The Association of Abdominal Aortic Aneurysm Diameter Indexed to Patient’s Height with Symptomatic Presentation and Mortality

Published:November 15, 2021DOI:



      Current guidelines to repair AAA is determined by AAA maximal diameter and/or its growth rate. However, many studies suggested that aneurysm diameter alone is not sufficient to predict risk of rupture or symptomatic presentation. Several investigators attempted to relate AAA diameter to body surface area in predicting rupture, but these calculations have not resulted in conclusive evidence. We sought in this analysis to introduce a novel diameter-to-height index (DHI) and test its utility in predicting symptomatic presentation including rupture, 30-day and 5-year mortality.


      The Vascular Quality Initiative database (VQI, 2003-2020) was used to identify patients undergoing open or endovascular abdominal aortic aneurysm repair (EVAR). DHI was defined as AAA diameter in centimeter/height in centimeter, which yielded a score of 1 to 10.
      Multivariable logistic regression analysis was performed to assess risk of symptomatic presentation including rupture and 30-day mortality. Receiver operating curves (ROC) were plotted. Survival analyses techniques were utilized to report hazard of 5-year mortality.


      A total of 64,595 patients were identified, and 16.3% of them presented with symptomatic AAA including rupture. EVAR was performed in 69.8% of symptomatic AAA compared with 84.3% of asymptomatic AAA (p<.001). Symptomatic group were more likely to be females (24.6%vs19.8%; p<.001) or black (7.81%vs4.44%; p<.001). Mean DHI was higher in symptomatic group compared with asymptomatic [Mean DHI(±SD): (3.92(±1.1) vs 3.24(±0.7), p<.001)]. Adjusted odds of symptomatic presentation increased with increasing DHI [aOR(95%CI): 1.70(1.59-1.83); p<.001]. Active smoking increased the risk of symptomatic presentation [aOR(95%CI):1.38(1.28-1.51); p<.001]. However, preoperative statins and beta-blockers significantly reduced odds of symptomatic presentation [0.58(0.53-0.64); p<.001, 0.76(0.69-0.84); p<.001]. When compared to diameter, ROC to predict symptomatic status was slightly but significantly higher [0.702(0.695-0.708) vs 0.695(0.688-0.701); p<.001]. DHI increment was associated with 1.08 higher odds of 30-day mortality [aOR(95%CI):1.08(1.01-1.15); p<.001] in symptomatic AAA. Similarly, the hazard of 5-year mortality increased with increasing DHI [aHR(95%): 1.20(1.13-1.29); p<.001] in asymptomatic AAA only.


      DHI is a simple tool that can be more effective than AAA diameter in predicting symptomatic presentation. DHI varies by gender and race which can collectively help provide individualized prognosis. DHI can additionally predict 5-year mortality following AAA repair in asymptomatic AAA only, however, the odds of 30-day mortality remain similar in both groups.


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