Once physical exam has low accuracy, an image test should be indicated to confirm the presence of the abdominal aortic aneurysm. Abdominal ultrasound is cheaper, most commonly used for surveillance, well accepted by patients, does not have radiation, and is relatively accurate over serial measurements. It is also very suitable to follow up aortic diameters of initially nonsurgical patients overtime [18].

In emergency department is frequently a test of choice. An association of free abdominal fluid and large aortic diameter reveals ruptured aneurysm in many cases.

It is also useful as screening method for patients with risk factors for abdominal aortic aneurysm (see below). However, if the patient has a surgical indication for the abdominal aortic aneurysm (see below), other imaging tests should be used for a precise preoperative planning [18, 19].

Angiotomography is more expensive than ultrasound and its use involves radiation exposure and intravenous hyperosmolar contrast medium injection that can lead to allergic reactions and nefrotoxicity. However, this method offers more accurate measurements possibilities. Thus, it is the method of choice in preoperative planning for abdominal aortic aneurysms repair [19].

This method is distinguished by the absence of ionizing radiation. However, the high cost, the difficulty of analyzing calcified plaques, the low resolution when compared to angiotomography , the complexity of standardization, and intolerance in claustrophobic patients are limiting factors. Magnetic resonance imaging has its use established in patients allergic to iodine medium contrast.

Historically, the use of this technique in patients with chronic renal failure and contraindication to use of iodine contrast medium has been observed. However, recent studies have shown an increased risk of fatal nephrogenic sclerosing fibrosis in patients with chronic renal failure after intravenous injection of gadolinium. It is a second-line method in the preoperative planning for abdominal aortic aneurysms surgical repair [19].

As previously seen, abdominal aortic aneurysms are mostly asymptomatic. However, its first symptom can be rupture. The mortality rate after abdominal aortic aneurysm rupture may be greater than 90 %. Once the mortality rate for the elective repair is around 5 %, it is advisable to actively screen for patients with asymptomatic abdominal aortic aneurysm in order to avoid death [20, 21]. Screening with abdominal ultrasound an asymptomatic and selected group of patients was able to reduce the overall mortality and aneurysm-related mortality in several studies. The recommendations of the U.S. Preventive Services Task Force are summarized below:

The treatment approach for abdominal aortic aneurysms is based on the natural history of the disease, balancing the risk of rupture and the risk of the intervention and the patient’s life expectancy [1, 4, 17].

As shown above, the risk of rupture is related to aortic diameter in fusiform aneurysms, the presence of saccular aneurysm , increase of aneurysm diameter >1 cm in 12 months, or the presence of recent symptoms, particularly abdominal or lumbar pain [1, 4, 17].

On the other hand, the risk of the intervention is associated with the presence of comorbidities such as symptomatic coronary artery disease , heart failure, renal failure, chronic obstructive pulmonary disease, and old age [1, 4, 17].

The method of interventional treatment also is related to postoperative mortality. Open repair for abdominal aortic aneurysm is performed under general anesthesia and through a large midline or retroperitoneal incision. After clamping the infrarenal aorta and iliac arteries to achieve hemostasis, the surgeon opens the aneurysm sac, removing thrombus and debris from within the aorta, suturing a graft into the aorta proximally and distally at the iliac or femoral vessels, whichever is deemed appropriate. Short-term mortality for elective series ranges from 1 to 5 % [22]. Perioperative complications related to the procedure include lower extremity ischemia, bowel ischemia, pelvic ischemia, renal dysfunction, and late complications include incisional hernia, anastomotic aneurysm, graft infection, and aortoenteric fistulae. Late complications were indentified in 9.5 % of patients [23].

Endovascular surgery is performed by inserting graft components folded and compressed within a delivery sheath through the lumen of an access vessel, usually the common femoral artery. Upon deployment, the endograft expands, attaching to the aorta wall and excluding the aneurysm. Endovascular repair is associated with lower perioperative morbidity and mortality compared with open surgical repair. The short-term mortality is 1.6 %. Endograft-related complications are common and occur in 11–30 % of the cases [24]. Technical complications include vascular injury, endoleak, breakdown, fracture, or endograft collapse. Endoleak is defined as persistent flow blood into the aneurysm sac after the device placement and indicates failure to completely exclude the aneurysm. This complication is the most prevalent, occurring with all device types in an incidence of 10–45 % [25] (Table 8.2).

Therefore, intervention should be indicated when the risk of rupture is higher than the risk of the intervention and that the patient has a life expectation >1 year [28]. Indications for surgical abdominal aortic aneurysms repair are summarized in Table 8.3.