- Email: [email protected]
The case for expanding abdominal aortic aneurysm screening
The case for expanding abdominal aortic aneurysm screening Thomas F. X. O’Donnell, MD,a,b Bruce E. Landon, MD, MBA,c,d and Marc L. Schermerhorn, MD, FACS,b Boston, Mass
ABSTRACT Both the U.S. Preventive Services Task Force and the UK National Institute for Health and Care Excellence are reevaluating their screening paradigms for abdominal aortic aneurysms (AAAs). Currently, most countries that screen for AAA do so only in male ever-smokers between the ages of 65 and 75 years and in patients with a family history of AAA. However, these recommendations are based primarily on screening trials predating the endovascular era. The wider applicability of endovascular aneurysm repair and its safety profile, especially in the elderly, have changed the risk-benefit of repair and, by extension, screening. This is despite the decreasing prevalence of AAA thanks to improved medical therapies and lower smoking rates. This evidence summary critically examines the evidence behind screening and the potential for expanded screening. (J Vasc Surg 2019;-:1-4.) Keywords: Abdominal aortic aneurysm; Screening; AAA; EVAR; Women; Guidelines
The first U.S. Preventive Services Task Force (USPSTF) recommendation on screening for abdominal aortic aneurysms (AAAs) was published in 2005. Based largely on four randomized trials, they recommended screening men between the ages of 65 and 75 years who had ever smoked, prompting the Centers for Medicare and Medicaid Services to reimburse a one-time screening ultrasound examination for this population.1-5 In 2014, the Centers for Medicare and Medicaid Services also approved screening for men and women with a family history of AAA. Similar screening programs exist in the United Kingdom, Canada, France, and Sweden.6-9 Despite significant advances in AAA repair, improved understanding of risk factors for AAA, and sophisticated computer modeling of screening strategies, when the USPSTF recently reviewed the evidence for AAA screening, their draft recommendation statement remained relatively unchanged.10 We contend that the available evidence supports a more expansive screening paradigm. Screening tests such as mammograms and colonoscopies identify potentially life-threatening conditions that are asymptomatic at the time of detection, for which intervention can improve outcomes. Screening paradigms consider four factors: the prevalence of the disease, the From the Department of Surgery, Massachusetts General Hospitala; the Division of Vascular and Endovascular Surgery,b and Division of General Medicine and Primary Care,c Beth Israel Deaconess Medical Center; and the Department of Health Care Policy, Harvard Medical School.d Author conflict of interest: none. Correspondence: Marc L. Schermerhorn, MD, FACS, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, 110 Francis St, Ste 5B, Boston, MA 02215 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.10.024
accuracy of the screening test, the risk of screening, and the potential benefit of screening. Lower smoking rates (possibly in conjunction with better blood pressure and lipid management) have decreased the prevalence of AAA to between 0.4% and 7.6%, depending on the population studied.11-19 Risk factors for AAA include age, smoking, hypertension, family history of AAA, atherosclerotic cardiovascular diseases (coronary artery disease, cerebrovascular disease, or peripheral artery disease), and male sex.12,15,17,19 Abdominal ultrasound is the principal screening modality for AAA as it is inexpensive and noninvasive, does not require contrast material or irradiation, and has a high sensitivity and specificity (both 94%100%).20 Whereas the risks of screening include the potential morbidity and mortality of surgery as well as the potential psychological impact on a patient, the benefits are clear: to prevent aneurysm rupture and death. At the time of the screening trials, open surgery was the only repair option, with perioperative mortality rates of 4.3% to 6%.1,3-6 However, the introduction of endovascular aneurysm repair (EVAR) dramatically changed the field of vascular surgery, with mortality rates of <2% even in patients unfit for open repair.1,35,21-23 The adoption of EVAR expanded the number of patients eligible for repair, and as more patients now undergo repair with low perioperative mortality, there has been a concomitant decrease in the number of aorta-related deaths.23-25 The shrinking fraction of patients who undergo open repair because of the patient’s preference or anatomic constraints also experience better outcomes in the modern era. Of the four screening trials, only one had perioperative mortality rates that would be considered even acceptable by the most recent Society for Vascular Surgery AAA guidelines, and several recent publications demonstrate that open repair is associated with acceptable results even in octagenarians.22,24-28 1
