients with unilateral occlusion and 11% with bilateral occlusion. Erectile dysfunction was reported in 9% of the unilateral group and 13% of the bilateral group. Mild lower limb neurological deficits were observed in 1.5% of patients with unilateral occlusion.

The individual studies included in the meta-analysis were small and predominantly retrospective and observational, introducing a high risk of bias. Significant heterogeneity in the effect sizes for buttock claudication and erectile dysfunction further limited confidence in the pooled estimates. Additionally, the low incidence and wide Cls for ischemic colitis made it difficult to draw strong conclusions. As such, the overall level of evidence was rated as low. Considering that buttock claudication, erectile dysfunction, and ischemic colitis often improve over time and that neurological complications are rare and typically mild, the recommendation grade was set as conditional.

|Study|Study design|Country|Population (unilateral:bilateral)|Result| |---|---|---|---|---| |Fujioka et al. [266], 2021|Retrospective observational|Japan|27 (19:8)|No direct reference| |Soares et al. [267], 2020|Retrospective observational|Brazil|43 (38:5)|No direct reference| |Kang et al. [261], 2020|Retrospective observational|South Korea|140 (126:14)|Selective use| |Warein et al. [264], 2016|Retrospective observational|France|169 (158:11)|No direct reference| |Chun et al. [265], 2014|Retrospective observational|UK|47 (37:10)|Selective use| |Maleux et al. [262], 2010|Retrospective observational|Belgium|13 (10:3)|No direct reference| |Rayt et al. [263], 2008|Retrospective observational|UK|29 (21:8)|Selective use| |Ha and Calcagno [260], 2005|Retrospective observational|USA|15 (14:1)|No direct reference| |Schoder et al. [259], 2001|Retrospective observational|Austria|46 (36:10)|Selective use| |Mehta et al. [256], 2001|Retrospective observational|USA|154 (134:20)|Selective use| |Karch et al. [258], 2000|Retrospective observational|USA|22 (20:2)|Avoided| |Criado et al. [257], 2000|Retrospective observational|USA|39 (28:11)|Allowed|

Population indicates the number of patients with unilateral or bilateral internal iliac artery (IIA) occlusion/embolization included in the outcome analysis as reported in each study.

Clinical Practice Guideline on AAA

![|Study|Experimental Events|Total|Control Events|Total|RR|95% CI|Weight (common)|Weight (random)|\n|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|\n|Chun et al. [265], 2014|6|10|12|37|1.85|[0.93; 3.68]|10.7%|11.9%|\n|Criado et al. [257], 2000|0|11|5|28|0.23|[0.01; 3.75]|0.6%|1.6%|\n|Fujioka et al. [266], 2021|4|8|4|19|2.38|[0.78; 7.23]|4.1%|7.1%|\n|Ha and Calcagno [260], 2005|0|1|5|14|0.88|[0.08; 9.28]|0.9%|2.2%|\n|Kang et al. [261], 2020|8|14|48|126|1.50|[0.90; 2.49]|19.7%|14.7%|\n|Karch et al. [258], 2000|2|2|5|20|3.73|[1.82; 7.62]|9.9%|11.5%|\n|Maleux et al. [262], 2010|2|3|1|10|6.67|[0.88; 50.47]|1.2%|2.8%|\n|Mehta et al. [256], 2001|2|20|16|134|0.84|[0.21; 3.37]|2.6%|5.1%|\n|Rayt et al. [263], 2008|5|8|16|21|0.82|[0.46; 1.48]|14.6%|13.4%|\n|Schoder et al. [259], 2001|8|10|13|36|2.22|[1.30; 3.78]|17.7%|14.2%|\n|Soares et al. [267], 2020|2|5|0|38|35.00|[1.92; 637.33]|0.6%|1.5%|\n|Warein et al. [264], 2016|7|11|34|158|2.96|[1.73; 5.06]|17.5%|14.2%|\n|Common effect model|103|641| | | |1.90|100.0%|--|\n|Random effects model| | | | | |1.93|--|100.0%|\n](1/parseimages/figure94b2cfedf577483fafa2c7e05d260026_0_1.png) ![|Study|Experimental Events|Experimental Total|Control Events|Control Total|RR|RR|95% CI|Weight (common)|Weight (random)|\n|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|\n|Chun et al. [265], 2014|0|10|0|37|nan|nan|nan|0.0%|0.0%|\n|Ha and Calcatro [260], 2005|0|1|0|14|nan|nan|nan|0.0%|0.0%|\n|Kang et al. [261], 2020|0|14|0|126|nan|nan|nan|0.0%|0.0%|\n|Karch et al. [258], 2000|2|2|1|20|nan|nan|nan|78.0%|78.0%|\n|Mehta et al. [256], 2001|0|20|0|134|nan|nan|nan|0.0%|0.0%|\n|Rayt et al. [263], 2008|0|8|0|21|nan|nan|nan|0.0%|0.0%|\n|Soares et al. [267], 2020|2|5|0|38|nan|nan|nan|22.0%|22.0%|\n|Common effect model|60|390|nan|nan|nan|nan|nan|100.0%|nan|\n|Random effects model|nan|nan|nan|nan|nan|nan|nan|nan|100.0%|\n](1/parseimages/figure0467dc8084034a63b9429447268782e8_0_2.png) ![|Study|Experimental Events|Control Events|RR|RR|95% CI|Weight (common)|Weight (random)|\n|:---:|:---:|:---:|:---:|:---:|:---:|:---:|:---:|\n|Chun et al. [265], 2014|0|10|4|0.40|[0.02; 6.80]|1.5%|1.5%|\n|Criado et al. [257], 2000|0|11|1|0.83|[0.04; 18.83]|1.2%|1.2%|\n|Ha and Calcagno [260], 2005|0|1|0|0.00|[0.00; 14.00]|0.0%|0.0%|\n|Kang et al. [261], 2020|3|14|0|61.07|[3.32; 1,124.32]|1.4%|1.4%|\n|Mehta et al. [256], 2001|2|20|7|1.91|[0.43; 8.58]|5.3%|5.3%|\n|Rayt et al. [263], 2008|3|8|3|2.62|[0.66; 10.41]|6.2%|6.2%|\n|Schoder et al. [259], 2001|10|10|15|2.35|[1.61; 3.44]|83.1%|83.1%|\n|Soares et al. [267], 2020|1|5|0|21.00|[0.97; 453.91]|1.3%|1.3%|\n|Common effect model|79|434|2.43|2.43|[1.72; 3.42]|100.0%|--|\n|Random effects model| | | | | |--|100.0%|\n](1/parseimages/figure4161d077bdb14e938a7ad30fca4b6fc5_0_3.png) Recommendation 15. Consider preserving at least one IIA during OSR or EVAR for AAAs. Grade of recommendation: Do, Conditional Level of evidence: Low

2) IMA reimplantation

Although the overall incidence of bowel ischemia following OSR is relatively low (reported between 2.1% and 3.6%)

Kim et al.

|Study|Experimental Events|Total|Control Events|RR|RR|95% CI| |---|---|---|---|---|---|---| |Gurakar et al. [268], 2019|64|862|497|8,918|1.33|[1.04; 1.71]| |Jayaraj et al. [272], 2020|1|70|4|770|2.75|[0.31; 24.27]| |Lee et al. [271], 2019|3|35|15|637|3.64|[1.11; 11.99]| |Senekowitsch et al. [273], 2006|7|71|16|86|—|0.53| |West et al. [274], 2006|1|8|3|239|9.96|[1.16; 85.55]| |Common effect model||1,046||10,650||1.33| |Random effects model|||||1.77|[0.72; 4.40]| |Heterogeneity: $I^{2}$=64%, $τ^{2}$=0.6681, P=0.02|||||||

ischemic colitis remains one of the most severe complications is associated with high mortality [268]. One proposed mechanism is impaired colonic perfusion due to IMA ligation [269]. The colon is typically supported by a rich collateral network connecting the celiac axis, superior mesenteric artery (SMA), and IMA. These anastomoses can enlarge and form the marginal artery of Drummond, which may supply the entire colon [270]. As a result, many patients remain asymptomatic even in the presence of significant atherosclerosis affecting one or more of these arterial origins. However, the splenic flexure and sigmoid colon are particularly vulnerable to ischemia. Moreover, anatomical studies have shown that the marginal artery of Drummond is absent in approximately 5% of individuals and underdeveloped in up to 50%. Therefore, patients in these subsets are at increased risk for ischemic colitis following IMA ligation.

The spectrum of ischemic colonic injury ranges from superficial mucosal damage to transmural bowel necrosis. Surgical intervention is required in approximately 20% of cases, with mortality rates reaching as high as 67% [271]. To mitigate this risk, IMA reimplantation has been advocated in selected patients based on intraoperative assessments, including colon viability, Doppler signal evaluation, IMA back-bleeding, and IMA stump pressure measurement. However, despite its theoretical rationale, evidence supporting the efficacy of IMA reimplantation in preventing ischemic colitis remains inconclusive.

A literature search on outcomes following OSR yielded 1,401 articles from PubMed, EMBASE, Cochrane Central, and KoreaMed. Of these, seven were deemed relevant through full-text review, comprising four retrospective observational studies, one prospectively assessed study with random assignment, and two case reports (Supplementary Table 7) [268,271-276].

One study assessing colonic ischemia as a primary outcome reported an adjusted OR of 1.41 (P<0.05) for colonic ischemia when the IMA was reimplanted, identifying ad-

advanced age, congestive heart failure, aneurysm rupture, blood transfusion, transperitoneal approach, upper abdominal aortic clamping, and IMA reimplantation itself as independent risk factors [268]. Another study reported a higher incidence of colonic ischemia in the IMA reimplantation group than in the ligation group (8.6% vs. 2.4%, P=0.027) [271]. Conversely, some reports suggested that IMA reimplantation may help prevent colonic ischemia in selected settings where collateral supply is inadequate [275]. However, a meta-analysis of five studies evaluating in-hospital colonic ischemia found no statistically significant difference between IMA reimplantation and ligation (RR, 1.77; 95% CI, 0.72-4.40) (Fig. 10).

Regarding short-term survival, two studies reported 30-day mortality. In one study, 30-day mortality was 4.2% with reimplantation and 6.9% with ligation (RR, 0.60; 95% CI, 0.15-2.30; P=0.511). In another study, 30-day mortality was 5.7% with reimplantation and 3.1% with ligation (P=0.320), again showing no statistically significant difference [271,273]. Operative duration associated with IMA reimplantation was reported in one study and was significantly longer with reimplantation (319.7±117.8 minutes) than with ligation [242.4±109.3 minutes) (P<0.001) [271].

Overall, evidence remains insufficient to conclude that IMA reimplantation independently reduces colonic ischemia or improves survival. Colonic perfusion is primarily supported by both the SMA and IMA, which are interconnected via the arc of Riolan. Moreover, when both IAs are patent, additional pelvic collaterals may also contribute. In this context, routine IMA reimplantation may prolong operative time without proven benefit. Several studies indicate that postoperative bowel ischemia is more strongly influenced by hemodynamic instability (including cardiogenic shock) than by IMA reimplantation [276]. Other contributing factors include advanced age, congestive heart failure, rupture status, transfusion volume, surgical approach, and duration of supraceliac clamping [268].

Clinical Practice Guideline on AAA

Therefore routine IMA reimplantation is not recommended. However, selective IMA reimplantation may be considered based on preoperative imaging (collateral adequacy and patency of relevant collaterals), hemodynamic status, and intraoperative findings such as IMA back-bleeding and colonic perfusion during aortic clamping.

The level of evidence was assessed as low, given the limited comparative evidence, inclusion of studies with high risk of bias, and the predominance of retrospective designs.

Recommendation 16. Consider reimplantation of the IMA during OSR of AAAs based on anatomical factors and surgeon preference.

Grade of recommendation: Do, Conditional

Level of evidence: Low

3) Retroperitoneal approach for inflammatory AAA or horseshoe kidney (HK)

Surgical access to the aorta is broadly categorized as transperitoneal or retroperitoneal. The transperitoneal approach via a midline laparotomy remains the most commonly employed technique due to its flexibility and ease of access to abdominal organs [1]. However, the retroperitoneal approach offers superior exposure to the juxtaprenal and suprarenal aorta and may help avoid technical challenges inherent to the transperitoneal route, particularly in cases involving a hostile abdomen or a HK [277].

A literature review was conducted to evaluate whether the retroperitoneal approach is more appropriate for individuals with inflammatory AAA or HK. Regarding HK, the search identified 4,137 papers on surgical approaches for AAA after excluding duplicates (PubMed, EMBASE, and Cochrane Central). Of these, 117 case reports specifically described either transabdominal or retroperitoneal approaches were included (Supplementary Table 8) [278-394].

A total of 220 patients were included, among whom 38 presented with ruptured aneurysms; all underwent transperitoneal repair via midline laparotomy. Among the 182 patients with non-ruptured aneurysms, four procedures were aborted because of extensive adhesions, and two cases involved aneurysms wrapping. The remaining 176 patients underwent aneurysm resection and aortic reconstruction using straight or Y-shaped prosthetic grafts. Of these, 24 procedures employed a retroperitoneal approach, including four that required thoracotomy. Notably, none of the retroperitoneal cases required division of the HK, and no perioperative deaths were reported.

Among the patients managed through the transperitoneal route, two required conversion involving midline laparotomy followed by medial retraction of the left colon and

kidney to gain retroperitoneal access. In the transperitoneal group, 46 patients (30.9%, 46/149) required HK separation (excluding five who underwent unilateral nephrectomy due to renal cell carcinoma), and no complications were attributed to HK separation. Complications occurred in 23 patients (14.9%) treated via the transperitoneal approach, including renal dysfunction necessitating hemodialysis (n=6), acute myocardial infarction (n=2), intestinal ischemia (n=3), lower limb or graft occlusion (n=5), ureteral obstruction (n=1), and pneumonia (n=3). Among those who underwent a retroperitoneal approach, three patients (12.5%) experienced complications: renal dysfunction not requiring hemodialysis (n=2), and intestinal ischemia (n=1).

The mortality rate following transperitoneal approach was 3.9% (6/154), with causes including acute myocardial infarction in two patients, renal failure and coagulopathy in one patient, and unspecified causes in three. In contrast, no deaths were reported among patients treated via a retroperitoneal approach; however, the small number of retroperitoneal cases limits firm conclusions regarding comparative mortality.

With respect to surgical management of inflammatory AAAs, 4,114 publications were screened from PubMed, EMBASE, and Cochrane Central after removing duplicates. Two observational studies were eligible for meta-analysis (Supplementary Table 9) [395,396].

In the study by Fiorani et al. [395], 45 patients underwent OSR for inflammatory AAAs over a 12-year period: 39 underwent transperitoneal midline laparotomy, four underwent left retroperitoneal approach, and two underwent thoracoabdominal approach. In the transperitoneal group, intraoperative injuries occurred in two patients (left renal vein injury and duodenal injury), and postoperative complications were reported in six patients; three (7.7%) died within 1 month of surgery. In the study by Todd and DeRose [396], 12 patients with inflammatory AAAs underwent OSR by a single surgeon over 7 years. Five underwent transperitoneal repair, six underwent retroperitoneal repair, and one required intraoperative conversion from transperitoneal to retroperitoneal due to anatomical constraints. One duodenal injury occurred in the transperitoneal group, and no deaths were reported in either group.

The meta-analysis demonstrated an RR of 0.41 (95 % Cl, 0.06-3.02) for perioperative complications after a retroperitoneal approach and an RR of 1.14 (95 % Cl, 0.07-19.05) for mortality, neither reaching statistical significance (Fig. 11).

Current evidence guiding the choice of surgical access in patients with HK is limited to case reports, and no randomized or adequately powered comparative studies exist for inflammatory AAAs. Consequently, selection of a transperitoneal or retroperitoneal approach should be based on

Kim et al.

|Study or subgroup|Retroperitoneal Events|Transperitoneal Events|Total|Weight|RR M-H, fixed, 95% CI|RR M-H, fixed, 95% CI| |---|---|---|---|---|---|---| |Fiorani et al. [395], 1991|0|4|7|39|50.8%|0.53 [0.04, 8.00]| |Todd and DeRose [396], 1995|0|6|1|5|49.2%|0.29 [0.01, 5.79]| |Total (95% CI)|0|10||44|100.0%|0.41 [0.06, 3.02]| |Total events:|0||8|||| |Heterogeneity: $Chi^{2}$=0.09, df=1 (P=0.76); $I^{2}$=0%||||||| |Test for overall effect: Z=0.87 (P=0.38)||||||| |Test for subgroup differences: not applicable|||||||

|Study or subgroup|Retroperitoneal Events|Transperitoneal Events|Total|Weight|RR M-H, fixed, 95% CI|RR M-H, fixed, 95% CI| |---|---|---|---|---|---|---| |Fiorani et al. [395], 1991|0|4|3|39|100.0%|1.14 [0.07, 19.05]| |Todd and DeRose [396], 1995|0|6|0|5|Not estimable|| |Total (95% CI)||10||44|100.0%|0.01 [0.07, 19.05]| |Total events:|0||3|||| |Heterogeneity: not applicable||||||| |Test for overall effect: Z=0.09 (P=0.93)||||||Favours| |Test for subgroup differences: not applicable|||||||

patient-specific anatomy and surgeon experience. Owing to substantial risk of bias, the overall quality of evidence was graded very low.

