Comment on: Decreasing aortic diameter and decreasing prevalence of infrarenal aortic aneurysms in a population-based screening programme

Correspondence to: Antonio Manenti (e-mail: antonio.manenti_2024@libero.it)

Department of Surgery

Polyclinic Hospital

Via Del Pozzo

41124 Modena, Italy

BJS, https://doi.org/10.1093/bjs/znaf156, published 20 August 2025

The interesting results reported by Siika et al.¹ demonstrate the dual possible evolution of abdominal aortic atherosclerosis. This can either result in the onset of an aneurysm or a 'small aorta', characterized by a diameter <17 mm, secondary to extensive parietal sclerosis and/or plaques infiltration. Both of these pathologies are associated with significant disruption to the elastic fibres and smooth muscle cells in the tunica media. The subsequent reparative process involves the formation of loose connective tissue, which has weak resistance to inner blood pressure and therefore favors the development of an aneurysm. Alternatively, it can consist of new, dense, irregular connective tissue with more densely packed and thickened collagen fibres, fewer cells, and intercellular substance extensively infiltrated by calcium compounds. This depends on the patient’s genetic predisposition or chemical characteristics of the atherosclerotic plaques.

A different evolution of atherosclerosis is typical of the elastic iliac arteries. Due to their smaller diameter, aneurysms are rare, whereas atherosclerotic narrowing or obstruction with a subsequent tortuous lengthening are more common. It is worth noting that these two types of pathology can occur in the same patient. Therefore, we recognize that atherosclerotic narrowing of the aorto-iliac trunks can indicate concomitant involvement of other medium-sized vessels in other vascular districts, such as the brain, heart, abdomen, and kidneys. This is often complicated by secondary thrombosis, and could explain the significant risk of death in the medium term in patients with a 'small aorta1.