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With these improvements, the risk-benefit of repair and thus the potential benefits of expanded screening have changed significantly. Abdominal ultrasound scans cost only about $53, and the safety of EVAR has dramatically reduced the risks of surgery, making screening beneficial even in the face of decreasing prevalence.29 Markov modeling using contemporary data has demonstrated that screening for AAA would be cost-effective in populations with prevalence rates as low as 0.5%.30,31 This is echoed in the recent draft of the UK National Institute for Health and Care Excellence (NICE) guidelines, which concluded that screening would be cost-effective as long as the prevalence exceeded 0.35%.32 Even using the more conservative threshold of 0.5% would expand screening to patients with more than one of the following risk factors: age older than 65 years, smoking, male sex, family history, chronic obstructive pulmonary disease, atherosclerotic cardiovascular disease, hypertension, and hyperlipidemia. These populations all have a disease prevalence exceeding 1%, and their effect is additive.4,8,11,12,14-16,19,32 Indeed, the draft of the recent NICE guidelines encourages screening of men older than 66 years or women older than 70 years if they have at least one of these risk factors.32 In addition, patients with a family history of AAA experience aneurysm rupture a decade earlier on average than those with sporadic AAA.33 Expanding screening to all patients between the ages of 50 and 65 years may be excessive, but targeted early screening of patients with family history represents an appealing alternative. Expanded screening in line with the proposed NICE guidelines would increase the number of eligible patients, with the most pronounced impact on women and the elderly (patients older than 75 years). Women with AAA experience higher risk than men, as aneurysms in women rupture at greater frequency and at smaller diameters.34,35 This may be due to the fact that when indexed to body size, women actually undergo repairs at relatively larger diameters than men do.36,37 Previously, arguments against screening of women centered around the low prevalence of disease and the inferior outcomes after repair compared with men. However, although AAA is less common in the overall population of women, the prevalence in select subgroups is comparable to that in men. For example, female smokers have a prevalence of 1.7%, and risk factors such as atherosclerotic cardiovascular disease, hypertension, and family history of AAA carry similar risk.11,13,15,19 In fact, the rate of AAA in these subpopulations is comparable to that in male smokers, for whom screening is currently reimbursed.11,13,15,19 The effect of these risk factors is additive; female smokers with heart disease had a prevalence of 3.4%, and those with three risk factors had a prevalence of 6.8%.15 In addition, with advancements in endovascular
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techniques, the outcomes gap between the sexes has been narrowed.38 Elderly patients have the highest risk of aneurysmrelated mortality but are not eligible for screening under current U.S. recommendations. AAA prevalence and rupture risk increase with age, and two-thirds of patients who present with rupture are older than 75 years.24 The upper limit for screening eligibility under every current international paradigm is 75 years, despite the fact that current life expectancy is 11 years for a 75year-old man and 13 years for a woman.39 In addition, elderly patients derive the greatest benefit from undergoing elective repair as emergent repair in the elderly carries substantial morbidity and mortality.40,41 Only one-third to one-half of patients who present with a rupture ever undergo surgery, and mortality rates even after repair in the elderly population exceed 50% in some reports.40,41 In contrast, elective aneurysm repairs in the elderly