Prediction of Abdominal Aortic Aneurysm Growth After Endovascular Aortic Repair by Measuring Brachial-Ankle Pulse Wave Velocity

Published:November 05, 2021DOI:


      Although endovascular aortic repair (EVAR) has become the dominant therapeutic approach for abdominal aortic aneurysm (AAA), continued sac growth after EVAR remains a major concern and is still unpredictable. Since AAA formation is thought to arise from atherosclerotic vascular damage of the aortic wall, we hypothesize that the severity of atherosclerosis in the AAA wall may influence sac growth. Therefore, we investigated whether brachial-ankle pulse wave velocity (baPWV), a marker of atherosclerosis severity obtained by noninvasive automatic devices, can predict sac growth after EVAR.


      The data from all patients who underwent elective EVAR for AAA at a single institution from January 2012 to March 2019 were reviewed. We extracted the baPWV before EVAR and divided patients into 2 groups according to the baPWV cut-off value identified by a classification and regression tree (CART). The primary outcome was significant sac growth, defined as an increment of 5 mm or more in aneurysm size after EVAR relative to the aneurysm size before EVAR. Cox regression analysis was performed to assess the potential predictors of sac growth.


      During the follow-up period, 222 consecutive patients underwent elective EVAR for AAA. Of these, 175 patients with a median follow-up period of 36 months were included. The baPWV values were classified as <1854 cm/s (Group 0) in 100 patients and ≥1854 cm/s (Group 1) in 75 patients according to the cut-off value identified by CART. During the follow-up period, 10 (10.0%) patients in Group 0 and 18 (24.0%) patients in Group 1 demonstrated significant sac growth (P = 0.021). Risk factors for significant sac growth included baPWV (hazard ratio [HR], 3.059; 95% confidence interval [CI], 1.41–6.64; P = 0.005), age (HR, 1.078; 95% CI, 1.01–1.16; P = 0.036), and persistent type II endoleak (HR, 3.552; 95% CI, 1.69–7.48; P < 0.001). Multivariate analysis revealed that baPWV remained a significant risk factor for sac growth after adjustment for age (HR, 2.602; 95% CI, 1.15–5.82; P = 0.02) and persistent type II endoleak (HR, 2.957; 95% CI, 1.36–6.43; P = 0.006).


      The baPWV before EVAR was associated with significant sac growth after EVAR; thus, measuring the baPWV may be useful for assessing the risk of future sac growth in patients after EVAR.



      AAA (abdominal aortic aneurysm), ABI (ankle/brachial systolic blood pressure index), baPWV (brachial-ankle pulse wave velocity), CART (classification and regression tree), CI (confidence interval), CT (computed tomography), EVAR (endovascular aortic repair), HR (hazard ratio), IFU (instructions for use), PWV (pulse wave velocity)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wyss TR
        • Brown LC
        • Powell JT
        • et al.
        Rate and predictability of graft rupture after endovascular and open abdominal aortic aneurysm repair: data from the EVAR Trials.
        Ann Surg. 2010; 252: 805-812
        • Barnes M
        • Boult M
        • Maddern G
        • et al.
        A model to predict outcomes for endovascular aneurysm repair using preoperative variables.
        Eur J Vasc Endovasc Surg. 2008; 35: 571-579
        • Karthikesalingam A
        • Holt PJ
        • Vidal-Diez A
        • et al.
        Predicting aortic complications after endovascular aneurysm repair.
        Br J Surg. 2013; 100: 1302-1311
        • Schanzer A
        • Greenberg RK
        • Hevelone N
        • et al.
        Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair.
        Circulation. 2011; 123: 2848-2855
        • Iwakoshi S
        • Ichihashi S
        • Higashiura W
        • 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
        • Campa JS
        • Greenhalgh RM
        • Powell JT.
        Elastin degradation in abdominal aortic aneurysms.
        Atherosclerosis. 1987; 65: 13-21
        • López-Candales A
        • Holmes DR
        • Liao S
        • et al.
        Decreased vascular smooth muscle cell density in medial degeneration of human abdominal aortic aneurysms.
        Am J Pathol. 1997; 150: 993-1007
        • van Popele NM
        • Grobbee DE
        • Bots ML
        • et al.
        Association between arterial stiffness and atherosclerosis: the Rotterdam Study.
        Stroke. 2001; 32: 454-460
        • Kadoglou NP
        • Moulakakis KG
        • Papadakis I
        • et al.
        Changes in aortic pulse wave velocity of patients undergoing endovascular repair of abdominal aortic aneurysms.
        J Endovasc Ther. 2012; 19: 661-666
        • Pini R
        • Gallitto E
        • Faggioli G
        • et al.
        Predictors of perioperative and late survival in octogenarians undergoing elective endovascular abdominal aortic repair.
        J Vasc Surg. 2019; 69: 1405-1411
        • Wanhainen A
        • Verzini F
        • Van Herzeele I
        • 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
        • Townsend RR
        • Wilkinson IB
        • Schiffrin EL
        • et al.
        Recommendations for Improving and Standardizing Vascular Research on Arterial Stiffness: A Scientific Statement From the American Heart Association.
        Hypertension. 2015; 66: 698-722
        • Tomiyama H
        • Yamashina A
        • Arai T
        • et al.
        Influences of age and gender on results of noninvasive brachial-ankle pulse wave velocity measurement–a survey of 12517 subjects.
        Atherosclerosis. 2003; 166: 303-309
        • Yamashina A
        • Tomiyama H
        • Takeda K
        • et al.
        Validity, reproducibility, and clinical significance of noninvasive brachial-ankle pulse wave velocity measurement.
        Hypertens Res. 2002; 25: 359-364
        • Henderson EL
        • Geng YJ
        • Sukhova GK
        • et al.
        Death of smooth muscle cells and expression of mediators of apoptosis by T lymphocytes in human abdominal aortic aneurysms.
        Circulation. 1999; 99: 96-104
        • Rizzo RJ
        • McCarthy WJ
        • Dixit SN
        • et al.
        Collagen types and matrix protein content in human abdominal aortic aneurysms.
        J Vasc Surg. 1989; 10: 365-373
        • Farrar DJ
        • Green HD
        • Bond MG
        • et al.
        Aortic pulse wave velocity, elasticity, and composition in a nonhuman primate model of atherosclerosis.
        Circ Res. 1978; 43: 52-62
        • Ruiz-Feria CA
        • Yang Y
        • Thomason DB
        • et al.
        Pulse wave velocity and age- and gender-dependent aortic wall hardening in fowl.
        Comp Biochem Physiol A Mol Integr Physiol. 2009; 154: 429-436
        • Yasmin McEniery CM
        • O'Shaughnessy KM
        • et al.
        Variation in the human matrix metalloproteinase-9 gene is associated with arterial stiffness in healthy individuals.
        Arterioscler Thromb Vasc Biol. 2006; 26: 1799-1805
        • Maguire EM
        • Pearce SWA
        • Xiao R
        • et al.
        Matrix metalloproteinase in abdominal aortic aneurysm and aortic dissection.
        Pharmaceuticals (Basel). 2019; 12: 118
        • Dias NV
        • Ivancev K
        • Malina M
        • et al.
        Intra-aneurysm sac pressure measurements after endovascular aneurysm repair: differences between shrinking, unchanged, and expanding aneurysms with and without endoleaks.
        J Vasc Surg. 2004; 39: 1229-1235
        • Dias NV
        • Ivancev K
        • Kölbel T
        • et al.
        Intra-aneurysm sac pressure in patients with unchanged AAA diameter after EVAR.
        Eur J Vasc Endovasc Surg. 2010; 39: 35-41