Recommendation 17. When performing OSR for inflammatory AAAs or those associated with complex abdominal pathology (e.g., HK), the surgical approach (retroperitoneal or transperitoneal) should be determined based on anatomical factors and surgeon preference.

Grade of recommendation: Do, Conditional

Level of evidence: Very low

4) Permissive hypotension in ruptured AAA

The concept of permissive hypotension was first introduced by Cannon et al. [397] in 1918 as a fluid resuscitation strategy for trauma patients with major hemorrhage, advocating maintenance of subnormotensive blood pressure during initial resuscitation. This principle has since been applied in the management of ruptured AAA (rAAA), primarily to minimize ongoing bleeding and avoid disruption of early hemostasis before proximal control is achieved.

A literature search on preoperative permissive hypotension in rAAA patients yielded 1,039 articles from PubMed, EMBASE, Cochrane Central, and KoreaMed. No RCTs or meta-analyses specifically addressing rAAA were available, largely due to the absence of comparative groups using nor-motensive resuscitation or the inability to extract mortality

data. Given the logistical and ethical challenges inherent in studying critically unstable patients in prehospital or intraoperative settings, the study group recognized the limitations of conducting such trials. Therefore, trauma evidence was considered alongside the limited rAAA-specific observational data. After screening, eight studies were ultimately included (Table 13) [398–405]. Of these, two evaluated patients with rAAA, whereas the remaining six were trauma studies involving hemorrhagic shock and were used as indirect (surrogate) evidence.

Two studies specifically examined fluid resuscitation strategies in patients with rAAA [400,403]. Dick et al. [400] found that aggressive fluid resuscitation prior to proximal aortic control was associated with higher postoperative mortality, even when accounting for blood pressure as a confounding factor. In another study, Li et al. [403] observed that both hypertension (systolic blood pressure (SBP) >140 mmHg) and severe hypotension (SBP <70 mmHg) during interhospital transfer were independently associated with increased 30-day mortality, indicating that resuscitation should focus on avoiding these extremes of blood pressure.

In trauma literature, controlled resuscitation strategies have been associated with reduced transfusion requirements and, in some analyses, lower mortality. A meta-analysis of trauma studies demonstrated lower postoperative mortality in the controlled hypotension group compared to standard resuscitation (RR, 0.76; 95% CI 0.62-0.92) (Sup-

Clinical Practice Guideline on AAA

|Study|Country|Study type|Population|Number|Intervention vs. control| |---|---|---|---|---|---| |Bickell et al. [398], 1994|USA|Randomized controlled|Penetrating torso injury|598|No resuscitation for SBP <90 mmHg vs. immediate resuscitation for target SBP >100 mmHg| |Carrick et al. [399], 2016|USA|Randomized controlled|Torso injury|168|MAP >50 mmHg vs. MAP >65 mmHg| |Dick et al. [400], 2013|Swiss|Retrospective observational|Ruptured AAA|248|Volume resuscitation below median vs. above median| |Dutton et al. [401], 2002|USA|Prospectively randomized|Active hemorrhage|110|Maintain SBP of 70 mmHg vs. SBP >100 mmHg| |Morrison et al. [402], 2011|USA|Randomized controlled|Patients with hemorrhagic shock|90|Maintain MAP >50 mmHg vs. Maintain MAP >65 mmHg| |Li et al. [403], 2022|USA|Retrospective observational|Ruptured AAA|271|No specific intervention. Analyzed outcome according to the blood pressure during transfer| |Lu et al. [404], 2018|China|Randomized controlled|Patients with hemorrhagic shock|164|Maintain MAP 40-50 mmHg vs. MAP 60-80 mmHg| |Schreiber et al. [405], 2015|USA and Canada|Randomized controlled|Patients with hemorrhagic shock|186|Maintain SBP >50 mmHg vs. SBP >110 mmHg|

AAA, abdominal aortic aneurysm; SBP, systolic blood pressure; MAP, mean arterial pressure.

plementary Fig. 7). However, extrapolation to rAAA requires caution because trauma cohorts typically include younger individuals with fewer comorbidities than patients with rAAA, and the physiologic context differs substantially.

In summary, direct evidence in rAAA is limited, and available data support avoiding both severe hypotension and hypertension during initial resuscitation and transfer. Given the reliance on indirect evidence from trauma literature and the lack of robust data specifically addressing rAAA, the recommendation was graded as conditional, and the level of evidence was rated as very low.

Recommendation 18. Consider permissive hypotension during resuscitation prior to surgery for ruptured AAAs.

Grade of recommendation: Do, Conditional

Level of evidence: Very low

FUNDING

None.

SUPPLEMENTARY MATERIALS

Supplementary data can be found via https://doi.org/10.5758/vsi.250023

CONFLICTS OF INTEREST

Sanghyun Ahn, Hyunmin Ko, and Shin-Seok Yang has

been the editorial board member of the VSI since 2019. They were not involved in the review process. Otherwise, no potential conflict of interest relevant to this article was reported.

ORCID

Hyangkyoung Kim https://orcid.org/0000-0002-2021-815X Ahram Han https://orcid.org/0000-0002-3866-5214 Minsu Noh https://orcid.org/0000-0002-2975-2500 Kyunghak Choi https://orcid.org/0000-0001-8273-2093 Sang Jun Park https://orcid.org/0000-0001-8112-6331 Sanghyun Ahn https://orcid.org/0000-0003-4308-4788 Chanjoong Choi https://orcid.org/0000-0002-7116-2619 Miju Bae https://orcid.org/0000-0003-1555-4113 Shin-Seok Yang https://orcid.org/0000-0003-4957-3080 Sungsin Cho https://orcid.org/0000-0003-2502-4204 Hyunmin Ko https://orcid.org/0000-0002-5078-6860

Kim et al.

Hyokee Kim https://orcid.org/0000-0002-0332-2326Eol Choi https://orcid.org/0000-0003-0576-9524Eunae Byunhttps://orcid.org/0000-0002-0130-5549Woo-Sung Yunhttps://orcid.org/0000-0002-7472-8067KangWoong Junhttps://orcid.org/0000-0002-0055-1115

AUTHOR CONTRIBUTIONS

Concept and design: SJP. Analysis and interpretation: Hyangkyoung Kim, AH, KC, SJP, SA, CC, SSY, SC, Hyunmin Ko, Hyokee Kim, EC, EB, WSY, KWJ. Data collection: Hyangkyoung Kim, AH, KC, SJP, SA, CC, SSY, SC, Hyunmin Ko, Hyogi Kim, EC, EB, WSY, KWJ. Writing the article: Hyangkyoung Kim. Critical revision of the article: SJP. Final approval of the article: all authors. Statistical analysis: Hyangkyoung Kim, AH, KC, SJP, SA, CC, SSY, SC, Hyunmin Ko, Hyokee Kim, EC, EB, WSY, KWJ. Obtained funding: none. Overall responsibility: SJP.

REFERENCES

1) Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, et al. Editor's choice -- European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg 2024;67:192-331. https://doi.org/10.1016/j.ejvs.2023.11.002

2) Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK small aneurysm trial participants. Ann Surg 1999;230:289-296; discussion 296-297. https://doi.org/10.1097/00000658-199909000-00002

3) Kim H, Kwon TW, Choi E, Jeong S, Kim HK, Han Y, et al. Aortoiliac diameter and length in a healthy cohort. PLoS One 2022;17:e0268077. https://doi.org/10.1371/journal.pone.0268077

4) Johnston KW, Rutherford RB, Tilson MD, Shah DM, Hollier L, Stanley JC. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991;13:452-458. https://doi.org/10.1067/mva.1991.26737

5) Cao P, De Rango P, Verzini F, Parlani G, Romano L, Cieri E, et al. Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from a randomised trial. Eur J Vasc Endovasc Surg 2011;41:13-25. https://doi.org/10.1016/j.ejvs.2010.08.026

6) The UK Small Aneurysm Trial Participants. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998;352:1649-1655. https://doi.org/10.1016/S0140-6736(98)10137-X

7. Lederle FA, Wilson SE, Johnson GR, Reinke DB, Littooy FN, Acher CW, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002:346:1437-1444. https://doi.org/10.1036/NEJMoa012573

8) Ouriel K, Clair DG, Kent KC, Zarins CK; Positive Impact of Endovascular Options for treating Aneurysms Early (PIVOTAL) Investigators. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms. J Vasc Surg 2010;51:1081-1087. https://doi.org/10.1016/j.jvs.2009.10.113 9) Taylor BV, Kalman PG. Saccular aortic aneurysms. Ann Vasc Surg 1999;

13:555-559. https://doi.org/10.1007/s100169900297 10) Kristmundsson T, Dias N, Resch T, Sonesson B. Morphology of small abdominal aortic aneurysms should be considered before continued ultrasound surveillance. Ann Vasc Surg 2016;31:18-22. https://doi.org/10.1016/j.avsg.2015.09.016

11) Karthaus EG, Tong TML, Vahl A, Hamming JF. Saccular abdominal aortic aneurysms: patient characteristics, clinical presentation, treatment, and outcomes in the Netherlands. Ann Surg 2019;270:852-858. https://doi.org/10.1097/sla.0000000000003529

12) Shang EK, Nathan DP, Boonn WW, Lys-Dobradin IA, Fairman RM, Woo EY, et al. A modern experience with saccular aortic aneurysms. J Vasc Surg 2013;57:84-88. https://doi.org/10.1016/j.jvs.2012.07.002

13) Mizoguchi T, Morikage N, Takeuchi Y, Nagase T, Samura M, Harada T, et al. Treatment results of endovascular aneurysm repair using the parallel stentgraft double D technique for distal saccular abdominal aortic aneurysms and common iliac aneurysms. Ann Vasc Surg 2021;71:392-401. https://doi.org/10.1016/j.avsg.2020.07.048

[4] Yoshida RA, Costa RF, Cunha DO, Palhares RM, Jaldin RG, Sobreira ML, et al. Unibody design for aortic dis-

Clinical Practice Guideline on AAA

ease with a narrow aortic bifurcation: tips and tricks for success. J Vasc Bras 2021;20:e20200230. https://doi.org/10.1590/1677-5449.200230 15) Blecha M, Crisostomo P, Bechara C. Saccular aneurysm of the infra-renal aorta inducing ureteral ob-struction. J Vasc Surg Cases Innover Tech 2021;7:157-158. https://doi.org/10.1016/j.jvscit.2020.11.006 16) Bornak A, Milner R. Endovascular ex-clusion of a saccular aortic aneurysm using a septal occluder device. J Vasc Surg 2011;53:1097-1099. https://doi.org/10.1016/j.jvsc.2010.11.054 17) Brake MA, Shalhoub J, Crane JS, Gibbs RG, Franklin IJ. Investigation and treatment of a complicated in-flammatory aortoiliac aneurysm. Vasc Endovascular Surg 2012;46:190-194. https://doi.org/10.1177/1538574411 433289 18) D'Oria M, Pipitone M, Riccitelli F, Mastrorilli D, Calvagna C, Zamolo F, et al. Custom-made unibody conical endografts for elective endovascular repair of saccular infrarenal abdominal aortic aneurysms with narrow aortic bifurcations-novel implementation of the aortoaortic concept. Ann Vasc Surg 2019;59:309.e5-309.e10. https://doi.org/10.1016/j.avsg.2018.12.102 19) Ducos C, de Lambert A, Pirvu A, Co-chet E, Sessa C, Magne JL. Endovas-cular treatment of aortic and primi- tive iliac artery aneurysms associated with Behcet disease. Ann Vasc Surg 2013;27:497.e5-497.e8. https://doi.org/10.1016/j.avsg.2012.07.014 20) Georgakarakos E, Argyriou C, Schoret-sanitis N, Georgiadis GS. Custom-made conical endograft in the treatment of saccular abdominal aortic aneurysms with tight and calcified distal neck: thinking out of the box. Ann Vasc Surg 2017;39:291.e15-291.e19. https://doi.org/10.1016/j.avsg.2016.08.018 21) Hans SS, Khoury MD, Bove P. Techni- cal considerations in endovascular repair of large symptomatic iliac anastomotic aneurysms. Ann Vasc

Surg 2007;21:376-379. https://doi.org/10.1016/j.avsg.2006.06.012 23) Khalid N, lantorno M, Shlofmitz E, Hashim H, Waksman R, Bernardo N. Kissing intravascular lithotripsy facilitated endovascular repair of a complex saccular abdominal aortic aneurysm with narrowed distal aorta: a first-in-human report. JACC Cardiovasc Interv 2019;12:e97-e99. https://doi.org/10.1016/j.jcin.2019.03.013 23) Mendonça CT, de Carvalho CA, Weingartner J, de Melo Costa DS, Shiomi AY. The use of a self-expandable aortic stent to incarcerate microcoils and to create a favourable infrarenal neck in an unusual case of endovascular abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2013;45:465-467. https://doi.org/10.1016/j.ejvs.2013.01.040 24) Minor ME, Menzoian JO, Raffetto JD. Noninfectious saccular abdominal aortic aneurysm--a report of two cases. Vasc Endovascular Surg 2003;37:353-358. https://doi.org/10.1177/153857440303700507 25) Nagel S, Katsargyris A, Oikonomou K, Verhoeven EL. Hybrid treatment of a suprarenal aortic aneurysm with an infrarenal aortic borfemoral surgical graft and a fenestrated stent graft. Ann Vasc Surg 2017;39:290.e11-290. e15. https://doi.org/10.1016/j.avsg.2016.07.076 26) Ng NZP, Chong TT. Endovascular aneurysm repair [EVAR] of an infrarenal abdominal aortic aneurysm (AAA) in a young patient with systemic lupus erythematosus (SLE). EJVES Short Rep 2017;37:8-11. https://doi.org/10.1016/j.ejvss.2017.09.003 27) Owen RP, Chan C. Saccular abdominal aortic aneurysm: clear cause of exquisite back pain. BMJ Case Rep 2012;2012:bcr2012006327. https://doi.org/10.1016/j.avsg-2012-006327 28) Umscheid T, Stelter WJ. Endovascular treatment of an aortic aneurysm ruptured into the inferior vena cava. J Endovasc Ther 2000;7:31-35. https://

doi.org/10.1177/152660280000700105 [29] Zhang YX, Lu QS, Jing ZP. Innovative sandwich technique in treating a symptomatic saccular suprarenal aneurysm involving the celiac trunk. Vasc Endovascular Surg 2013; 47:102-105. https://doi.org/10.1177/1538574412471210 [30] Metzger PB, Costa KR, Metzger SL, de Almeida LC. Endovascular treatment of aortic saccular aneurysms associated with Adamantiades-Behçet disease. J Vasc Bras 2021;20:e20200201. https://doi.org/10.1590/1677-5449.200201 [31] Papageorgopoulou CP, Nikolakopoulos KM. Eccentric saccular aneurysm formation of the infrarenal aorta from an arterial wall tear. Radiol Case Rep 2021;16:1854-1856. https://doi.org/10.1016/j.radcr.2021.04.046 [32] Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018;67:2-77. e2. https://doi.org/10.1016/j.jvs.2017.10.044 [33] Cambria RA, Glyiczki P, Stanson AW, Cherry KJ Jr, Hallett JW Jr, Bower TC, et al. Symptomatic, nonruptured abdominal aortic aneurysms: are emergent operations necessary? Ann Vasc Surg 1994;8:121-126. https://doi.org/10.1007/bf02018859 [34] Chandra V, Trang K, Virgin-Downey W, Tran K, Harris EJ, Dalman RL, et al. Management and outcomes of symptomatic abdominal aortic aneurysms during the past 20 years. J Vasc Surg 2017;66:1679-1685. https://doi.org/10.1016/j.jvs.2017.04.033 [35] Haug ES, Romundstad P, Aadahl P, Myhre HO. Emergency non-ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2004;28:612-618. https://doi.org/10.1016/j.ejvs.2004.09.013 [36] Johnson G Jr, McDevitt NB, Proctor HJ, Mandel SR, Peacock JB. Emergent or elective operation for

Kim et al.