have more than doubled, and as of 2012, octogenarians represented almost a quarter of the annual repairs.42 As operative mortality has fallen and the number of repairs performed in elderly patients increased, AAA-related mortality in patients older than 80 years has fallen by more than half.24 In the Society for Vascular Surgery Vascular Quality Initiative, perioperative mortality for patients older than 75 years undergoing EVAR is only 1.4%, a stark contrast to the roughly 5% mortality experienced by younger patients during the screening trials.43 In addition to the low perioperative risk of EVAR, elderly patients have excellent longer term life expectancy after repair. The Vascular Quality Initiative study showed 5-year survival of 79% after repair, and even the highest risk group (only 4% of the patients) experienced 50% 5-year survival.43 As such, we would argue that our approach to screening elderly patients for AAA should mirror that of colorectal cancer, eschewing hard age limits in favor of individualizing screening on the basis of life expectancy. The potential impact of these changes is significant. Currently, there are roughly 8 million male eversmokers between 65 and 75 years of age in the United States, plus hundreds of thousands with a family history of AAA. Extending the age range for male ever-smokers would add another approximately 3 million eligible men, and adding female smokers would add another 12 million or so. In addition, >40 million patients older than 65 years have at least one form of atherosclerotic cardiovascular disease, and two-thirds of adults older than 65 years have at least one risk factor for AAA.44 Even accounting for the 25% to 40% of eligible patients who already underwent abdominal imaging for other reasons, this proposal would expand screening considerably.16 In addition to expanding the number of patients eligible for screening, more effective programs are needed to ensure that eligible patients actually undergo
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screening. The first year in which screening ultrasound was reimbursed, only 1% of eligible beneficiaries were screened, and despite progress, current estimates suggest that number is still only 15%.45,46 Several groups have used the electronic health record to increase the proportion of patients screened, but significant gaps remain.46 We believe that the best approach to screening is a liberal approach, as ultrasound scans detect not only the presence or absence of an aneurysm but its size and therefore its rupture risk. These data, in combination with currently available models for both perioperative and long-term mortality after AAA repair, provide patients with important information to aid in individualized decision-making. A patient with limited life expectancy but a 10-cm aneurysm has a 30% chance of rupture per year and therefore may actually benefit from repair.47 Although expanded screening holds the potential to prevent many deaths from aneurysm-related mortality, a note of caution is warranted. More than a third of the repairs in the United States are currently performed for aneurysms that do not meet the diameter criteria set forth in guidelines (although many may have been for other indications, such as saccular aneurysms, rapid growth, symptoms, tenderness, concomitant iliac aneurysms, or other concerns).42 Strong guidance from professional societies, stakeholders, and thought leaders is critical to guard against overuse and to ensure that the patient’s interests remain at the forefront. In addition, currently available risk models for perioperative risk and long-term survival could aid clinicians in deciding who to screen and who to repair.26,43,48 The field of vascular surgery has changed dramatically since the time of the screening trials and the original USPSTF guidelines. We contend that the recently drafted NICE guidelines for AAA screening more accurately reflect the currently available data than the USPSTF guidelines. Patients older than 65 years (including women and those older than 75 years) with at least one risk factor and a life expectancy of >5 years as well as patients older than 50 years with a strong family history should be offered a one-time screening ultrasound examination. The cost of screening is low, and those populations have sufficiently high prevalence of the disease and experience relatively low morbidity and mortality after elective repair, especially with EVAR.
