**6. General**

At this point, it is important to highlight two aspects. The first one is that the accumulation of knowledge around the topic of accurate prediction of AAA rupture is large enough and significant advances have been achieved in last years although the physicians continue using the same criteria. The second one is related to the growing consensus that it is possible to improve the reliability of the AAA rupture assessment by means of the biomechanical approach.

Despite the growing interest for the behaviour of all these factors, many physicians question its clinical utility advocating the difficulties in its assessing during the everyday clinical practice. Often, these procedures require sophisticated software, very specific and accurate correlations and highly qualified personnel. This feeling appears clearly reflected in a survey carried out among vascular surgeons [85], whose outcomes are summarized in:

90% of the institutions rely their rupture risk estimation on the maximum diameter and the expansion rate, whereas only 15% use the high mechanical stress criteria;

40% of the institutions think that using their criteria, the rupture risk of AAAs is reliable in up to 75% of all cases;

18% of surveyed know and are familiar with the biomechanical criteria to estimate the aneurysm rupture risk, 63% know it but are not familiar with these criteria, where the other percentage has never heard about it.

Seems to be unlikely this knowledge replace the use of current criteria. Clinicians will always feel that large AAAs represent a rupture-threat and should be repaired. It is the small and medium size AAAs that could be examined by using these alternative diagnostic tools which, in the future, may prove to be useful adjunct to maximum diameter.