symptomatic abdominal aortic aneurysm. Arch Surg 1980;115:51-53. https://doi.org/10.1001/archsurg.1980.01380010043008 37) Leo E, Biancari F, Kechagias A, Ylönen K, Rainio P, Romsi P, et al. Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: results in 42 patients and review of the literature. Scand Cardiovasc J 2005;39:91-95. https://doi.org/10.1080/14017403410016422 38) Soisalon-Soininen S, Salo JA, Perhoniemi V, Mattila S. Emergency surgery of non-ruptured abdominal aortic aneurysm. Ann Chir Gynaecol 1999; 88:38-43. 39) Sullivan CA, Rohrer MJ, Cutler BS. Clinical management of the symptomatic but unruptured abdominal aortic aneurysm. J Vasc Surg 1990;11:799-803. https://doi.org/10.1016/0741-5214 (90)90076-M 40) Tambyraja AL, Raza Z, Stuart WP, Murie JA, Chalmers RT. Does immediate operation for symptomatic non-ruptured abdominal aortic aneurysm compromise outcome? Eur J Vasc Endovasc Surg 2004;28:543-546. https://doi.org/10.1016/j.ejvs.2004.06.017 41) De Martino RR, Nolan BW, Goodney PP, Chang CK, Schanzer A, Cambria R, et al.; Vascular Study Group of Northern New England. Outcomes of symptomatic abdominal aortic aneurysm repair. J Vasc Surg 2010;52:5-12.e1. https://doi.org/10.1016/j.jvs.2010.01.095 42) Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, et al. Editor's choice - European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg 2019;57:8-93. https://doi.org/10.1016/j.ejvs.2018.09.020 43) Kim H, Kwon TW, Cho YP, Gwon JG, Han Y, Lee SA, et al. Treatment of abdominal aortic aneurysms in Korea: a nationwide study. Ann Surg

Treat Res 2023;105:37-46. https://doi.org/10.4174/astr.2023.105.1.37 44 Cuypers PW, Gardien M, Buth J, Peels CH, Charbon JA, Hop WC. Randomized study comparing cardiac response in endovascular and open abdominal aortic aneurysm repair. Br J Surg 2001;88:1059-1065. https://doi.org/10.1046/j.0007-1323.2001.01834. x 45 Lottman PE, Laheij RJ, Cuypers PW, Bender M, Buth J. Health-related quality of life outcomes following elective open or endovascular AAA repair: a randomized controlled trial. J Endovasc Ther 2004;11:323-329. https://doi.org/10.1583/03-1141.1 46 Lederle FA, Freischlag JA, Kyriakides TC, Padberg FT Jr, Matsumura JS, Kohler TR, et al.; Open Versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study Group. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA 2009;302:1535-1542. https://doi.org/10.1001/jama.2009.1426 47 Soulez G, Thérasse E, Monfared AA, Blair JF, Choinière M, Elkouri S, et al. Pain and quality of life assessment after endovascular versus open repair of abdominal aortic aneurysms in patients at low risk. J Vasc Interv Radiol 2005;16:1093-1100. https://doi.org/10.1097/01.rvi.0000167858.16223. d5 48 Becquemin JP, Pillet JC, Lescalie F, Sapoval M, Goueffic Y, Lermusiaux P, et al.; ACE trialists. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011;53:1167-1173.el. https://doi.org/10.1016/j.jvs.2010.10.124 49 van Schaik TG, Yeung KK, Verhagen HJ, de Bruin JL, van Sambeek MRHM, Balm R, et al.; DREAM trial participants. Long-term survival and secondary procedures after open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2019;380:2126-2135. https://doi.org/10.1016/j.jvs.2010.10.124

aneurysms. J Vasc Surg 2017;66:1379-1389. https://doi.org/10.1016/j.jvs.2017.05.122 50) Patel R, Sweeting MJ, Powell JT, Greenhalgh RM; EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm in 15-years' follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet 2016;388:2366-2374. https://doi.org/10.1016/s0140-6736(16)31135-7 51) De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven EL, Cuypers PW, et al.; DREAM Study Group. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1881-1889. https://doi.org/10.1056/nejmoa0909499 52) Lederle FA, Freischlag JA, Kyriakides TC, Matsumura JS, Padberg FT Jr, Kohler TR, et al.; OVER Veterans Affairs Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med 2012;367:1988-1997. https://doi.org/10.1056/nejmoa1207481 53) Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, et al.; Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 54) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 55) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 56) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 57) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 58) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 56) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 57) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 58) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 58) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 59) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 58) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 59) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 59) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 59) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 59) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr, Matsumura JS, et al.; OVER Veterans Affairs Cooperative Study Group. N Engl J Med 2004;351:1607-1618. https://doi.org/10.1056/nejmoa042002 59) Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. https://doi.org/10.1056/nejmoa0909305 59) Greenhalgh RM, Brown LC, Sulberd A, Beth J, B, C, D, M, B, C, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M, D, M,

Clinical Practice Guideline on AAA

org/10.1056/nejmoa1715955 56) Li B, Khan S, Salata K, Hussain MA, de Mestral C, Greco E, et al. A systematic review and meta-analysis of the long-term outcomes of endovascular versus open repair of abdominal aortic aneurysm. J Vasc Surg 2019;70:954-969. e30. https://doi.org/10.1016/j.jvjs.2019.01.076 57) Arenas Azofra E, Rey VM, Marcos FÁ, Al-Sibbai AZ, García FV, Pérez MA. Results of transarterial embolization for treating type 2 endoleaks: a single-center experience. Ann Vasc Surg 2020;66:104-109. https://doi.org/10.1016/j.avsg.2019.05.020 58) Bae M, Chung SW, Lee CW, Song S, Kim E, Kim CW. A comparative study of abdominal aortic aneurysm: endovascular aneurysm repair versus open repair. Korean J Thorac Cardiovasc Surg 2017;50:263-269. https://doi.org/10.5090/kjtcs.2017.50.4.263 59) Gallitto E, Faggioli G, Mascoli C, Spath P, Pini R, Ricco JB, et al. Long-term efficacy of EVAR in patients aged less than 65 years with an infrarenal abdominal aortic aneurysm and favorable anatomy. Ann Vasc Surg 2020;67:283-292. https://doi.org/10.1016/j.avsg.2020.03.038 60) Lee K, Tang E, Dubois L, Power AH, DeRose G, Forbes TL. Durability and survival are similar after elective endovascular and open repair of abdominal aortic aneurysms in younger patients. J Vasc Surg 2015;61:636-641. https://doi.org/10.1016/j.jvjs.2014.01.012 61) Schmid BP, Polsin LLM, Menezes FH. Dilatation of aortic neck and common iliac arteries after open repair of abdominal aortic aneurysms: long-term follow-up according to aortic reconstruction configuration. Ann Vasc Surg 2020;69:345-351. https://doi.org/10.1016/j.avsg.2020.05.051 62) Reitz KM, Liang NL, Xie B, Makaroun M, Tzeng E. Inferior mid-term dura-bility with comparable survival for younger patients undergoing elective endovascular infrarenal versus open

abdominal aortic aneurysm repair. Ann Vasc Surg 2020;64:143-150.e1. https://doi.org/10.1016/j.avsg.2019.10.039 63) Abdulrasak M, Sonesson B, Singh B, Resch T, Dias NV. Long-term outcomes of infrarenal endovascular aneurysm repair with a commercially available stent graft. J Vasc Surg 2020;72:520-530.e1. https://doi.org/10.1016/j.jvs.2019.09.061 64) Ballotta E, Da Giau G, Bridda A, Gruppo M, Pauletto A, Martella B. Open abdominal aortic aneurysm repair in octogenarians before and after the adoption of endovascular grafting procedures. J Vasc Surg 2008;47:23-30. https://doi.org/10.1016/j.jvs.2007.08.054 65) Bastos Gonçalves F, Verhagen HJ, Va-santhananthan K, Zandvoort HJ, Moll FL, van Herwaarden JA. Spontaneous delayed sealing in selected patients with a primary type-la endoleak after endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2014;48:53-59. https://doi.org/10.1016/j.jejs.2014.01.018 66) Charbonneau P, Hongku K, Herman CR, Habib M, Girsowicz E, Doonan RJ, et al. Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular aneurysm repair. J Vasc Surg 2019;70:1823-1830. https://doi.org/10.1016/j.jvs.2019.01.08 67) Gennai S, Andreoli F, Saitta G, Leone N, Migliari M, Covic T, et al. Two decades of abdominal aortic endovascular repair with the anatomical fixation at the aortic bifurcation in a large single-center experience. J Endovasc Ther 2022;29:42-56. https://doi.org/10.1177/15266028211030537 68) Iwakoshi S, Ichihashi S, Higashiura W, Itoh H, Sakaguchi S, Tabayashi N, et al. A decade of outcomes and predictors of sac enlargement after endovascular abdominal aortic aneurysm repair using zenith endografts in a Japanese population. J Vasc Interv

Radiol 2014;25:694-701. https://doi.org/10.1016/j.jvir.2014.01.017 69) Oliveira-Pinto J, Oliveira NFG, Bastos-Gonçalves FM, Hoeks S, Rijn MJV, Raa ST, et al. Long-term results after standard endovascular aneurysm repair with the Endurant and Excluder stent grafts. J Vasc Surg 2020;71:64-74. https://doi.org/10.1016/j.jvjs.2019.03.039 70) Patel R, Powell JT, Sweeting MJ, Epstein DM, Barrett JK, Greenhalgh RM. The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis. Health Technol Assess 2018;22:1-132. https://doi.org/10.3310/hta22050 71) Salata K, Hussain MA, de Mestral C, Greco E, Aljabri BA, Mamdani M, et al. Comparison of outcomes in elective endovascular aortic repair vs open surgical repair of abdominal aortic aneurysms. JAMA Netw Open 2019;2:e196578. https://doi.org/10.1001/jamanetworkopen.2019.6578 72) Alsusa H, Shahid A, Antoniou GA. A comparison of endovascular versus open repair for ruptured abdominal aortic aneurysm - meta-analysis of propensity score-matched data. Vascular 2022;30:628-638. https://doi.org/10.1177/17085381211025168 73) D'Oria M, Gunnarsson K, Wanhainen A, Mani K. Long-term survival after repair of ruptured abdominal aortic aneurysms is improving over time: nationwide analysis during twenty-four years in Sweden (1994-2017). Ann Surg 2023;277:e670-e677. https://doi.org/10.1097/sla.0000000000005030 74) Robinson WP, Schanzer A, Aiello FA, Flahive J, Simons JP, Doucet DR, et al. Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair. J Vasc Surg 2016;63:617-624. https://doi.org/10.1016/j.jvs.2015.09.057 75) van Beek SC, Vahl A, Wisselink W, Reekers JA, Legemate DA, Balm R;

Kim et al.

Amsterdam Acute Aneurysm Trial Collaborators. Midterm re-interventions and survival after endovascular versus open repair for ruptured abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2015;49:661-668. https://doi.org/10.1016/j.ejvs.2015.02.015 76) Wang LJ, Locham S, Al-Nouri O, Eagleton MJ, Clouse WD, Malas MB. Endovascular repair of ruptured abdominal aortic aneurysm is superior to open repair: propensity-matched analysis in the Vascular Quality Initiative. J Vasc Surg 2020;72:498-507. https://doi.org/10.1016/j.jvjs.2019.11.063 77) Anjum A, Thompson L, Azhar B, Hughes C, Karthikesalingam A, Ashleigh R, et al. The effect of aortic morphology on peri-operative mortality of ruptured abdominal aortic aneurysm. Eur Heart J 2015;36:1328-1334. https://doi.org/10.1093/eurheartj/edu521 78) Powell JT, Sweeting MJ, Thompson MM, Ashleigh R, Bell R, Gomes M, et al. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ 2014;348:f7661. https://doi.org/10.1136/bmj.f7661 79) Reimerink JJ, Hoornweg LL, Vahl AC, Wisselink W, van den Broek TA, Legemate DA, et al.; Amsterdam Acute Aneurysm Trial Collaborators. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg 2013;258:248-256. https://doi.org/10.1097/sla.0b013e31828d4b76 80) Giles KA, Pomposelli FB, Hamdan AD, Wyers MC, Schermerhorn ML. Comparison of open and endovascular repair of ruptured abdominal aortic aneurysms from the ACS-NSQIP 2005-07. J Endovasc Ther 2009;16:365-372. https://doi.org/10.1583/09-2735.1 81) Schechter MA, Pascarella L, Thomas S, McCann RL, Mureebe L. Endovascular and open repair of ruptured

infrarenal aortic aneurysms at a tertiary care center. Ann Vasc Surg 2017;41:83-88. https://doi.org/10.1016/j.avsg.2016.10.037 82) Speicher PJ, Barbas AS, Murebee L. Open versus endovascular repair of ruptured abdominal aortic aneurysms. Ann Vasc Surg 2014;28:1249-1257. https://doi.org/10.1016/j.avsg.2013.12.025 83) Davenport DL, O'Keeffe SD, Minion DJ, Sorial EE, Endean ED, Xenos ES. Thir-ty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2010;51:305-309. E1. https://doi.org/10.1016/j.jvs.2009.08.086 84) Lyons OT, Black S, Clough RE, Bell RE, Carrell T, Waltham M, et al. Emergency endovascular aneurysms repair for ruptured abdominal aortic aneurysm: the way forward? Vascuar 2010;18:130-135. https://doi.org/10.2310/6670.2010.00033 85) Wang T, Zhao J, Yuan D, Ma Y, Huang B, Yang Y, et al. Comparative effectiveness of open surgery versus endovascular repair for hemodynamically stable and unstable ruptured abdominal aortic aneurysm. Medicine (Baltimore) 2018;97:e11313. https://doi.org/10.1097/md.00000000000011313 86) Guo B, Dong Z, Fu W, Guo D, Xu X, Chen B, et al. Endovascular versus open repair for ruptured abdominal aortic aneurysms in a Chinese population. Ann Vasc Surg 2016;36:74-84. https://doi.org/10.1016/j.avsg.2016.03.006 87) Noorani A, Page A, Walsh SR, Varty K, Hayes PD, Boyle JR. Mid-term outcomes following emergency endovascular aortic aneurysm repair for ruptured abdominal aortic aneurysms from the ACS-NSQIP 2005-07. J Endovasc Ther 2009;16:365-372. https://doi.org/10.1583/09-2735.1 88) Wu CY, Chan CY, Huang SC, Chi NS, Wang SS, Wu IH. Outcomes following endovascular or open repair for ruptured abdominal aortic aneurysm.

rysm in a Chinese population. Heart Vessels 2014;29:71-77. https://doi.org/10.1007/s00380-012-0320-z 89) Gup ta AK, Dakour-Aridi H, Locham S, Nejim B, Veith FJ, Malas MB. Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysm. J Vasc Surg 2018;68:74-81. https://doi.org/10.1016/j.jvs.2017.11.065 90) Martinelli O, Fenelli C, Ben-Hamida JB, Fresilli M, Irace FG, Picone V, et al. One-year outcomes after ruptured abdominal aortic aneurysms repair: is endovascular aortic repair the best choice? A single-center experience. Ann Vasc Surg 2018;53:63-69. https://doi.org/10.1016/j.avsg.2018.04.004 91) Mukherjee D, Kfoury E, Schmidt K, Waked T, Hashemi H. Improved results in the management of ruptured abdominal aortic aneurysm may not be on the basis of endovascular aneurysm repair alone. Vascular 2014;22:51-54. https://doi.org/10.1177/1708538112473974 92) Laohapensang K, Rutherford RB, Arworn S. Infected aneurysm. Ann Vasc Dis 2010;3:16-23. https://doi.org/10.3400/avd.avdctiia09002 93) Osler W. The Gulstonian lectures, on malignant endocarditis. Br Med J 1885;1:467-470. https://doi.org/10.1136/bmj.1.1262.467 94) Osler W. The Gulstonian lectures, on malignant endocarditis. Br Med J 1885;1:577-579. https://doi.org/10.1136/bmj.1.1264.577 95) Sörelius K, Wyss TR, Adam D, Beck AW, Berard X, Budtz-Lilly J, et al. Editor's choice - infective native aortic aneurysms: a Delphi consensus document on terminology, definition, classification, diagnosis, and reporting standards. Eur J Vasc Endovasc Surg Surg 2023;65:323-329. https://doi.org/10.1016/j.ejvs.2022.11.024 96) Kan CD, Lee HL, Luo CY, Yang YJ. The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm-institute case man-