AUTHOR CONTRIBUTIONS Conception and design: TO, BL, MS Analysis and interpretation: TO, BL, MS Data collection: TO Writing the article: TO, MS Critical revision of the article: TO, BL, MS Final approval of the article: TO, BL, MS
Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: MS
REFERENCES 1. Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA, et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002;360:1531-9. 2. LeFevre ML; U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;161:281. 3. Scott RA, Wilson NM, Ashton HA, Kay DN. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study. Br J Surg 1995;82:1066-70. 4. Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer CA, Tuohy RJ, et al. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm. BMJ 2004;329:1259. 5. Lindholt JS, Sørensen J, Søgaard R, Henneberg EW. Longterm benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial. Br J Surg 2010;97:826-34. 6. Cosford PA, Leng GC, Thomas J. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007;2: CD002945. 7. UK National Screening Committee. Abdominal aortic aneurysm screening: a decision for men aged 65 or over. London: National Health Service; 2015. 8. Kent KC, Zwolak RM, Egorova NN, Riles TS, Manganaro A, Moskowitz AJ, et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg 2010;52:539-48. 9. Johansson M, Zahl PH, Siersma V, Jørgensen KJ, Marklund B, Brodersen J. Benefits and harms of screening men for abdominal aortic aneurysm in Sweden: a registry-based cohort study. Lancet 2018;391:2441-7. 10. U.S. Preventive Services Task Force. Draft recommendation statement: abdominal aortic aneurysm: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/ Document/draft-recommendation-statement/abdominalaortic-aneurysm-screening1. Accessed July 1, 2019. 11. Berger JS, Hochman J, Lobach I, Adelman MA, Riles TS, Rockman CB. Modifiable risk factor burden and the prevalence of peripheral artery disease in different vascular territories. J Vasc Surg 2013;58:673-81.e1. 12. Bonamigo TP, Siqueira I. Screening for abdominal aortic aneurysms. Rev Hosp Clin Fac Med Sao Paulo 2003;58:63-8. 13. Svensjö S, Björck M, Wanhainen A. Current prevalence of abdominal aortic aneurysm in 70-year-old women. Br J Surg 2013;100:367-72. 14. Chun KC, Teng KY, Chavez LA, Van Spyk EN, Samadzadeh KM, Carson JG, et al. Risk factors associated with the diagnosis of abdominal aortic aneurysm in patients screened at a regional Veterans Affairs health care system. Ann Vasc Surg 2014;28:87-92. 15. DeRubertis BG, Trocciola SM, Ryer EJ, Pieracci FM, McKinsey JF, Faries PL, et al. Abdominal aortic aneurysm in women: prevalence, risk factors, and implications for screening. J Vasc Surg 2007;46:630-5.e1. 16. Hager J, Länne T, Carlsson P, Lundgren F. Lower prevalence than expected when screening 70-year-old men for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2013;46:453-9.
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17. Svensjö S, Björck M, Wanhainen A. Editor’s choice: five-year outcomes in men screened for abdominal aortic aneurysm at 65 years of age: a population-based cohort study. Eur J Vasc Endovasc Surg 2014;47:37-44. 18. Lederle FA, Johnson GR, Wilson SE, Chute EP, Hye RJ, Makaroun MS, et al. The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med 2000;160:1425-30. 19. Makrygiannis G, Labalue P, Erpicum M, Schlitz M, Seidel L, El Hachemi M, et al. Extending abdominal aortic aneurysm detection to older age groups: preliminary results from the Liège screening programme. Ann Vasc Surg 2016;36:55-63. 20. Guirguis-Blake JM, Beil TL, Senger CA, Whitlock EP. Ultrasonography screening for abdominal aortic aneurysms: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2014;160:321-9. 21. Scott RA, Bridgewater SG, Ashton HA. Randomized clinical trial of screening for abdominal aortic aneurysm in women. Br J Surg 2002;89:283-5. 22. Chaikof EL, Dalman RL, Eskandari MK, Jackson BM, Lee WA, Mansour MA, 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.e2. 23. Schermerhorn ML, Buck DB, O’Malley AJ, Curran T, McCallum JC, Darling J, et al. Long-term outcomes of abdominal aortic aneurysm in the Medicare population. N Engl J Med 2015;373:328-38. 