Abstract:Background and Aims Abdominal aortic aneurysm (AAA) is a common vascular disorder associated with substantial morbidity and mortality. Although physical activity and exercise training have well-established benefits in cardiovascular diseases, their associations with AAA risk and clinical outcomes remain incompletely understood. This study aimed to investigate the dose-response relationship between physical activity and AAA risk and to evaluate the effects of exercise training on exercise capacity, aneurysm progression, and perioperative outcomes in patients with AAA.Methods PubMed, Embase, and the Cochrane Library were searched for prospective cohort studies and randomized controlled trials (RCTs) investigating physical activity or exercise interventions in AAA up to December 13, 2025. Robust error Meta-regression (REMR) was used to assess the dose-response relationship between physical activity and AAA risk. Random-effects meta-analysis was performed for RCTs, and pooled effects were expressed as standardized mean differences (SMD) with 95% confidence intervals (CI).Results Sixteen studies were included. Four prospective cohort studies involving 94 109 participants were eligible for dose-response analysis. Physical activity was linearly associated with a lower risk of AAA occurrence or screening detection (P for non-linearity=0.582), with a 14% reduction in risk for every 20 metabolic equivalent of task (MET)-hour/week increase in physical activity. Six RCTs demonstrated that exercise training did not increase aneurysm diameter (SMD=-0.03, 95% CI=-0.29-0.24, P=0.85), but significantly improved MET levels at both 3 months (SMD=0.49, 95% CI=0.20-0.78, P<0.001) and 12 months (SMD=0.71, 95% CI=0.47-0.96, P<0.001). No significant effects were observed on blood pressure, BMI, or serum MMP-9 levels. In perioperative patients, preoperative exercise-based prehabilitation significantly reduced the length of hospital stay (SMD=-0.75, 95% CI=-1.08- -0.42, P<0.001).Conclusion Higher levels of habitual physical activity are associated with a lower risk of AAA. In patients with small AAA, long-term exercise training appears safe and improves exercise capacity without accelerating aneurysm growth. In patients undergoing AAA repair, preoperative exercise-based prehabilitation may facilitate postoperative recovery and shorten the hospital stay.