Our Goal

The WARRIORS trial aims to improve outcomes and reduce aneurysm-related death for women diagnosed with small abdominal aortic aneurysms. To achieve this goal, the research is designed to answer six key questions, stated here in clear, non-technical language:

Primary Question: Does early repair reduce AAA-related death and rupture?

This is the central question of the trial. For women with small AAA (4.0–5.4 cm), does performing EVAR repair at an earlier stage — rather than waiting until the aneurysm reaches 5.5 cm — reduce the risk of dying from experiencing a AAA-rupture or related cause over five years?

Because women face a greater rupture risk at smaller aneurysm sizes than men, earlier intervention may save lives. WARRIORS is designed to find out.

Additional Questions:

Question 2: Does early repair improve quality of life for women over 5 years?

Living with an unrepaired aneurysm can cause anxiety and uncertainty. At the same time, having surgery carries its own recovery period and emotional impact. We want to understand how each approach affects women’s overall well-being.

Studies examining decision-making around aneurysm surgery have rarely included women, so we don’t yet know what matters most to women when navigating AAA care. WARRIORS will measure quality of life and anxiety through surveys at enrollment and again at years 1, 3, and 5. This will help ensure that future recommendations for women with AAA reflect their whole health — not just clinical outcomes.

Question 3: Does early repair lower the risk of dying during or after surgery?

Women face a significantly higher risk of dying during a planned AAA repair than men — for both open surgery and minimally invasive EVAR (both at 5.5cm or greater). In emergency (unplanned) repairs, this difference for women is even more striking: in-hospital death for women undergoing emergency AAA repair was approximately 45.9%, compared to 34.5% for men.

[EDITOR NOTE: Insert in-hospital mortality chart here (Fig. 2 from investigators’ PDF: elective AAA repair mortality by sex, open vs EVAR).]

By repairing the aneurysm while it is still small and the patient is healthier, early EVAR (4.0-5.4cm) may reduce the risk of dying during surgery. WARRIORS will track death around time of surgeries across both groups.

Question 4: Does early repair reduce major cardiovascular complications over 5 years?

Current AAA repair — whether open surgery or standard EVAR at 5.0–5.5 cm — can place significant stress on the heart and vascular system. Patients may experience complications such as heart attack or abnormal heart rhythms (arrhythmia) during or after the procedure, and these types of complications are associated with lower long-term survival.

WARRIORS is investigating whether performing EVAR earlier, at 4.0–5.4 cm, may reduce the frequency of these major cardiovascular events (MACE). By intervening while the aneurysm is smaller and the patient may be in better health, early EVAR has the potential to lower the cardiovascular risks associated with AAA care. WARRIORS will track how often women in each group experience major cardiovascular events (MACE) over the five-year follow-up period.

Question 5: Are more women able to have a minimally invasive repair if treated earlier?

As an aneurysm grows, it can change shape in ways that make minimally invasive EVAR technically impossible. To perform EVAR, surgeons need enough healthy vessel wall above and below the aneurysm to anchor a stent graft securely without blocking blood flow to nearby organs, such as the kidneys. When this is no longer achievable, a higher-risk open repair or complex endovascular procedure may be the only treatment options.

If waiting leads to more women losing the ability for their AAA to have a minimally invasive repair, that represents a direct harm from delayed treatment.

WARRIORS will track how many women whose aneurysms are watched in the surveillance group lose their ability to have a standard EVAR as their aneurysm grows.

[EDITOR NOTE: Insert Kaplan-Meier survival curves here (oAAA and EVAR: No Postop Arrythmia vs Postop Arrythmia, from investigators’ PDF).]

Question 6: Are there lower costs to treating an aneurysm early?

Aneurysm care involves ongoing imaging, clinic visits, and potentially multiple procedures over many years. Understanding the full cost of each approach — early repair versus long-term surveillance followed by later surgery — matters for patients, providers, and healthcare systems alike.

WARRIORS will track the costs of AAA imaging and procedures over five years. This information will help patients and providers make informed decisions about the value of different care pathways.