Whom should you screen for abdominal aortic aneurysm?

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Applied Evidence

Whom should you screen for abdominal aortic aneurysm?

J Fam Pract. 2020 May;69(4):188-191

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References

1. Assar AN, Zarins CK. Ruptured abdominal aortic aneurysm: a surgical emergency with many clinical presentations. Postgrad Med J. 2009;85:268-273.

2. SBU—Swedish agency for Health Technology Assessment and Assessment of Social Services. Screening for abdominal aortic aneurysm. 2018. www.sbu.se/en/publications/sbu-assesses/screening-for-abdominal-aortic-aneurysm/. Accessed April 24, 2020.

3. Spanos K, Labropoulos N, Giannoukas A. Abdominal aortic aneurysm screening: do we need to shift toward a targeted strategy? Angiology. 2018;69:192-194.

4. Canadian Task Force on Preventive Health Care. Recommendations on screening for abdominal aortic aneurysm in primary care. CMAJ. 2017;189:E1137-1145.

5. Stackelberg O, Wolk, A, Eliasson K, et al. Lifestyle and risk of screening-detected abdominal aortic aneurysm in men. J Am Heart Assoc. 2017;6:e004725.

6. Tikagi H, Ando T, Umemoto T; ALICE (All-Literature Investigation of Cardiovascular Evidence) group. Abdominal aortic aneurysm screening reduces all-cause mortality: make screening great again. Angiology. 2017;69:205-211.

7. Fleming C, Whitlock EP, Beil TL, et al. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the US Preventive Services Task Force. Ann Intern Med. 2005;142:203-211.

8. Ashton HA, Gao L, Kim LG, et al. Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg. 2007;94:696-701.

9. Thompson SG, Ashton HA, Gao L, et al. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg. 2012;99:1649-1656.

10. Lindholdt JS, Sørenson J, Søgaard R et al. Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial. Br J Surg. 2010;97:826-834.

11. McCaul KA, Lawrence-Brown M, Dickinson JA, et al. Long-term outcomes of the Western Australian trial of screening for abdominal aortic aneurysms: secondary analysis of a randomized clinical trial. JAMA Intern Med. 2016;176:1761-1766.

12. Earnshaw JJ, Lees T. Update on screening for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2017;54:1-2.

13. Zucker EJ, Misono AS, Prabhakar AM. Abdominal aortic aneurysm screening practices: impact of the 2014 US Preventive Services Task Force recommendations. J Am Coll Radiol. 2017;14:868-874.

14. USPSTF. Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement. JAMA. 2019;322:2211-2218.

15. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67:2-77.

16. Venkatasubramaniam AK, Mehta T, Chetter IC, et al. The value of abdominal examination in the diagnosis of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2004;24:56-60.

17. Lindholdt JS, Vammen S, Juul S, et al. The validity of ultrasonographic scanning as screening method for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 1999;17:472-475.

18. Desjardins B, Dill KE, Flamm SD, et al. ACR Appropriateness Criteria®, pulsatile abdominal mass, suspected abdominal aortic aneurysm. Int J Cardiovasc Imaging. 2013;29:177-183.

19. Sisó-Almirall A, Kostov B, Navarro-González M, et al. Abdominal aortic aneurysm screening program using hand-held ultrasound in primary healthcare. PLoS One. 2017;12:e0176877.

20. Shreibati JB, Baker LC, Hlatky MA, et al. Impact of the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act on abdominal ultrasonography use among Medicare beneficiaries. Arch Intern Med. 2012;172:1456-1462.

21. Olchanski N, Winn A, Cohen JT, et al. Abdominal aortic aneurysm screening: how many life years lost from underuse of the Medicare screening benefit? J Gen Intern Med. 2014;29:1155-1161.

22. Mell MW, Hlatky MA, Shreibati JB, et al. Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries. J Vasc Surg. 2013;57:1519-1523.

23. England A, McWilliams R. Endovascular aortic aneurysm repair (EVAR). Ulster Med J. 2013;82:3-10.

24. Dillavou ED, Muluk SC, Makaroun MS. Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. J Vasc Surg. 2006;43:446-451.

What is the evidence that screening is effective?

In 1988, researchers in Chichester, England, randomized > 6000 men ages 65 to 80 years to either a control group or a group that was offered a one-time US screen for AAA. After 15 years of follow-up, no significant difference in AAA mortality was seen between the groups, although 26% of those invited for screening declined to participate and accounted for more than half of the AAA-related deaths in the group receiving an invitation for screening.⁸

The MASS Trial,⁹ another British study, began in 1997 and screened men ages 65 to 74. More than 67,000 men were randomized, with 1 group invited for AAA screening and the other serving as a control. The final report on this trial was published in 2012. After 13 years of follow-up, there was a 42% reduction in AAA-related deaths in the group invited for screening, a small reduction in all-cause mortality, and a significant reduction in risk of AAA rupture (hazard ratio = 0.57). The researchers noted that 216 patients would have to be invited for screening to prevent 1 death over 13 years. They also reported that 21% of the invited patients that had an AAA-related death had an initial scan that was negative for AAA (aortic diameter < 3 cm). However, despite this finding, screening still appeared to be beneficial.

Lindholdt et al¹⁰ randomized > 12,000 Danish men ages 64 to 73 to serve as controls or to be invited for US screening for AAA. After 13 years of follow-up, those invited for screening had a 66% relative risk reduction in AAA-related mortality, with screening considered cost effective. There were no differences between the groups in all-cause mortality. Conversely, the Western Australia Trial studied an older group of men, ages 64 to 83, but was unable to show a benefit of screening in lowering AAA-related mortality.¹¹

Tikagi et al⁶ performed a meta-analysis on the data from the 4 trials above and reported up to 15 years of follow-up. Patients who attended screening sessions had a reduction in all-cause mortality with an odds ratio (OR) of 0.6, and a marked reduction in AAA-related mortality with an OR of 0.4. The favorable data on screening have prompted the United Kingdom and Sweden to offer screening to all men ≥ 65 years, based on the current estimate of a 1% prevalence of AAA, although screening is felt to remain cost effective down to a prevalence of 0.35%.¹²

Handheld ultrasound is a viable method to detect AAA in an outpatient primary care setting at a reasonable cost.

Massachusetts General Hospital also reported¹³ that the detection rate of AAA increased, with the diagnosis made at smaller aneurysm dimensions, following publication of the US Preventive Services Task Force recommendations (reviewed below).

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