Clinical Practice Guideline on AAA

agement with systemic literature comparison. Ann Vasc Surg 2010;24:433-440. https://doi.org/10.1016/j.avsg.2009.08.004 97) Dubois M, Daenens K, Houthoofd S, Peetermans WE, Fourneau I. Treatment of mycotic aneurysms with involvement of the abdominal aorta: single-centre experience in 44 consecutive cases. Eur J Vasc Endovasc Surg 2010;40:450-456. https://doi.org/10.1016/j.ejvs.2010.07.017 98) Lai CH, Luo CY, Lin PY, Kan CD, Chang RS, Wu HL, et al. Surgical consideration of in situ prosthetic replacement for primary infected abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2011;42:617-624. https://doi.org/10.1016/j.ejvs.2011.07.005 99) Yu SY, Hsieh HC, Ko PJ, Huang YK, Chu JJ, Lee CH. Surgical outcome for mycotic aortic and iliac aneurysm. World J Surg 2011;35:1671-1678. https://doi.org/10.1007/s00268-011-1104-9 100) Sedivy P, Spacek M, El Samman K, Belohlavek O, Mach T, Jindrak V, et al. Endovascular treatment of infected aortic aneurysms. Eur J Vasc Endovasc Surg 2012;44:385-394. https://doi.org/10.1016/j.ejvs.2012.07.011 101) Yamanaka K, Omura A, Nomura Y, Miyahara S, Shirasaka T, Sakamoto T, et al. Surgical strategy for aorta-related infection. Eur J Cardiothorac Surg 2014;46:974-980; discussion 980. https://doi.org/10.1093/ejts/ezu/119 102) Sörelius K, Mani K, Björck M, Sedivy P, Wahlgren CM, Taylor P, et al.; European MAA collaborators. Endovascular treatment of mycotic aortic aneurysms: a European multicenter study. Circulation 2014;130:236-2142. https://doi.org/10.1161/circulationaha.114.009481 103) Youn JK, Kim SM, Han A, Choi C, Min SI, Ha J, et al. Surgical treatment of infected aortoiliac aneurysm. Vasc Specialist Int 2015;31:41-46. https://doi.org/10.5758/vsi.2015.31.2.41 104) Sörelius K, Wanhainen A, Furebring M,

Björck M, Gillgren P, Mani K; Swedish Collaborator Group for Mycotic Abdominal Aortic Aneurysms. Nationwide study of the treatment of mycotic abdominal aortic aneurysms comparing open and endovascular repair. Circulation 2016;134:1822-1832. https://doi.org/10.1161/CIRCULATIONAHA.116.024021

105) Luo CM, Chan CY, Chen YS, Wang SS, Chi NH, Wu IH. Long-term outcome of endovascular treatment for mycotic aortic aneurysm. Eur J Vasc Endovasc Surg 2017;54:464-471. https://doi.org/10.1016/j.ejvs.2017.07.004

106) Zhu C, Zhao J, Huang B, Yuan D, Yang Y, Wang T. Long-term outcome of endovascular aortic repair for mycotic abdominal aortic aneurysm. ANZ J Surg 2020;90:1376-1380. https://doi.org/10.1111/ans.16122

107) Di X, Liu C, Zeng R, Ni L. Endovascular aortic repair is a viable strategy for treatment of primary infected abdominal aortic aneurysm. Ann Vasc Surg 2020;63:117-128. https://doi.org/10.1016/j.avsg.2018.12.080

108) Tshomba Y, Sica S, Minelli F, Giovanni S, Murri R, De Nigris F, et al. Management of mycotic aorti-iliac aneurysms: a 30-year monocentric experience. Eur Rev Med Pharmacol Sci 2020;24:3274-3281. https://doi.org/10.26355/eurrev202003_20695

109) Kwon TW, Kim HK, Moon KM, Cho YP, Park SJ. In situ polytetrafluoroethylene graft bypass for primary infected aneurysm of the infrarenal abdominal aorta. World J Surg 2010;34:1689-1695. https://doi.org/10.1007/s00268-010-0507-3

110) Fatima J, Duncan AA, de Grandis E, Oderich GS, Kalra M, Gloviczki P, et al. Treatment strategies and outcomes in patients with infected aortic endoragrafts. J Vasc Surg 2013;58:371-379. https://doi.org/10.1016/j.jvs.2013.01.047

111) Sörelius K, Budtz-Lilly J, Mani K, Wanhainen A. Systematic review of the management of mycotic aortic

aneurysms. Eur J Vasc Endovasc Surg 2019;58:426-435. https://doi.org/10.1016/j.ejvs.2019.05.004 112) Leurs LJ, Laheij RJ, Buth J; EURO-STAR Collaborators. What determines and are the consequences of surveillance intensity after endovascular abdominal aortic aneurysm repair? Ann Vasc Surg 2005;19:868-875. https://doi.org/10.1007/s10016-005-7751-2 113) Jones WB, Taylor SM, Kalbaugh CA, Joels CS, Blackhurst DW, Langan EM 3rd, et al. Lost to follow-up: a potential under-appreciated limitation of endovascular aneurysm repair. J Vasc Surg 2007;46:434-440; discussion 440-441. https://doi.org/10.1016/j.jvs.2007.05.002 114) Sarangarm D, Knepper J, Marek J, Biggs KL, Robertson D, Langsfeld M. Post-endovascular aneurysm repair patient outcomes and follow-up are not adversely impacted by long travel distance to tertiary vascular surgery centers. Ann Vasc Surg 2010;24:1075-1081. https://doi.org/10.1016/j.avsg.2010.05.009 115) Waduud MA, Choong WL, Ritchie M, Williams C, Yadavali R, Lim S, et al. Endovascular aneurysm repair: is imaging surveillance robust, and does it influence long-term mortality? Cardiovasc Intervent Radiol 2015;38:33-39. https://doi.org/10.1007/s00270-014-0890-5 116) Godfrey AD, Morbi AH, Nordon IM. Patient compliance with surveillance following elective endovascular aneurysm repair. Cardiovasc Intervent Radiol 2015;38:1130-1136. https://doi.org/10.1007/s00270-015-1073-8 117) Wu CY, Chen H, Gallagher KA, Eliason JL, Rectenwald JE, Coleman DM. Predictors of compliance with surveillance after endovascular aneurysm repair and comparative survival outcomes. J Vasc Surg 2015;62:27-35. https://doi.org/10.1016/j.jvs.2015.02.023 118) AbuRahma AF, Yacoub M, Hass SM, AbuRahma J, Mousa AY, Dean LS, et

Kim et al.

al. Compliance of postendovascular aortic aneurysm repair imaging surveillance. J Vasc Surg 2016;63:589-595. https://doi.org/10.1016/j.jvs.2015.09.021

119. Grima MJ, Karthikesalingam A, Holt PJ; EVAR-SCREEN Collaborators. Multicentre post-EVAR surveillance evaluation study (EVAR-SCREEN). Eur J Vasc Endovasc Surg 2019;57:521-526. https://doi.org/10.1016/j.ejvs.2018.10.032

120. Behrendt CA, Rieß HC, Schwaneberg T, Larena-Avellaneda A, Kölbel T, Tsilimparis N, et al. Incidence, predictors, and outcomes of colonic ischaemia in abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2018;56:507-513. https://doi.org/10.1016/j.ejvs.2018.06.010

121. Bast TJ, van der Biezen JJ, Scherpenisse J, Eikelboom BC. Ischaemic disease of the colon and rectum after surgery for abdominal aortic aneurysm: a prospective study of the incidence and risk factors. Eur J Vasc Surg 1990;4:253-257. https://doi.org/10.1016/s0950-821x(05)80203-8

122. Fanti L, Masci E, Mariani A, Chiesa R, Jannello A, Melissano G, et al. Is endoscopy useful for early diagnosis of ischaemic colitis after aortic surgery? Results of a prospective trial. Ital J Gastroenterol Hepatol 1997;29:357-360.

123. Champagne BJ, Darling RC 3rd, Daneshmand M, Kreienberg PB, Lee EC, Mehta M, et al. Outcome of aggressive surveillance colonoscopy in ruptured abdominal aortic aneurysm. J Vasc Surg 2004;39:792-796. https://doi.org/10.1016/j.jvs.2003.12.002

124. Champagne BJ, Lee EC, Valerian B, Mulhotra N, Mehta M. Incidence of colonic ischemia after repair of ruptured abdominal aortic aneurysm with endograft. J Am Coll Surg 2007;204:597-602. https://doi.org/10.1016/j.jamcollsurg.2007.01.030

125. Megalopoulos A, Vasiliadis K, Tsalis K, Kapetanos D, Bitzani M, Tsachalis

T, et al. Reliability of selective surveillance colonoscopy in the early diagnosis of colonic ischemia after successful ruptured abdominal aortic aneurysm repair. Vasc Endovascular Surg 2007;41:509–515. https://doi.org/10.1177/1538574407306797 126 Assadian A, Senekowitsch C, Assadian O, Hartleb H, Hagmüller GW. Diagnostic accuracy of sigmoidoscopy compared with histology for ischemic colitis after aortic aneurysm repair. Vascular 2008;16:243-247. https://doi.org/10.2310/6670.2008.00038 127 Töttrup M, Fedder AM, Jensen RH, Töttrup A, Laustsen J. The value of routine flexible sigmoidoscopy within 48 hours after surgical repair of ruptured abdominal aortic aneurysms. Ann Vasc Surg 2013;27:714-718. https://doi.org/10.1016/j.avsg.2012.07.030 128 Urbonavicius S, Feuerhake IL, Srianthalogen R, Urbonavicius M, Baltrunas T, Grøndal NF, et al. Value of routine flexible sigmoidoscopy and potential predictive factors for colonic ischemia after open ruptured abdominal aortic aneurysm repair. Medicina (Kaunas) 2020;56:229. https://doi.org/10.3390/medicina56050229 129 Serizawa F, Ohara M, Kotegawa T, Watanabe S, Shimizu T, Akamatsu D. The incidence of para-anastomotic aneurysm after open repair surgery for abdominal aortic aneurysm through routine annual computed tomography imaging. Eur J Vasc Endovasc Surg 2021;62:187-192. https://doi.org/10.1016/j.ejvs.2021.01.010 130 Plate G, Holller LA, O'Brien P, Parolero PC, Cherry KJ, Kazmier FJ. Recurrent aneurysms and late vascular complications following repair of abdominal aortic aneurysms. Arch Surg 1985;120:590-594. https://doi.org/10.1001/archsurg.1985.01390290068011 131 Marković DM, Davidović LB, Kostić DM, Maksimović ZL, Kuzmanovic IB, Koncar IB, et al. False anastomotic aneurysms.

Vascular 2007;15:141-148. https://doi.org/10.2310/6670.2007.00026 132) Sachdev U, Baril DT, Morrissey NJ, Silverberg D, Jacobs TS, Carroccio A, et al. Endovascular repair of ana-anastomotic aortic aneurysms. J Vasc Surg 2007;46:636-641. https://doi.org/10.1016/j.jvs.2007.05.032 133) Moreira M, Antunes L, Moreira J, Ana-cleto G. Aortic anastomotic aneurysm after infra renal grafting. Rev Port Cir Cardiotorac Vasc 2020;27:145. 134) Baker DM, Hinchliffe RJ, Yusuf SW, Whitaker SC, Hopkinson BR. True jux-ta-anastomotic aneurysms in the re-sidual infra-renal abdominal aorta. Eur J Vasc Endovasc Surg 2003;25:412-415. https://doi.org/10.1053/ejvs.2002.1819 135) Ten Bosch JA, Waasdorp EJ, de Vries JP, Moll FL, Teijink JA, van Her-waarden JA. The durability of endo-vascular repair of para-anastomotic aneurysms after previous open aortic reconstruction. J Vasc Surg 2011; 54:1571-1578. https://doi.org/10.1016/j.jvs.2011.04.072 136) Mii S, Mori A, Sakata H, Kawazoe N. Para-anastomotic aneurysms: inci-dence, risk factors, treatment and prognosis. J Cardiovasc Surg (Torino) 1998;39:259-266. 137) Gawenda M, Zaehringer M, Brunkwall J. Open versus endovascular repair of para-anastomotic aneurysms in patients who were morphological candidates for endovascular treat-ment. J Endovasc Ther 2003;10:745-751. https://doi.org/10.1177/15266028 0301000410 138) Tshomba Y, Mascia D, Kahlberg A, Ma-rone EM, Melissano G, Chiesa R. On-label use of commercially-available abdominal endografts for para-anas-tomotic aneurysms and pseudoaneu-rymss after infrarenal abdominal aortic aneurysm open repair. Eur J Vasc Endovasc Surg 2013;46:657-666. https://doi.org/10.1016/j.ejvs.2013.09.013 139) Szilagyi DE, Smith RF, Elliott JP, Hage-man JH, Dall'Olmo CA. Anastomotic

Clinical Practice Guideline on AAA

aneurysms after vascular reconstruction: problems of incidence, etiology, and treatment. Surgery 1975;78:800-816. 140) Ylönen K, Biancari F, Leo E, Rainio P, Salmela E, Lahtinen J, et al. Predictors of development of anastomotic femoral pseudoaneurysms after aortobifemoral reconstruction for abdominal aortic aneurysms. Am J Surg 2004;187:83-87. https://doi.org/10.1016/j.amjsurg.2002.09.001 141) Edwards JM, Teefey SA, Zierler RE, Kohler TR. Intraabdominal paraanastomotic aneurysms after aortic bypass grafting. J Vasc Surg 1992;15:344-350; discussion 351-353. https://doi.org/10.1016/0741-5214(92)90256-8 142) Morrissey NJ, Yano OJ, Soundarrajan K, Eisen L, McArthur C, Teo-dorescu V, et al. Endovascular repair of para-anastomotic aneurysms of the aorta and iliac arteries: preferred treatment for a complex problem. J Vasc Surg 2001;34:503-512. https://doi.org/10.1067/mva.2001.114811 143) Mitchell JH, Dougherty KG, Strickman NE, Mortazavi A, Krajcer Z. Endovascular repair of paraanastomotic aneurysms after aortic reconstruction. Tex Heart Inst J 2007;34:148-153. 144) Hertzer NR, Mascha EJ, Karafa MT, O'Hara PJ, Krajewski LP, Beven EG. Open infrarenal abdominal aortic aneurysms repair: the Cleveland Clinic experience from 1989 to 1998. J Vasc Surg 2002;35:1145-1154. https://doi.org/10.1067/mva.2002.123686 145) Curti T, Stella A, Rossi C, Galaverni C, Saccà A, Resta F, et al. Endovascular repair as first-choice treatment for anastomotic and true iliac aneurysms. J Endovasc Ther 2001;8:139-143. https://doi.org/10.1177/152660280100800207 146) Tiesenhausen K, Hausegger KA, Tauss J, Amann W, Koch G. Endovascular treatment of proximal anastomotic aneurysms after aortic prosthetic reconstruction. Cardiovasc Intervent Radiol 2001;24:49-52. https://doi.org/

10.1007/s002700001740 147) Johal AS, Loftus IM, Boyle JR, Heikkila K, Waton S, Cromwell DA. Long-term survival after endovascular and open repair of unruptured abdominal aortic aneurysm. Br J Surg 2019; 106:1784-1793. https://doi.org/10.1002/bjs.11215 148) Conrad MF, Crawford RS, Pedraza JD, Brewster DC, Lamuraglia GM, Corey M, et al. Long-term durability of open abdominal aortic aneurysm repair. J Vasc Surg 2007;46:669-675. https://doi.org/10.1016/j.jvs.2007.05.046 149) Argyriou C, Georgiadis GS, Lazarides MK, Georgakarakos E, Antoniou GA. Endograft infection after endovascular abdominal aortic aneurysm repair: a systematic review and meta-anal-ysis. J Endovasc Ther 2017;24:688-697. https://doi.org/10.1177/15266027722018 150) Antonello RM, D'Oria M, Cavallaro M, Dore F, Cova MA, Ricciardi MC, et al. Management of abdominal aortic prosthetic graft and endograft infections. A multidisciplinary update. J Infect Chemother 2019;25:669-680. https://doi.org/10.1016/j.jiac.2019.05.013 151) Batt M, Feugier P, Camou F, Coffy A, Senneville E, Caillon J, et al.; Research Group for Vascular Graft Infection. A meta-analysis of outcomes after in situ reconstructions for aortic graft infection. Angiology 2018;69:370-379. https://doi.org/10.1177/0003319717710114 152) Gouveia E Melo R, Martins B, Pedro DM, Santos CM, Duarte A, et al. Microbial evolution of vascular graft infections in a tertiary hospital based on positive graft cultures. J Vasc Surg 2021;74:276-284.e4. https://doi.org/10.1016/j.jvjs.2020.12.071 153) Lyons OT, Baguneid M, Barwick TD, Bell RE, Foster N, Homer-Vannin- asinkam S, et al. Diagnosis of aortic graft infection: a case definition by the management of aortic graft infection collaboration (MAGIC). Eur J

