Editor's Choice - Systematic Review and Meta-analysis on the Use of Aortic Size Index in Women with Infrarenal Abdominal Aortic Aneurysms

Laurence Bertrand; Anna Pouncey; Daniel Caldeira; Ryan Gouveia E Melo; Isabelle Van Herzeele; Carlota F Prendes; ESVS Consensus Group on Women with Arterial Vascular Disease

doi:10.1016/j.ejvs.2025.07.053

Editor's Choice - Systematic Review and Meta-analysis on the Use of Aortic Size Index in Women with Infrarenal Abdominal Aortic Aneurysms

Eur J Vasc Endovasc Surg. 2025 Dec;70(6):766-775. doi: 10.1016/j.ejvs.2025.07.053. Epub 2025 Aug 11.

Authors

Laurence Bertrand¹, Anna Pouncey², Daniel Caldeira³, Ryan Gouveia E Melo³, Isabelle Van Herzeele⁴, Carlota F Prendes⁵; ESVS Consensus Group on Women with Arterial Vascular Disease

Collaborators

ESVS Consensus Group on Women with Arterial Vascular Disease:
Barbara Rantner⁶, Venita Chandra⁷, Jos C van den Berg⁸, Zayed Hany⁹, Riikka Tulamo¹⁰, Anders Wanhainen¹¹, Chris Twine¹²

Affiliations

¹ Vascular Surgery Department, Ludwig Maximilian University Hospital, Munich, Germany.
² Department of Surgery and Cancer, Imperial College London, London, UK.
³ Vascular Surgery Department, Cardiology Department, Unidade Local de Saúde de Santa Maria (ULSSM), Lisbon, Portugal; Faculty of Medicine of the University of Lisbon, Lisbon, Portugal; Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE) and CEMBE (Centro de Estudos de Medicina Baseada na Evidência), Lisbon, Portugal.
⁴ Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium.
⁵ Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden. Electronic address: carlota.f.prendes@gmail.com.
⁶ Vascular surgery Department, Ludwig Maximilian University Hospital, Munich, Germany.
⁷ Division of Vascular Surgery, Stanford University Medical Center, Stanford, California, USA.
⁸ Interventional Radiology, Clinica Luganese Moncucco, Lugano, Switzerland.
⁹ Department of Vascular Surgery, Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK.
¹⁰ Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
¹¹ Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden.
¹² North Bristol NHS Trust and University of Bristol, Bristol, UK.

PMID: 40803504
DOI: 10.1016/j.ejvs.2025.07.053

Abstract

Objective: The aim of this study was to compare aortic size index (ASI) (aortic diameter/body surface area) with aortic diameter (AD) in patients with infrarenal abdominal aortic aneurysms (AAAs) for screening, diagnosis, and outcomes, focusing on women.

Data sources: Cochrane, MEDLINE, and Web of Science Core Collection databases.

Review methods: Databases were searched (last update 14 May 2024) for reports on ASI in patients with AAA reporting sex disaggregated data. A systematic review and meta-analysis was performed following the PRISMA guidelines.

Results: Eleven studies with 150 028 cases (19.8% women) were included. The reported outcomes exhibited considerable heterogeneity. Three studies evaluated incidence and or prevalence rates, seven reported on AD and ASI at the time of repair, three considered rupture risk, and five evaluated peri-operative outcomes. In one study, AAA prevalence was 5.7% in men and 4.5% in women with a cutoff ASI ≥ 1.5 cm/m² (corresponding to a 30 mm AD in men and 26 mm AD in women), compared with 5.7% in men vs. 2.4% in women using an AD ≥ 30 mm cutoff. ASI ≥ 2.7 cm/m² was found to be associated with a distribution of ruptured repairs of 12% in both sexes, corresponding to 55 mm AD in men and 49 mm AD in women. A meta-analysis of aneurysm size at the time of surgical repair found that women were operated on at an estimated 3.05 mm smaller diameter but 0.32 cm/m² higher ASI. Higher ASI was associated with worse clinical outcomes in women, but not consistently so in men.

Conclusion: Women undergo AAA repair at lower AD but higher ASI than men. Use of ASI suggests that women undergo diagnosis and treatment at a later stage of disease. This warrants reconsideration of current AD threshold recommendations and further in depth studies assessing the impact of ASI standardisation.

Keywords: Abdominal aortic aneurysm; Aortic diameter; Aortic size index; Infrarenal; Treatment; Women.

Publication types

Systematic Review
Meta-Analysis

MeSH terms

Aorta, Abdominal* / diagnostic imaging
Aorta, Abdominal* / pathology
Aortic Aneurysm, Abdominal* / diagnosis
Aortic Aneurysm, Abdominal* / diagnostic imaging
Aortic Aneurysm, Abdominal* / epidemiology
Aortic Aneurysm, Abdominal* / pathology
Aortic Aneurysm, Abdominal* / surgery
Body Surface Area
Female
Humans
Male
Prevalence
Risk Assessment
Risk Factors
Sex Factors