Vasc Endovasc Surg 2016;52:758-763. https://doi.org/10.1016/j.ejvs.2016.09.007 154] Schmitt DD, Seabrook GR, Bandyk DF, Towne JB. Graft excision and extra-anatomic revascularization: the treatment of choice for the septic aortic prosthesis. J Cardiovasc Surg (Torino) 1990;31:327-332. 155] Jausseran JM, Stella N, Courbier R, Bergeron P, Ferdani M, Houel H, et al. Total prosthetic graft excision and extra-anatomic bypass. Eur J Vasc Endovasc Surg 1997;14 Suppl A:59-65. https://doi.org/10.1016/s1078-5884 (97)80156-6 156] Charlton-Ouw KM, Sandhu HK, Huang G, Leake SS, Miller CC 3rd, Estrera AL, et al. Reinfection after resection and revascularization of infected infra-renal abdominal aortic grafts. J Vasc Surg 2014;59:684-692. https://doi.org/10.1016/j.jvs.2013.09.030 157] Perera GB, Fujitani RM, Kubaska SM. Aortic graft infection: update on management and treatment options. Vasc Endovascular Surg 2006;40:1-10. https://doi.org/10.1177/153857440604 000101 158] Ricotta JJ, Faggioli GL, Stella A, Curl GR, Peer R, Upson J, et al. Total excision and extra-anatomic bypass for aortic graft infection. Am J Surg 1991;162:145-149. https://doi.org/10.1016/0002-9610(91)90177-f 159] Li HL, Chan YC, Cheng SW. Current evidence on management of aortic stent-graft infection: a systematic review and meta-analysis. Ann Vasc Surg 2018;51:306-313. https://doi.org/10.1016/j.avsg.2018.02.038 160] Armstrong PA, Back MR, Wilson JS, Shames ML, Johnson BL, Bandyk DF. Improved outcomes in the recent management of secondary aortoenteric fistula. J Vasc Surg 2005;42:660-666. https://doi.org/10.1016/j.jvs.2005.06.020 161] Arya S, Coleman DM, Knepper J, Henke PK, Upchurch GR, Rectenwald JE, et al. Outcomes after late explan-

Kim et al.

tation of aortic endografts depend on indication for explanation. Ann Vasc Surg 2013;27:865-873. https://doi.org/10.1016/j.avsg.2013.03.009 162) Capoccia L, Speziale F, Menna D, Esposito A, Sirignano P, Rizzo AR, et al. Preliminary results from a national enquiry of infection in abdominal aortic endovascular repair (registry of infection in EVAR--R.I.EVAR). Ann Vasc Surg 2016;30:198-204. https://doi.org/10.1016/j.avsg.2015.07.017 163) Chaufour X, Gaudric J, Goueffic Y, Khodja RH, Feugier P, Malikov S, et al.; AURC (French University Surgeons Association) Collaborators. A multicenter experience with infected abdominal aortic endograft explanation. J Vasc Surg 2017;65:372-380. https://doi.org/10.1016/j.jvs.2016.07.126 164) Chen CL, Kuo TT, Chen IM, Chen TW, Chen PL, Huang CY, et al. Mid-term outcome of infected abdominal aortic stent graft dismantlement with reconstruction of bilateral axillofemoral bypass. Surg Infect (Larchmt) 2021;22:680-683. https://doi.org/10.1089/sur.2020.332 165) Darling RC 3rd, Resnikoff M, Kreienberg PB, Chang BB, Paty PS, Leather RP, et al. Alternative approach for management of infected aortic grafts. J Vasc Surg 1997;25:106-112. https://doi.org/10.1016/s0741-5214(97)70326-4 166) Davila VJ, Stone W, Duncan AA, Wood E, Jordan WD Jr, Zea N, et al. A multicenter experience with the surgical treatment of infected abdominal aortic endografts. J Vasc Surg 2015;62:877-883. https://doi.org/10.1016/j.jvs.2015.04.440 167) Dominguez-Cainzos J, Rodrigo-Manjon A, Rodriguez-Chinesta JM, Apoda-KieDz A, Bonmatí G, Bereciartua E. Abdominal aortic endograft infection. A decade of experience and literature review. Enferm Infecc Microbiol Clin (Engl Ed) 2023;41:155-161. https://doi.org/10.1016/j.eimce.2022.07.002

168) Dorigo W, Pulli R, Azas L, Pratesi G, Innocenti AA, Pratesi C. Early and long-term results of conventional surgical treatment of secondary aorto-enteric fistula. Eur J Vasc Endovasc Surg 2003;26:512-518. https://doi.org/10.1016/s1078-5884(03)00379-4 169) Filiberto AC, Scall ST, Patterson S, Neal D, Elder CT, Shah SK, et al. Treatment and outcomes of aortic graft infection using a decision algorithm. Ann Vasc Surg 2021;76:254-268. https://doi.org/10.1016/j.avsg.2021.04.047 170) Hayes PD, Nasim A, London NJ, Sayers RD, Barrie WW, Bell PR, et al. In situ replacement of infected aortic grafts with rifampicin-bonded pros-theses: the Leicester experience (1992 to 1998). J Vasc Surg 1999;30:92-98. https://doi.org/10.1016/s0741-5214(99)70180-1 171) Jicha DL, Reilly LM, Kuestner LM, Stoney RJ. Durability of cross-femo-ral grafts after aortic graft infection: the fate of autogenous conduits. J Vasc Surg 1995;22:393-405; discus-sion 406-407. https://doi.org/10.1016/s0741-5214(95)70006-4 172) Maze MJ, Laws P, Buckenham T, Pithie A, Gallagher K, Metcalf S, et al. Outcomes of infected abdominal aortic grafts managed with antimicrobial therapy and graft retention in an un-selected cohort. Eur J Vasc Endovasc Surg 2013;45:373-380. https://doi.org/10.1016/j.ejvs.2013.01.019 173) Mirzale M, Schmitto JD, Tirilomis T, Fatehpur S, Liakopoulos OJ, Teucher N, et al. Surgical management of vascular graft infection in severely ill patients by partial resection of the infected prosthesis. Eur J Vasc Endovasc Surg 2007;33:610-613. https://doi.org/10.1016/j.ejvs.2006.11.042 174) O'Hara PJ, Hertzer NR, Beven EG, Krajewski LP. Surgical management of infected abdominal aortic grafts: review of a 25-year experience. J Vasc Surg 1986;3:725-731. 175) Quiñones-Baldrich WJ, Hernández JJ, Moore WS. Long-term

results following surgical management of aortic graft infection. Arch Surg 1991;126:507-511. https://doi.org/10.1001/archsurg.1991.01410280111018

76) Reilly LM, Stoney RJ, Goldstone J, Ehrenfeld WK. Improved management of aortic graft infection: the influence of operation sequence and staging. J Vasc Surg 1987;5:421-431. https://doi.org/10.1067/mva.1987.avs0050421

77) Schaefers JF, Donas KP, Panuccio G, Kasprzak B, Heine B, Torsello GB, et al. Outcomes of surgical explanation of infected aortic grafts after endovascular and open abdominal aneurysm repair. Eur J Vasc Endovasc Surg 2019;57:130-136. https://doi.org/10.1016/j.ejvs.2018.07.021

78) Seeger JM, Pretus HA, Welborn MB, Ozaki CK, Flynn TC, Huber TS. Long-term outcome after treatment of aortic graft infection with staged extra-anatomic bypass grafting and aortic graft removal. J Vasc Surg 2000;32:451-459; discussion 460-461. https://doi.org/10.1067/mva.2000.109471

79) Shukuzawa K, Ohki T, Maeda K, Kanaoka Y. Risk factors and treatment outcomes for stent graft infection after endovascular aortic aneurysm repair. J Vasc Surg 2019;70:181-192. https://doi.org/10.1016/j.jvs.2018.10.062

180) Turney EJ, Steenberge SP, Lyden SP, Eagleton MJ, Srivastava SD, Sarac TP, et al. Late graft explants in endovascular aneurysm repair. J Vasc Surg 2014;59:886-893. https://doi.org/10.1016/j.jvs.2013.10.079

181) Yeager RA, Moneta GL, Taylor LM Jr, Harris EJ Jr, McConnell DB, Porter JM. Improving survival and limb salvage in patients with aortic graft infection. Am J Surg 1990;159:466-469. https://doi.org/10.1016/s0002-9610(05)81247-4

182) Rokosh RS, Wu WW, Dalman RL, Chaikof EL. Society for Vascular Surgery implementation of clinical practice guidelines for patients

Clinical Practice Guideline on AAA

with an abdominal aortic aneurysm: Endoleak management. J Vasc Surg 2021;74:1792-1794. https://doi.org/10.1016/j.jvs.2021.04.042

[183] Major M, Long GW, Eden CL, Studzinski DM, Callahan RE, Brown OW. Long-term outcomes and interventions of postoperative type 1a endoleak following elective endovascular aortic aneurysm repair. J Vasc Surg 2022;75:136-143.e1. https://doi.org/10.1016/j.jvs.2021.07.122

[184] Kontopodis N, Tavlas E, Galanakis N, Chronis C, Kafetzakis A, Tsetis D, et al. Spontaneous type la endoleak sealing in patients undergoing endovascular aneurysm repair with the ovation stent graft. Ann Vasc Surg 2019;54:240-247. https://doi.org/10.1016/j.avsg.2018.04.041

[185] Stenson KM, Patterson BO, Grima MJ, De Bruin JL, Holt PJE, Loftus I. Midterm results of endovascular aneurysm sealing to treat abdominal aortic aneurysm. J Vasc Surg 2019;69:53-62.e1. https://doi.org/10.1016/j.jvs.2018.04.016

[186] Goudeketting SR, van Noort K, Ouriel K, Jordan WD Jr, Panneton JM, Slump CH, et al. Influence of aortic neck characteristics on successful aortic wall penetration of Endo-Anchors in therapeutic use during endovascular aneurysm repair. J Vasc Surg 2018;68:1007-1016. https://doi.org/10.1016/j.jvs.2018.01.039

[187] van den Ham LH, Holden A, Savlovskis J, Witterbottom A, Ouriel K, Reijnen MMPJ; EVAS Type IA Endoleak Study Group. Editor's choice - Occurrence and classification of proximal type I endoleaks after endovascular aneurysm sealing using the Nellix™ device. Eur J Vasc Endovasc Surg 2017;54:729-736. https://doi.org/10.1016/j.jvs.2017.09.016

[188] Marcelin C, Le Bras Y, Petitpierre F, Midy D, Grenier N, Ducasse E, et al. Embolization for persistent type IA endoleaks after chimney endovascuar aneurysm repair with Onyx®. Di-

agn Interv Imaging 2017;98:849-855. https://doi.org/10.1016/j.diii.2017.04.005 189) Perini P, de Troia A, Tecchio T, Azzarone M, Bianchini Massoni C, Salcuni P, et al. Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair. J Vasc Surg 2017;66:1048-1055. https://doi.org/10.1016/j.jvs.2017.01.057 190) Gargilo M, Gallitto E, Wattez H, Verzini F, Bianchini Massoni C, Loschi D, et al. Outcomes of endovascular aneurysm repair performed in abdominal aortic aneurysms with large infrarenal necks. J Vasc Surg 2017;66:1065-1072. https://doi.org/10.1016/j.jvs.2017.01.066 191) Ameli-Renani S, Pavlidis V, Morgan RA. Early and midterm outcomes after transcatheter embolization of type 1 endoleaks in 25 patients. J Vasc Surg 2017;65:346-355. https://doi.org/10.1016/j.jvs.2016.06.101 192) Graif A, Vance AZ, Garcia MJ, Lie KT, McGarry MK, Leung DA. Transcatheter embolization of type 1 endoleaks associated with endovascular abdominal aortic aneurysm repair using ethylene vinyl alcohol copolymer. Vasc Endovascular Surg 2017;51:28-32. https://doi.org/10.1177/15385744 16687733 193) Millen AM, Osman K, Antoniou GA, McWilliams RG, Brennan JA, Fisher RK. Outcomes of persistent intraoperative type la endoleak after standard endovascular aneurysm repair. J Vasc Surg 2015;61:1185-1191. https://doi.org/10.1016/j.jvs.2014.02.041 194) XiaoHui M, Wei G, ZhongZhou H, XiaoPing L, Jiang X, Xin J. Endovascular repair with chimney technique for juxtarenal aortic aneurysm: a single center experience. Eur J Vasc Endovasc Surg 2015;49:271-276. https://doi.org/10.1016/j.ejvs.2014.11.012 195) Wijffels CJ, Van Lammeren GW, Waasdorp EJ, Wille J, Werson DA, Van Den Heuvel DA, et al. Results of

reinterventions for failed endovascular aortic repair: a single-center experience. J Cardiovasc Surg (Torino) 2014;55:593-600. 196) Scali ST, McNally MM, Feezor RJ, Chang CK, Waterman AL, Berceli SA, et al. Elective endovascular aortic repair conversion for type la endoleak is not associated with increased morbidity or mortality compared with primary juxtarenal aneurysm repair. J Vasc Surg 2014;60:286-294.e1. https://doi.org/10.1016/j.jvs.2014.02.046 197) Setacci F, Sirignano P, de Donato G, Galzerano G, Messina G, Guerrini S, et al. Two-year-results of Endurant stent-graft in challenging aortic neck morphologies versus standard anatomies. J Cardiovasc Surg (Torino) 2014;55:85-92. 198) Kim SM, Ra HD, Min SI, Jae HJ, Ha J, Min SK. Clinical significance of type I endoleak on completion angiography. Ann Surg Treat Res 2014;86:95-99. https://doi.org/10.4174/astr.2014.86.2.95 199) 194) Prusa AM, Wibmer AG, Schoder M, Funovics M, Lammer J, Polterauer P, et al. Aortomonoliac endografting after failed endovascular aneurysm repair: indications and long-term results. Eur J Vasc Endovasc Surg 2012; 44:378-383. https://doi.org/10.1016/j.ejs.2012.07.009 200) Avci M, Vos JA, Kolvenbach RR, Verhoeven EL, Perdikides T, Resch TA, et al. The use of endoanchors in repair EVAR cases to improve proximal endograft fixation. J Cardiovasc Surg (Torino) 2012;53:419-426. 201) Krajcer Z, Dougherty KG, Gregoric ID. Long-term results of aortic banding for complex infrarenal neck anatomy and type I endoleak after endovascular abdominal aortic aneurysm repair. Tex Heart Inst J 2012;39:799-805. 202) Naughton PA, Garcia-Toca M, Rodriguez HE, Keeling AN, Resnick SA, Morasch MD, et al. Endovascular treatment of delayed type 1 and 3 endoleaks. Cardiovasc Intervent Radiol

Kim et al.

2011;34:751-757. https://doi.org/10.1007/s00270-010-0020-y 203) Jim J, Rubin BG, Geraghty PJ, Money SR, Sanchez LA. Midterm outcomes of the Zenith Renu AAA Ancillary Graft. J Vasc Surg 2011;54:307-315.e1. https://doi.org/10.1016/j.jvs.2010.12.058 204) van Lammeren GW, Fioole B, Waasdorp EJ, Moll FL, van Herwaarden JA, de Vries JP. Long-term follow-up of secondary interventions after endovascular aneurysm repair with the AneuRx endoprostesis: a single-center experience. J Endovasc Ther 2010;17:408-415. https://doi.org/10.1583/10-3086.1 205) Nabi D, Murphy EH, Pak J, Zarins CK. Open surgical repair after failed endovascular aneurysm repair: is endograft removal necessary? J Vasc Surg 2009;50:714-721. https://doi.org/10.1016/j.jvs.2009.05.024 206) Azizzadeh A, Sanchez LA, Rubin BG, Parodi JC, Godshall CJ, Geraghty PJ, et al. Aortic neck attachment failure and the AneuRx graft: incidence, treatment options, and early results. Ann Vasc Surg 2005;19:516-521. https://doi.org/10.1007/s10016-005-4619-4 207) Faries PL, Cadot H, Agarwal G, Kent KC, Hollier LH, Marin ML. Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion. J Vasc Surg 2003;37:1155-1161. https://doi.org/10.1016/j.0016/s0741-5214(03)00084-3 208) White SB, Stavropoulos SW. Management of endoleaks following endovascular aneurysm repair. Semin Intervent Radiol 2009;26:33-38. https://doi.org/10.1055/s-0029-1208381 209) Silverberg D, Baril DT, Ellozy SH, Carroccio A, Greyrose SE, Lookstein RA, et al. An 8-year experience with type II endoleaks: natural history suggests selective intervention is a safe approach. J Vasc Surg 2006;44:453-459. https://doi.org/10.1016/j.jvs.2006.04.058 210) Brown A, Saggu GK, Bown MJ, Sayers RD, Sidloff DA. Type II endoleaks:

challenges and solutions. Vasc Health Risk Manag 2016;12:53-63. https://doi.org/10.2147/vhrm.s81275 211) Aziz A, Menias CO, Sanchez LA, Picus D, Saad N, Rubin BG, et al. Outcomes of percutaneous endovascular intervention for type II endoleak with aneurysm expansion. J Vasc Surg 2012;55:1263-1267. https://doi.org/10.1016/j.jvs.2011.10.1016/j.jvs.2011.10.1013 212) Beeman BR, Murtha K, Doerr K, McAfee-Bennett S, Dougherty MJ, Calligaro KD. Duplex ultrasound factors predicting persistent type II endoleak and increasing AAA sac diameter after EVAR. J Vasc Surg 2010;52:1147-1152. https://doi.org/10.1016/j.jvs.2010.06.099 213) Boniakowski AE, De Martino RR, Coleman DM, Eliason JL, Goodney PP, Rectenwald JE. The natural history of type II endoleaks after endovascular aneurysm repair for ruptured abdominal aortic aneurysm. J Vasc Surg 2016;64:1645-1651. https://doi.org/10.1016/j.jvs.2016.04.063 214) Carrafiello G, Ierardi AM, Radaelli A, De Marchi G, Floridi C, Piffaretti G, et al. Unenhanced cone beam computed tomography and fusion imaging in direct percutaneous sac injection for treatment of type II endoleak: technical note. Cardiovasc Intervent Radiol 2016;39:447-452. https://doi.org/10.1007/s00270-015-1217-x 215) Chikazawa G, Hiraoka A, Hirai Y, Tamura K, Totsugawa T, Ishida A, et al. Open reintervention for aneurysmal sac enlargement after EVAR. Ann Vasc Dis 2014;7:350-353. https://doi.org/10.3400/avd.hdi.14-00052 216) Cieri E, De Rango P, Isernia G, Simon-te G, Ciucci A, Parlani G, et al. Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair. J Vasc Surg 2014;59:930-937. https://doi.org/10.1016/j.jvs.2013.10.092 217) Coppi G, Saitta G, Coppi G, Gennai S, Lauricella A, Silingardi R. Transealing: a novel and simple technique

for embolization of type 2 endoleaks through direct sac access from the distal stent-graft landing zone. Eur J Vasc Endovasc Surg 2014;47:394-401. https://doi.org/10.1016/j.ejvs.2014.01.013 218) Dobes D, Hajek M, Raupach J, Be-lobradek Z, Kuriakose J, Arestis N. Surgical treatment of the progres-sive endoleak type II after EVAR. Eur Surg 2016;48:141-143. https://doi.org/10.1007/s10353-016-0409-1 219) Fanelli F, Cannavale A, Chisci E, Ci-tone M, Falcone GM, Michelagnoli S, et al. Direct percutaneous emboliza-tion of aneurysm sac: a safe and ef-fective procedure to treat post-EVAR type II endoleaks. Radiol Med 2021; 126:258-263. https://doi.org/10.1007/s11547-020-01247-2 220) Fujimura N, Obara H, Matsubara K, Watada S, Shibutani S, Akiyoshi T, et al. Characteristics and risk factors for type 2 endoleak in an East Asian population from a Japanese multi-center database. Circ J 2016;80:118-123. https://doi.org/10.1253/circj.CJ-15-0850 221) Funaki B, Birouti N, Zangan SM, Van Ha TG, Lorenz JM, Navuluri R, et al. Evaluation and treatment of suspected type II endoleaks in pa-tients with enlarging abdominal aor-tic aneurysms. J Vasc Interv Radiol 2012;23:866-872; quiz 872. https:// doi.org/10.1016/j.jvir.2012.04.003 222) Gallagher KA, Ravin RA, Meltzer AJ, Khan MA, Coleman DM, Graham AR, et al. Midterm outcomes after treat-ment of type II endoleaks associated with aneurysm sac expansion. J En-dovasc Ther 2012;19:182-192. https:// doi.org/10.1583/11-3653.1 223) Gandini R, Chiocchi M, Loreni G, Del Giudice C, Morosetti D, Chiaravalloti A, et al. Treatment of type II endoleak after endovascular aneurysm repair: after endovascular aneurysm repair: the role of selective vs. nonselective transcaval embolization. J Endovasc Ther 2014;21:714-722. https://doi.org/10.1583/14-4571MR.1

Clinical Practice Guideline on AAA

224) Giles KA, Fillinger MF, De Martino RR, Hoel AW, Powell RJ, Walsh DB. Results of transcaval embolization for sac expansion from type II endoleaks after endovascular aneurysm repair. J Vasc Surg 2015;61:1129-1136. https://doi.org/10.1016/j.jvs.2014.12.002 225) Hongo N, Kiyosue H, Shuto R, Kamei N, Miyamoto S, Tanoue S, et al. Dou-ble coaxial microcatheter technique for transarterial aneurysm sac em-bolization of type II endoleaks after endovascular abdominal aortic repair. J Vasc Interv Radiol 2014;25:709-716. https://doi.org/10.1016/j.jvir.2014.01. 012 226) Jones JE, Atkins MD, Brewster DC, Chung TK, Kwolek CJ, LaMuraglia GM, et al. Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes. J Vasc Surg 2007;46:1-8. https://doi.org/10.1016/j.jvs.2007.02.073 227) Jouhannet C, Alsac JM, Julia P, Sapoval M, El Batti S, Di Primio M, et al. Reinterventions for type 2 endole-aks with enlargement of the aneuris-mal sac after endovascular treatment of abdominal aortic aneurysms. Ann Vasc Surg 2014;28:192-200. https:// doi.org/10.1016/j.avsg.2012.10.038 228) Kumar L, Cowled P, Boult M, Howell S, Fitridge R. Type II endoleak after endovascular aneurysm repair: natural history and treatment outcomes. Ann Vasc Surg 2017;44:94-102. https://doi.org/10.1016/j.avsg.2017.04.029 229) Loy LM, Chua JME, Chong TT, Chao VTT, Irani FG, Damodharan K, et al. Type 2 endoleaks: common and hard to eradicate yet benign? Cardiovasc Intervent Radiol 2020;43:963-970. https://doi.org/10.1007/s00270-020-02497-3 230) Maitrias P, Kaladji A, Plissonnier D, Amiot S, Sabatier J, Coggia M, et al.; Association Universitaire de Recherche en Chirurgie Vasculaire (AURC). Treatment of sac expansion after endovascular aneurysm repair with

obliterating endoaneurysmorrhaphy and stent graft preservation. J Vasc Surg 2016;63:902-908. https://doi.org/10.1016/j.jvs.2015.10.059 231) Marcelin C, Le Bras Y, Petitpierre F, Midy D, Ducasse E, Grenier N, et al. Safety and efficacy of embolization using Onyx® of persistent type II endoleaks after abdominal endovascular aneurysm repair. Diagn Interv Imaging 2017;98:491-497. https://doi.org/10.1016/j.diii.2017.0.003 232) Massis K, Carson WG 3rd, Rozas A, Patel V, Zwiebel B. Treatment of type II endoleaks with ethylene-vinyl-alcohol copolymer (Onyx). Vasc Endovascular Surg 2012;46:251-257. https://doi.org/10.1177/1538574412442401 233) Menges AL, Trenner M, Radu O, Bed-doe D, Kallmayer M, Zimmermann A, et al. Lack of durability after transarterial ethylene-vinyl alcohol copolymer-embolization of type II endoleak following endovascular abdominal aortic aneurysm repair. Vasa 2020;49:483-491. https://doi.org/10.1024/0301-1526/a000905 234) Moulakakis KG, Klonaris C, Kakis J, Antonopoulos CN, Lazaris A, Sfyroeras GS, et al. Treatment of type II endoleak and aneurysm expansion after EVAR. Ann Vasc Surg 2017;39:56-66. https://doi.org/10.1016/j.avsg.2016.08.029 235) Mulay S, Geraedts ACM, Koelemay MJW, Balm R; ODYSSEUS study group. Type 2 endoleak with or without intervention and survival after endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2021;61:779-786. https://doi.org/10.1016/j.ejvs.2021.01.017 236) Müller-Wille R, Wohlgemuth WA, Heiss P, Wiggermann P, Güntner O, Schreyer AG, et al. Transarterial embolization of type II endoleaks after EVAR: the role of ethylene vinyl alcohol copolymer (Onyx). Cardiovasc Intervent Radiol 2013;36:1288-1295. https://doi.org/10.1007/s00270-013-0567-5 237) Rahimi S, Nassiri N, Huntress L,

Crystal D, Thomas J, Shafritz R. An institution-wide algorithm for treatment of type II endoleak following endovascular aneurysm repair (EVAR). Vasc Endovascular Surg 2018;52:249-254. https://doi.org/10.1177/1538574418761269

Ribé L, Bicknell CD, Gibbs RG, Burfitt N, Jenkins MP, Cheshire N, et al. Long-term results of intra-arterial onyx injection for type II endoleaks following endovascular aneurysm repair. Vascar 2017;25:266-271. https://doi.org/10.1177/1708538116671467

Sakaki M, Handa N, Onohara T, Okamoto M, Yamamoto T, Shimoe Y, et al.; National Hospital Organization Network Study Group in Japan for Abdominal Aortic Aneurysm. Influence of type 2 endoleaks on long-term outcomes after endovascular repair for abdominal aortic aneurysms: a national hospital organization network study for abdominal aortic aneurysms in Japan. Ann Vasc Surg 2020;64:116-123. https://doi.org/10.1016/j.avsg.2019.09.014

240) Sarac TP, Gibbons C, Vargas L, Liu J, Srivastava S, Bena J, et al. Long-term follow-up of type II endoleak embolization reveals the need for close surveillance. J Vasc Surg 2012;55:33-40. https://doi.org/10.1016/j.jvs.2011.07.092

241) Scallan O, Kribs S, Power AH, DeRose G, Duncan A, Dubois L. Onyx versus coil embolization for the treatment of type II endoleaks. J Vasc Surg 2021;73:1966-1972. https://doi.org/10.1016/j.jvs.2020.10.069

242) Steinmetz E, Rubin BG, Sanchez LA, Choi ET, Geraghty PJ, Baty J, et al. Type II endoleak after endovascular aortic aneurysm repair: a conservative approach with selective intervention is safe and cost-effective. J Vasc Surg 2004;39:306-313. https://doi.org/10.1016/j.jvs.2003.10.026

243) Walker J, Tucker LY, Goodney P, Candell L, Hua H, Okuhn S, et al. Type II

Kim et al.

endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth. J Vasc Surg 2015;62:551-561. https://doi.org/10.1016/j.jvs.2015.04.389 244) Wang Y, Yuan F, Bai Y, Yao W, Zhou C, Liu J, et al. Natural history and influence on long-term outcomes of isolated type II endoleak after endovascular aneurysm repair: a 10-year experience at a single center. Rev Cardiovasc Med 2022;23:99. https://doi.org/10.31083/j.rcm2303099 245) Wojtaszek M, Wnuk E, Maciag R, Solonynko B, Korzeniowski K, Lamparski K, et al. Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx. Wideochir Inne Tech Maloinwazyjne 2016;11:259-267. https://doi.org/10.5114/wiitm.2016.64747 246) Wu WW, Swerdlow NJ, Dansey K, Shuja F, Wyers MC, Schermerhorn ML. Surgical treatment patterns and clinical outcomes of patients treated for expanding aneurysm sacs with type II endoleaks after endovascular aneurysm repair. J Vasc Surg 2021;73:484-493. https://doi.org/10.1016/j.jvs.2020.05.062 247) Yang RY, Tan KT, Beecroft JR, Rajan DK, Jaskolka JD. Direct sac puncture versus transarterial embolization of type II endoleaks: an evaluation and comparison of outcomes. Vascular 2017;25:227-233. https://doi.org/10.1177/1708538116663992 248) Goodney PP, Fillinger MF. The effect of endograft relining on sac expansion after endovascular aneurysm repair with the original-permeability Gore Excluder abdominal aortic aneurysm endoprostthesis. J Vasc Surg 2007;45:686-693. https://doi.org/10.1016/j.jvs.2006.12.025 249) Koole D, Moll FL, Buth J, Hobo R, Zandvoort HJ, Bots ML, et al.; European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR). Annual rupture risk of

abdominal aortic aneurysm enlargement without detectable endoleak after endovascular abdominal aortic repair. J Vasc Surg 2011;54:1614-1622. https://doi.org/10.1016/j.jvs.2011.06.095 250) Meier GH, Parker FM, Godziachvili V, Demasi RJ, Parent FN, Gayle RG. Endotension after endovascular aneurysm repair: the Ancure experience. J Vasc Surg 2001;34:421-426; discussion 426-427. https://doi.org/10.1067/mva.2001.117145 251) O'Donnell TFX, Deery SE, Boitano LT, Siracuse JJ, Schermerhorn ML, Scali ST, et al. Aneurysm sac failure to regress after endovascular aneurysm repair is associated with lower long-term survival. J Vasc Surg 2019;69:414-422. https://doi.org/10.1067/j.jvs.2018.04.050 252) Schlösser FJ, Gusberg RJ, Dardik A, Lin PH, Verhagen HJ, Moll FL, et al. Aneurysm rupture after EVAR: can the ultimate failure be predicted? Eur J Vasc Endovasc Surg 2009;37:15-22. https://doi.org/10.1016/j.ejvs.2008.10.011 253) Bekdache K, Dietzek AM, Cha A, Neychev V. Endovascular hypogastric artery preservation during endovascular aneurysm repair: a review of current techniques and devices. Ann Vasc Surg 2015;29:367-376. https://doi.org/10.1016/j.avsg.2014.0109 254) de Athayde Soares R, Campos ABC, Figueiredo PWS, Vaz. JHL, Brienze CS, Waisberg J, et al. The importance of the hypogastric artery preservation during treatment for aortoiliac aneurysms: a prospective single-center study. Ann Vasc Surg 2023;92:201-210. https://doi.org/10.1016/j.avsg.2022.12.095 255) Bae M, Lee CW, Chung SW, Huh U, Jin M, Kim MS. Failure to preserve the internal iliac artery during abdominal aortic aneurysm repair is associated with mortality and ischemic complications. J Vasc Surg 2022;76:122-131. https://doi.org/

org/10.1016/j.jvs.2021.11.077 256 Mehta M, Veith FJ, Ohki T, Cynamon J, Goldstein K, Suggs WD, et al. Uni-lateral and bilateral hypogastric artery interruption during aortoiliac aneur-rysm repair in 154 patients: a relatively innocuous procedure. J Vasc Surg 2001;33(2 Suppl):S27-S32. https://doi.org/10.1067/mva.2001.111678 257 Criado FJ, Wilson EP, Velazquez OC, Carpenter JP, Barker C, Wellons E, et al. Safety of coil embolization of the internal iliac artery in endovascular grafting of abdominal aortic aneur-rysms. J Vasc Surg 2000;32:684-688. https://doi.org/10.1067/mva.2000.110052 258 Karch LA, Hodgson KJ, Mattos MA, Bohannon WT, Ramsey DE, McLaf-ferty RB. Adverse consequences of internal iliac artery occlusion during endovascular repair of ab-dominal aortic aneuryams. J Vasc Surg 2000;32:676-683. https://doi.org/10.1067/mva.2000.109750 259 Schoder M, Zaunbauer L, Hölzen-bein T, Fleischmann D, Cejna M, Kretschmer G, et al. Internal iliac artery embolization before endo-vascular repair of abdominal aortic aneuryams: frequency, efficacy, and clinical results. AJR Am J Roent-genol 2001;177:599-605. https://doi.org/10.2214/ajr.177.3.1770599 260 Ha CD, Calcagno D. Amplatzer Vas-cular Plug to occlude the internal iliac arteries in patients undergoing aortoiliac aneurysm repair. J Vasc Surg 2005;42:1058-1062. https://doi.org/10.1016/j.jvs.2005.08.017 261 Kang J, Chung BH, Hyun DH, Park YJ, Kim DI. Clinical outcomes after internal iliac artery embolization prior to endovascular aortic aneuryams repair. Int Angiol 2020;39:323-329. https://doi.org/10.23736/s0392-9590.20.04328-x 262 Maleux G, Willems E, Vaninbroukx J, Nevelsteen A, Heye S. Outcome of proximal internal iliac artery coil embolization prior to stent-graft exten-

Clinical Practice Guideline on AAA

sion in patients previously treated by endovascular aortic repair. J Vasc Interv Radiol 2010;21:990-994. https://doi.org/10.1016/j.jvir.2010.02.041 263] Rayt HS, Bown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London NJ, et al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol 2008;31:728-734. https://doi.org/10.1007/s00270-008-9319-3 264] Warein E, Feugier P, Chaufour X, Molin V, Malikov S, Bartoli MA, et al.; AURC (Association Universitaire de Recherche en Chirurgie) - University Association for Research in Surgery. Amplatzer plug to occlude the internal iliac artery during endovascular aortic aneurysm repair: a large multicenter study. Eur J Vasc Endovasc Surg 2016;51:641-646. https://doi.org/10.1016/j.ejvs.2015.12.021 265] Chun JY, Mailli L, Abbasi MA, Belli AM, Gonsalves M, Munneke G, et al. Embolization of the internal iliac artery before EVAR: is it effective? Is it safe? Which technique should be used? Cardiovasc Intervent Radiol 2014;37:329-336. https://doi.org/10.1007/s00270-013-0659-2 266] Fujioka S, Kitamura T, Mishima T, Nakajima R, Tamura Y, Horikoshi R, et al. Gluteal blood flow monitoring in endovascular aneurysm repair with internal iliac artery embolization. Circ J 2021;85:345-350. https://doi.org/10.1253/circj.CJ-20-1002 267] Soares RA, Matielo MF, Brochado FC, Palomo AT, Lourenço RA, Tanaka C, et al. The outcomes of internal iliac artery preservation during endovascular or open surgery treatment for aortoliiac aneurysms. J Vasc Bras 2020;19:e20200087. https://doi.org/10.1590/1677-5449.200087 268] Gurakar M, Locham S, Alshaikh HN, Malas MB. Risk factors and outcomes for bowel ischemia after open and endovascular abdominal aortic aneurysm

rysm repair. J Vasc Surg 2019;70:869-881. https://doi.org/10.1016/j.jvs.2018.11.047 269) Son GM, Kim TU, Park BS, Jung HJ, Lee SS, Yoon JU, et al. Colonic hypo-perfusion following ligation of the inferior mesenteric artery in rectosig-moid colon cancer patients. Ann Surg Treat Res 2019;97:74-82. https://doi.org/10.4174/astr.2019.97.2.74 270) Mann MR, Kawzowicz M, Komosa AJ, Sherer YM, tazarz DP, Loukas M, et al. The marginal artery of Drummond revisited: a systematic review. Transl Res Anat 2021;24:100118. https://doi.org/10.1016/j.tria.2021.100118 271) Lee KB, Lu J, Macsata RA, Patel D, Yang A, Ricotta JJ, et al. Inferior mesenteric artery replantation does not decrease the risk of ischemic colitis after open infrarenal abdominal aortic aneurysm repair. J Vasc Surg 2019;69:1825-1830. https://doi.org/10.1016/j.jvs.2018.09.046 272) Jayaraj A, DeMartino RR, Bower TC, Oderich GS, Gloviczki P, Kalra M, et al. Outcomes following inferior mesenteric artery reimplantation during elective aortic aneurysm surgery. Ann Vasc Surg 2020;66:65-69. https://doi.org/10.1016/j.avsg.2019.12.035 273) Senekowitsch C, Assadian A, Assadian O, Hartleb H, Ptakovsky H, Hag-müller GW. Replanting the inferior mesenteracy artery during infrarenal aortic aneurysm repair: influence on postoperative colon ischemia. J Vasc Surg 2006;43:689-694. https://doi.org/10.1016/j.jvs.2005.12.016 274) West CA, Noel AA, Bower TC, Cherry KJ Jr, Gloviczki P, Sullivan TM, et al. Factors affecting outcomes of open surgical repair of pararenal aortic aneurysms: a 10-year experience. J Vasc Surg 2006;43:921-927; discussion 927-928. https://doi.org/10.1016/j.jvs.2006.01.018 275) Kaczynski J, Jaber B, Atherton S, Fli-gelstone L. Successful reimplantation of the hypertrophied inferior mesenteric artery during an open abdomi-teric artery result.

nal aortic aneurysm repair. Interv Med Appl Sci 2014;6:85-88. https://doi.org/10.1556/imas.6.2014.2.5 276 Saito S, Shirota K, Nakamura H, Sakaguchi K, Ozawa K, Ueda Y. Two cases of colonic necrosis following aortoiliac surgery due to coronary-induced cardiogenic shock. Gen Thorac Cardiovasc Surg 2007;55:208-211. https://doi.org/10.1007/s11748-007-0107-9 277 Twine CP, Lane IF, Williams IM. The retroperitoneal approach to the abdominal aorta in the endovascular era. J Vasc Surg 2012;56:834-838. https://doi.org/10.1016/j.jvs.2012.04.021 278 Julian OC, Javid H, Dye WS, El Issa S. Diagnosis and surgical approach to aorticoiliac arterial disease. Am J Cardiol 1959;4:622-631. https://doi.org/10.1016/0002-9149(59)90146-8 279 Dahlen CP, Schlumberger FC. Surgery of the diseased horseshoe kidney. Am J Surg 1957;93:405-412. https://doi.org/10.1016/0002-9610(57)90830-9 280 Szilagyi DE, Smith RF, Whitcomb JG. The kidneys in surgery of the abdominal aorta. AMA Arch Surg 1959;79:252-268. https://doi.org/10.1001/archsurg.1959.04320080088011 281 Felton WL 2nd, Miller JE. Surgical re-section of abdominal aortic aneurysm associated with horseshoe kidney. J Okla State Med Assoc 1962;55:480-483. 282 Wilder JR, Koch JM, Stein A. Abdominal aortic aneurysms in association with horseshoe kidney. JAMA 1963;183:1038-1041. https://doi.org/10.1001/jama.1963.63700120035017a 283 Falor WH, Rufflo RA. Horsehoe kidney complicated by abdominal aortic aneurysm. J Urol 1964;91:131-134. https://doi.org/10.1016/s0022-5347 (17)64074-6 284 Mannick JA, Brooks JW, Bosher LH Jr, Hume DM. Ruptured aneurysms of the abdominal aorta; a reappraisal. N Engl J Med 1964;271:915-920. https://doi.org/10.1056/nejm196410292711801 285 Lynn RB, Bruce AW. An abdominal

Kim et al.

aortic aneurysm associated with a horseshoe kidney. Can Med Assoc J 1965;93:979-980. 286) Minken SL, Rob CG. Abdominal an-eurysm and horseshoe kidney: a case report and collective review. Surgery 1967;61:719-722. 287) Cox WL Jr, Machado G. Abdominal aortic aneurysm with a horseshoe kidney. Angiology 1968;19:351-353. https://doi.org/10.1177/000331976801900605 288) Killen DA, Scott HW Jr, Rhamy RK. Aneurysm and arterial occlusive disease of the abdominal aorta and its major branches associated with horse-shoe kidney. Am J Surg 1968;116:920-924. https://doi.org/10.1016/0002-9610(68)90467-4 289) Cohn LH, Stoney RJ, Wylie EJ. Abdominal aortic aneurysm and horseshoe kidney. Ann Surg 1969;170:870-874. https://doi.org/10.1097/00000658-196911000-00022 290) Scott R Jr, DeBakey ME, Mani P. Surgical correction of abdominal aortic disease in 8 patients with horseshoe kidney. J Urol 1969;102:21-26. https://doi.org/10.1016/s0022-5347(17)62063-9 291) Sigler L, Geary JE. Abdominal aortic aneurysm and unexpected horseshoe kidney. J Cardiovasc Surg (Torino) 1969;10:320-323. 292) Lacombe M, Vaysse J, Andreassian B, Desmonts JM. [Aneurysm of the abdominal aorta and horse-shoe kidney. A review apropos of 2 further cases]. Ann Chir Thorac Cardiovasc 1970;9:207-215. French. 293) Marable SA, Thomford NR. Abdominal aortic aneurysm associated with horseshoe kidney: 1970;21:124-129. https://doi.org/10.1177/000331977002100210 294) Press C. An abdominal aortic aneurysm associated with a horseshoe kidney. Vasc Surg 1970;4:71-75. https://doi.org/10.1177/153857447000400111 295) Coquillaud JP, Roullet JC, Bersay C, Roger W. [A new case of abdominal

aorta aneurysm associated with a horseshoe kidney]. Chirurgie 1971;97: 717-721. French. 296) Davis JT Jr, Hardin WJ, Hardy JD, Neely WA. Abdominal aneurysm and horseshoe kidney. South Med J 1971;64:75-77. https://doi.org/10.1097/00007611-197101000-00015 297) Hardy JD, Timmis HH. Abdominal aortic aneurysms: special problems. Ann Surg 1971;173:945-965. https://doi.org/10.1097/0000658-197106010-00013 298) Cayten CG, Davis AV, Berkowitz HD, Roberts B. Ruptured abdominal aortic aneurysms in the presence of horse-shoe kidneys. Surg Gynecol Obstet 1972;135:945-949. 299) Frawley JE, Dickson GH, Jamieson CW, Eastcott HH. Abdominal aortic aneurysm and horse-shoe kidney. Br J Surg 1972;59:513-517. https://doi.org/10.1002/bjs.1800590705 300) Evans WE, Moser BM. Aortic aneurysm and horseshoe kidney. Vasc Surg 1973;7:56-59. https://doi.org/10.1177/153857447300700108 301) Symes JM, Eadie DG. Horseshoe kidney and abdominal aortic aneurysm. Br J Surg 1973;60:243-245. https://doi.org/10.1002/bjs.1800600321 302) Vereecken L, Derom F, De Roosevelt J. A case of ruptured aortic aneurysm associated with horseshoe kidney. Acta Chir Belg 1973;22:46-49. 303) Fuller CH, Spence HM, Willbanks OL. Management of horseshoe kidney and pelvic kidney during aortic operation. South Med J 1974;67:492-494. https://doi.org/10.1097/00007611-197404000-00026 304) Bietz DS, Merendino KA. Abdominal aneurysm and horseshoe kidney: a review. Ann Surg 1975;181:333-341. https://doi.org/10.1097/00000658-197503000-00015 305) van Gelderen PW, Brands LC. Rup-tured aneurysm of the abdominal aorta in the presence of a horseshoe kidney. Arch Chir Neerl 1975;27:271-276.

306) Soriano J, Alpert J, Parsonnet V, Brief DK, Brener BJ. Abdominal aortic aneurysm and the horseshoe kidney. J Med Soc N J 1976;73:584-588. 307) Brown L, Martinez L, Mannix H Jr. Abdominal aortic aneurysm and horseshoe kidney in a 91-year-old man. Am Surg 1977;43:531-533. 308) Bugge-Asperheim B, Birkeland S, Helgerud P. Horseshoe kidney and ruptured abdominal aortic aneurysm. Scand J Urol Nephrol 1977;11:89-92. https://doi.org/10.3109/00365597709179699 309) Ezzet F, Dorazio R, Herzberg R. Horseshoe and pelvic kidneys associated with abdominal aortic aneurysms. Am J Surg 1977;134:196-198. https://doi.org/10.1016/0002-9610(77)90342-7 310) Landes RG, Trumbull HR, Nicoloff DM. Abdominal aortic aneurysm with rupture into inferior vena cava associated with horseshoe kidney. Ann Surg 1978;187:329-331. https://doi.org/10.1097/00000658-197803000-00021 311) Lobe TE, Martin EW Jr, Cooperman M, Vasko J, Evans WE. Abdominal aortic surgery in the presence of a horse-shoe kidney. Ann Surg 1978;188:71-78. https://doi.org/10.1097/00000658-197807000-00012 312) Schwilden ED, Barwegen M, van Dongen RJ. [Aortic aneurysm and horseshoe kidney--case report and collective review (author's transl)]. Langenbecks Arch Chir 1978;346:135-148. German. https://doi.org/10.1007/bf01261400 313) Zisis EG, McCann WJ, Mahoney WD, Schraft WC. Clinical case reports. Vasc Surg 1978;12:198-203. https://doi.org/10.1177/153857447801200308 314) Brown OW, Dosick SM, Blakemore WS. Abdominal aortic aneurysm and horseshoe kidney. A different perspective. Arch Surg 1979;114:860-861. https://doi.org/10.1001/archsurg. 1979.01370310102020 315) Sidell PM, Pairolero PC, Payne WS, Bernatz PE, Spittel JA Jr. Horseshoe

Clinical Practice Guideline on AAA

kidney associated with surgery of the abdominal aorta. Mayo Clin Proc 1979;54:97-103. 316) Connelly TL, McKinnon W, Smith RB 3rd, Perdue GD. Abdominal aortic surgery and horseshoe kidney. Arch Surg 1980;115:1459-1463. https://doi.org/10.1001/archsurg.1980.01380120031008 317) Donati A, Di Bartolomeo R, Turinetto B, Coli G, Galli R. Abdominal aortic aneurysm and horseshoe kidney. J Cardiovasc Surg (Torino) 1980;21:632-636. 318) Starr DS, Foster WJ, Morris GC Jr. Re- section of abdominal aortic aneurysm in the presence of horseshoe kidney. Surgery 1981;89:387-389. 319) Gillet M, Mantion G, Boillot A, Causs- in J. [Abdominal aortic aneurysm ruptured into the inferior vena cava, and horseshoe kidney]. Chirurgie 1982;108:811-815. French. 320) Poulias GE, Polemis L, Skoutas B, Doundoulakis N, Papaoannou K, Sendekeya S, et al. Successful resection of ruptured abdominal aortic aneurysm into the inferior vena cava, in the presence of a horseshoe kidney. Case report and review of the literature. J Cardiovasc Surg (Torino) 1982;23:415-421. 321) Du Toit DF, Louwrens H, Klompje J, Groenewald JH. Ruptured abdominal aortic aneurysm and horseshoe kidney. A case report. S Afr Med J 1983; 64:750-751. 322) Gutowicz MA, Smullens SN. Ruptured abdominal aortic aneurysm with horseshoe kidney. J Vasc Surg 1984; 1:689-691. https://doi.org/10.1067/mva.1984.avs0010689 323) Louagie YA, Schoevaerdts JC, D'Udekem FD, Ponlot R. Horseshoe kidney and abdominal aortic aneurysm rysm. Acta Chir Belg 1984;84:249-254. 324) Costantino MJ, Montgomery TA. Horseshoe kidney associated with aortic aneurysm. J Med Assoc Ga 1986;75:212-214. 325) Hardin CA. Abdominal aortic sur-

gery & horseshoe kidney. Kans Med 1986;87:274-275, 290. 326) Martorell A, Callejas JM, Caralps A, Viver E. [Aneurism of the abdominal aorta and horseshoe kidney. Apropos of a case]. Angiologia 1986;38:208-211. Spanish. 327) Pender DJ. Ruptured abdominal aortic aneurysm with horseshoe kidney. Br J Hosp Med 1986;35:414-415. 328) Moer A, Solheim K. [Horseshoe kidney and abdominal aortic aneurysm]. Tidsskr Nor Laegeforen 1987;107:540-541. Norwegian. 329) Svensson LG, Persson LA, Cohen PM, Gaylis H. Successful management of ruptured septic aortic aneurysm and horseshoe kidney with multiple renal arteries. A case report. S Afr J Surg 1987;25:161-163. 330) Taylor DC, Sladen JG, Maxwell T. Aortic surgery and horseshoe kidney: a challenging surgical problem. Can J Surg 1987;30:431-433. 331) Van Damme H, Garcez JL, Dereume JP. [Aneurism of the abdominal aorta and horseshoe kidney. Apropos of a case and review of the literature]. J Mal Vasc 1987;12:241-245. French. 332) Waters DJ, Esper AN, Stanley WE. Abdominal aortic aneurysm repair and the horseshoe kidney. J Am Ostepathox Assoc 1987;87:681-683. 333) Bomalaski MD, Gardner AL, Madison DL. Aortic surgery complicated by horseshoe kidney. Indiana Med 1988;81:688-693. 334) Morin JF, Johnston KW. Thoracoabdominal retroperitoneal approach for repair of abdominal aortic aneurysm associated with horseshoe kidney. Ann Vasc Surg 1988;2:82-84. https://doi.org/10.1016/50890-5096(06)60784-x 335) Huber D, Griffin A, Niesche J, Frawley J, Gray L. Aortic aneurysm surgery in the presence of a horseshoe kidney. Aust N Z J Surg 1990;60:963-966. https://doi.org/10.1111/j.1445-2197.1990.tb07514.x 336) Tapper SS, Martin RS 3rd, Edwards WH, Meacham PW. Ruptured ab-

dominal aortic aneurysm and horseshoe kidney. South Med J 1990;83:224-226. https://doi.org/10.1097/00007611-199002000-0002337) de Brito CJ, Silva LA, Fonseca Filho VL, Fernandes DC. Abdominal aortic aneurysm in association with horseshoe kidney. Int Angiol 1991;10:122-125.338) Giordanengo F, Vandone P, Pizzocari P, De Monti M, Mattioli A. [Abdominal aortic aneurysm and horseshoe kidney. Clinical cases]. Minerva Cardio-angiol 1991;39:97-102. Italian.339) Mason RA, Kvilekval KH, Hartman A, Giron F. The retroperitoneal approach to aortic surgery associated with horseshoe kidney. J Cardiovasc Surg (Torino) 1991;32:763-766.340) Yaman M, Wooster D, Bojanowski V, Louch R. Two patients with horseshoe kidney and ruptured abdominal aortic aneurysm. Can J Surg 1991;34:238-241.341) Giorgetti PL, Bordoni MG, De Monti M, Rignano A, Marenghi MC, Giordanengo F. [The rupture of an abdominal aortic aneurysm in a patient with a fused horseshoe kidney. A clinical case report]. Minerva Chir 1992;47:59-63. Italian.342) Gutowski P, Sikorski A, Cnotliwy M, Michalak T. [Symptomatic aneurysm of the abdominal aorta with coex-istent horseshoe kidney]. Wiad Lek 1993;46:394-396. Polish.343) Julia P, Hanotel MC, Ghalayini B, Fabiani JN. Abdominal aortic aneurysm associated with horseshoe kidney and duplication of the inferior vena cava. Ann Vasc Surg 1993;7:587-589.https://doi.org/10.1007/bf02000156344344344444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444

Kim et al.

346) Shortell CK, Welch EL, Ouriel K, Green RM, DeWeese JA. Operative management of coexistent aortic disease and horseshoe kidney. Ann Vasc Surg 1995;9:123-128. https://doi.org/10.1007/bf02015326 347) Liapis C, Misiakos E, Verikokos C, Dousaitou B, Gugulakis A, Sechas M. Seclusion of an abdominal aortic aneurysm in the presence of an unusual horseshoe kidney: a case report. Vasc Surg 1996;30:349-354. https://doi.org/10.1177/153857449603000415 348) Moriyasu K, Funami M, Narisawa T, Matsuo Y, Inoue K, Takaba T. The retroperitoneal approach to aortoiliac surgery associated with a horseshoe kidney: report of a case. Surg Today 1996;26:655-657. https://doi.org/10.1007/bf00311676 349) Adoumie R, Hamman J. Retroperitoneal repair of an abdominal aortic aneurysm associated with a horseshoe kidney. J Ky Med Assoc 1997;95:143-144. 350) Artioukh DY, Wake PN, Edwards PR, Moody AP. Problems of abdominal aortic aneurysm associated with a vasc Eung 1997;14:75-78. https://doi.org/10.1016/s1078-5884(97)80230-4 351) Lee F, Quick CR. Abdominal aortic aneurysm associated with horseshoe kidney and duplication of inferior vena cava--an extra-peritoneal approach. Eur J Vasc Endovasc Surg 1997;14:40-467. https://doi.org/10.1016/s1078-5884(97)80293-6 352) Lotina SL, Davidović LB, Kostić DM, Velimirović DV, Petrović PL, Perisić-Savić MV, et al. [Surgery of abdominal aorta with horseshoe kidney]. Srp Arh Celok Lek 1997;125:36-44. Serbian. 353) Luther B, Sandmann W, Reiher L, Lynen P. [Aortic aneurysm in horse-shoe kidney—special diagnosis and therapy]. Chirurg 1997;68:403-409. German. 354) Canova G, Masini R, Santoro E, Bartolomeo S, Martini C, Becchi G. Surgical treatment of abdominal aortic

aneurysm in association with horseshoe kidney. Three case reports and a review of technique. Tex Heart Inst J 1998;25:206-210. 355) Akiyama K, Inoue T, Nemoto M, Goshima M, Koga M, Negishi N, et al. A case report of nonresective staple exclusion of abdominal aortic aneurysm associated with horseshoe kidney. Ann Thorac Cardiovasc Surg 2000;6:199-202. 365) Kouzai T, Takase K, Suwa Y, Moriyama M, Mou M, Kurata H, et al. [Renal cell carcinoma in a horseshoe kidney with abdominal aortic aneurysm: a case report]. Hinyokika Kiyo 2000;46:15-17. Japanese. 357) Vogt PR, Schmidli J. [Horseshoe kidney and aneurysm of the abdominal aorta]. Schweiz Med Wochenschr 2000;130:756. German. 358) Jansen WB, Bogdanowicz JF, Welling L. Surgical treatment of renal cell carcinoma in a horseshoe-shaped kidney concomitant with an aortic aneurysm. Eur J Vasc Endovasc Surg 2001;22:280-281. https://doi.org/10.1053/ejvs.2001.1254 359) Lauter DM, Maxin M. Abdominal aortic aneurysm and a horseshoe kidney. J Am Coll Surg 2001;192:410. https://doi.org/10.1016/s1072-7515(01)00779-7 360) Bastounis E, Georgopoulos S, Pikoulis E, Leppaniemi A, Diamantis T. Abdominal aortic aneurysm associated aneurysm associated with a horseshoe kidney and renal carcinoma: a case report. Cardiovasc Surg 2002;10:506-507. https://doi.org/10.1016/s0967-2109(02)00062-5 361) Mcllhenny C, Scott RN. Abdominal aortic aneurysm in association with horseshoe kidney. Eur J Vasc Endovasc Surg 2002;23:556-558. https://doi.org/10.1053/ejvs.2002.1624 362) Meyer A, Roesler S, Schmidt M, Vetter S, Preuss M, Omlor G. [Primary and secondary aortoiliac reconstructions in patients with coexistent horseshoe and pelvic kidney]. Zentralbl Chir 2002;127:110-113. German. https://

doi.org/10.1055/s-2002-22023 363) Silverstein AD, Weizer AZ, Anderson EE. Ruptured abdominal aortic aneurysm complicated by horseshoe kidney and renal cell carcinoma. Urology 2002;60:1108. https://doi.org/10.1016/s0090-4295(02)01986-6 364) Jakutis A, Mickevicius J, Putelis R, Inciūra D, Trumbeckas D. [Abdominal aortic aneurysm and horseshoe kidney anomaly]. Medicina (Kaunas) 2003;39:574-578. Lithuanian. 365) Renzulli JF, Borromeo JR, Barkhordarian S, Sumpio BE. Abdominal aortic aneurysm in association with a congenital pelvic horseshoe kidney: sentinel report and technical consideration. Vasc Med 2003;8:197-199. https://doi.org/10.1191/1358863x03vm495cr 366) Noguchi M, Hirashima S, Eishi K, Takahashi H, Hazama S, Takai H, et al. Surgical treatment of abdominal aortic aneurysm associated with horseshoe kidney and coagulopathy case report. J Cardiovasc Surg (Torino) 2004;45:505-509. 367) Okraszewski J, Górski A. Abdominal aortic aneurysm with horseshoe kidney. Acta Angiol 2005;11:222-225. 368) Göksel O, Cinar B, Kömürcü G, Ahin S, Eren T. Surgical treatment of abdominal aortic aneurysms associated with horseshoe kidney. Vascular 2006;14:27-31. https://doi.org/10.2310/6670.2006.00002 369) Yamamoto N, Mohri M, Kato G, Oki A, Tedoriya T. Isthmus of a horse-shoe kidney overlying a ruptured abdominal aortic aneurysm: a case report. Ann Thorac Cardiovasc Surg 2006;12:149-151. 370) Frego M, Bianchera G, Angriman I, Pilon F, Fittà C, Miotto D. Abdominal aortic aneurysm with coexistent horseshoe kidney. Surg Today 2007;37:626-630. https://doi.org/10.1007/s00595-006-3451-y 371) Kawanishi Y, Tanaka H, Nakagiri K, Yamashita T, Okada K, Okita Y. Abdominal aortic aneurysm associated with horseshoe kidney. Asian Cardiovasc

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Thorac Ann 2008;16:e28-e29. https://doi.org/10.1177/021849230801600325 372) Radermecker MA, Van Damme H, Kerzmann A, Creemers E, Limet R. Association of abdominal aortic aneurysm, horseshoe kidneys, and left-sided inferior vena cava: report of two cases. J Vasc Surg 2008;47:645-648. https://doi.org/10.1016/j.jvs.2007.08.053 373) Senarriaga Ruiz de la Illa N, Vega Manrique R, Lacasa Viscasillas I, Irarte Soldevilla I, Unda Urzaiz M. New case of an infrarenal abdominal aortic aneurysm associated with horseshoe kidney. Actas Urol Esp 2009;33:1141-1144. 374) Makita S, Yoshizaki T, Tabuchi N. A case of abdominal aortic aneurysm with horseshoe kidney. Ann Thorac Cardiovasc Surg 2009;15:129-132. 375) Davidović L, Marković M, Ilic N, Koncar I, Kostić D, Simić D, et al. Repair of abdominal aortic aneurysms in the presence of the horseshoe kidney. Int Angiol 2011;30:534-540. 376) Galiñanes EL, Quick J, Nichols WK, Ross CB, Faizer R, Morris ME. Horseshoe kidney and inflammatory abdominal aortic aneurysm: a case report and literature review. Ann Vasc Surg 2011;25:387.e7-387.e9. https://doi.org/10.1016/j.avsg.2010.09.019 377) Arquillo IML, Rey JV, Muñoz EF, de Sá JME, Carrera AR. Repair of an abdominal aortic aneurysm in a patient with a horseshoe kidney and iliac occlusion. Is endovascular treatment the only option? Angiología 2013;65:228-230. https://doi.org/10.1016/j.angio.2013.03.004 378) Muñoz-García R, González-González S, Biguria-Rodríguez F, González-López M, Rubio-Lobato L, Arango-Segura P, et al. Retroperitoneal surgical approach to a mycotic aneurysm in a patient with a horseshoe kidney. Cir Cardiovasc 2013;20:39-41. https://doi.org/10.1016/S1134-0096(13)70010-X 379) Chihara S, Fujino T, Matsuo H, Hidaka A. Surgical treatment of ab-

dominal aortic aneurysm associated with horseshoe kidney: symphysiotomy using harmonic focus. Ann Thorac Cardiovasc Surg 2014;20 Suppl:922-925. https://doi.org/10.5761/atcs.cr.13-00115 380) Obidike S, Woha A, Aftab F. Fused ureters in patient with horseshoe kidney and aortic abdominal aneurysm. J Surg Case Rep 2014;2014:rju113. https://doi.org/10.1093/jscr/rju113 381) De Caridi G, Massara M, Greco M, Mastrojeni C, Serra R, Salomone I, et al. Surgical treatment of a voluminous infrarenal abdominal aortic aneurysm with horseshoe kidney: tips and tricks. Ann Vasc Dis 2015;8:324-327. https://doi.org/10.3400/avd.cr.15-00083 382) Hajibandeh S, Hajibandeh S, Johnpulle M, Perricone V. Transperitoneal repair of a juxtaprenal abdominal aortic aneurysm and co-existent horseshoe kidney with division of the renal isthmus. J Surg Case Rep 2015;2015:rjv134. https://doi.org/10.1093/jscr/rjv134 383) Han A, Kim SM, Choi C, Min SI, Ha J, Min SK. Open surgical repair of abdominal aortic aneurysm coexist-ing with horseshoe kidney. Vasc Spe-cialist Int 2015;31:54-57. https://doi.org/10.5758/vsi.2015.31.2.54 384) Ikeda A, Tsukada T, Konishi T, Matsuzaki K, Jikuya T, Hiramatsu Y. Open surgical repair for a ruptured abdominal aortic aneurysm with a horseshoe kidney. Ann Vasc Dis 2015;8:52-55. https://doi.org/10.3400/avd.cr.14-00099 385) Petrovic N, Eynaud SM, Pejkic S. Rup-tured abdominal aortic aneurysm with a horseshoe kidney: an uncommon but potentially troublesome coexist-tence. Malta Med J 2017;29:29-33. 386) Davidovic LB, Markovic M, Kos-tic D, Zlatanovic P, Mutavdzic P, Cvetic V. Open repair of ruptured abdominal aortic aneurysm with as-sociated horseshoe kidney. Int Angi 2018;37:471-478. https://doi.org/10.23736/s0392-9590.18.04039-7 387) Gabriele P, Emanuele G, Grilli Cicil-

ioni C, Sara S, Luciano C. Ruptured abdominal aortic aneurysm and horseshoe kidney: isthmus sectioning by Endo GIA. Vasc Endovascular Surg 2019;53:599-601. https://doi.org/10.1177/1538574419859451 388) Bálint S, Mihály Z, Oláh Z, Sótonyi P. [Open repair of abdominal aortic aneurysms in patients with horseshoe kidney]. Orv Hetil 2020;161:1966-1971. Hungarian. https://doi.org/10.1556/650.2020.31863 389) Bounssir A, Bakkali T, Taghi H, Sefiani Y, Lekehal B. Best strategy in managing the association of horse-shoe-kidney and abdominal aortic aneurysm: case report. Int J Surg Case Rep 2020;75:11-15. https://doi.org/10.1016/j.ijscr.2020.08.034 390) Coelho GMA, França RAA, da Rocha RDL, Pantoja MO, Lacerda PS, Souza JEDS, et al. Symptomatic abdominal aortic aneurysm in a patient with a horseshoe kidney. J Vasc Bras 2020; 19:e20200088. https://doi.org/10.1590/1677-5449.200088 391) Tinelli G, Sica S, Minelli F, Natola M, De Nigris F, Tshomba Y. Horseshoe kidney protection with histidine-tryptophan-ketoglutarate solution during surgical abdominal aortic aneurysm repair. Ann Vasc Surg 2020;63:459.e5-459.e8. https://doi.org/10.1016/j.avsg.2019.08.105 392) Yesildal C, Yavuzsan AH, Kirecci SL, Koramaz I, Yilmaz M, Albayrak A. The rupture of an abdominal aortic aneurysm at the level of horseshoe kidney: a case report. Urol Case Rep 2019;30:101110. https://doi.org/10.1016/j.eucr.2019.101110 393) Tomić A, Marjanović I, Sekulić D. Abdominal aortic aneurysm and horseshoe kidney - open surgical repair: a case report. Vojnosanit Pregl 2021;78:261-264. https://doi.org/10.2298/VSP190925059T 394) Christoforou P, Kapoulas K, Bekos C. Open surgical repair of abdominal repair of abdominal aortic aneurysm and horseshoe kidney: a strange relationship. Int J Surg

Kim et al.

Case Rep 2022;93:106971. https://doi.org/10.1016/j.ijscr.2022.10.06971 395) Fiorani P, Faraglia V, Speziale F, Lauri D, Massucci M, De Santis F. Extraperitoneal approach for repair of inflammatory abdominal aortic aneurysm. J Vasc Surg 1991;13:692-697. https://doi.org/10.1067/mva.1991.26792 396) Todd GJ, DeRose JJ Jr. Retroperito-neal approach for repair of inflammatory aortic aneurysms. Ann Vasc Surg 1995;9:525-534. https://doi.org/10.1007/bf02018825 397) Cannon WB, Fraser J, Cowell EM. The preventive treatment of wound shock. JAMA 1918;70:618-621. 398) Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-1109. https://doi.org/10.1056/nejm199410273311701 399) Carrick MM, Morrison CA, Tapia NM, Leonard J, Suliburk JW, Norman MA, et al. Intraoperative hypotensive resuscitation for patients

undergoing laparotomy or thoracotomy for trauma: early termination of a randomized prospective clinical trial. J Trauma Acute Care Surg 2016;80:886-896. https://doi.org/10.1097/ta.00000000000001044 400) Dick F, Erdoes G, Opfermann P, Eberle B, Schmidli J, Von Allmen RS. Delayed volume resuscitation during initial management of ruptured abdominal aortic aneurysm. J Vasc Surg 2013;57:943-950. https://doi.org/10.1016/j.jvs.2012.09.072. 401) Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma 2002;52:1141-1146. https://doi.org/10.1097/00005373-200206000-00020 402) Morrison CA, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J

Trauma 2011;70:652-663. https://doi.org/10.1097/ta.0b013e31820e77ea 403] Li S, Phillips A, Mikati N, Brown J, Tzeng E, Makaroun M, et al. Blood pressure control during transfer for patients with ruptured abdominal aortic aneurysms. J Vasc Surg 2022;76:E36-E37. https://doi.org/10.1016/j.jvs.2022.06.065 404] Lu Y, Liu L, Wang J, Cui L. Controlled blood pressure elevation and limited fluid resuscitation in the treatment of multiple injuries in combination with shock. Pak J Med Sci 2018;34:1120-1124. https://doi.org/10.12669/pjms.345.15465 405] Schreiber MA, Meier EN, Tisherman SA, Kerby JD, Newgard CD, Brasel K, et al.; ROC Investigators. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial. J Trauma Acute Care Surg 2015;78:687-695; discussion 695-697. https://doi.org/10.1097/ta.000000000000600