24. Schermerhorn ML, Bensley RP, Giles KA, Hurks R, OʼMalley AJ, Cotterill P, et al. Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study. Ann Surg 2012;256:651-8. 25. Giles KA, Pomposelli F, Hamdan A, Wyers M, Jhaveri A, Schermerhorn ML. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg 2009;49:543-50. 26. Schermerhorn ML, Giles KA, Sachs T, Bensley RP, O’Malley AJ, Cotterill P, et al. Defining perioperative mortality after open and endovascular aortic aneurysm repair in the US Medicare population. J Am Coll Surg 2011;212:349-55. 27. Paolini D, Chahwan S, Wojnarowski D, Pigott JP, LaPorte F, Comerota AJ. Elective endovascular and open repair of abdominal aortic aneurysms in octogenarians. J Vasc Surg 2008;47:924-7. 28. Woo EY, Ullery BW, Carpenter JP, Wang GJ, Fairman RM, Jackson BM. Open abdominal aortic aneurysm repair is feasible and can be done with excellent results in octogenarians. J Vasc Surg 2011;53:278-84. 29. Shreibati JB, Baker LC, Hlatky MA, Mell MW. Impact of the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act on abdominal ultrasonography use among Medicare beneficiaries. Arch Intern Med 2012;172:1456. 30. Wanhainen A, Lundkvist J, Bergqvist D, Björck M. Costeffectiveness of different screening strategies for abdominal aortic aneurysm. J Vasc Surg 2005;41:741-51. 31. Svensjö S, Mani K, Björck M, Lundkvist J, Wanhainen A. Screening for abdominal aortic aneurysm in 65-year-old men remains cost-effective with contemporary epidemiology and management. Eur J Vasc Endovasc Surg 2014;47:357-65. 32. Abdominal aortic aneurysm: diagnosis and management. Evidence review A: risk factors for predicting presence of an abdominal aortic aneurysm. London: National Institute for Health and Care Excellence; 2018. 33. Verloes A, Sakalihasan N, Koulischer L, Limet R. Aneurysms of the abdominal aorta: familial and genetic aspects in three hundred thirteen pedigrees. J Vasc Surg 1995;21:646-55.
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34. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg 1999;230:289-96; discussion: 296-7. 35. Lo RC, Bensley RP, Hamdan AD, Wyers M, Adams JE, Schermerhorn ML. Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England. J Vasc Surg 2013;57:1261-8.e5. 36. Matyal R, Shakil O, Hess PE, Lo R, Jainandunsing JS, Mahmood B, et al. Impact of gender and body surface area on outcome after abdominal aortic aneurysm repair. Am J Surg 2015;209:315-23. 37. Lo RC, Lu B, Fokkema MT, Conrad M, Patel VI, Fillinger M, et al. Relative importance of aneurysm diameter and body size for predicting abdominal aortic aneurysm rupture in men and women. J Vasc Surg 2014;59:1209-16. 38. Dubois L, Novick TV, Harris JR, DeRose G, Forbes TL. Outcomes after endovascular abdominal aortic aneurysm repair are equivalent between genders despite anatomic differences in women. J Vasc Surg 2013;57:382-9.e1. 39. Social Security Administration. Actuarial life table. Available at: https://www.ssa.gov/oact/STATS/table4c6.html. Accessed September 11, 2018. 40. Parkinson F, Ferguson S, Lewis P, Williams IM, Twine CP; South East Wales Vascular Network. Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair. J Vasc Surg 2015;61:1606-12. 41. Tan TW, Eslami M, Rybin D, Doros G, Zhang WW, Farber A. Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients. J Vasc Surg 2017;66:64-70. 42. Beck AW, Sedrakyan A, Mao J, Venermo M, Faizer R, Debus S, et al. Variations in abdominal aortic aneurysm care: a report from the International Consortium of Vascular Registries. Circulation 2016;134:1948-58. 43. O’Donnell TF, Wade JE, Liang P, Li C, Swerdlow NJ, DeMartino RR, et al. EVAR in patients over 75 is associated with excellent 5-year survival, which suggests benefit from expanded screening into this cohort. J Vasc Surg 2019;69:728-37. 44. National Center for Health Statistics. Table A-1. Selected circulatory diseases among adults aged 18 and over, by selected characteristics: United States, 2016. Available at: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2 016_SHS_Table_A-1.pdf. Accessed March 12, 2018. 45. Mell MW, Hlatky MA, Shreibati JB, Dalman RL, Baker LC. Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries. J Vasc Surg 2013;57: 1519-23.e1. 46. Hye RJ, Smith AE, Wong GH, Vansomphone SS, Scott RD, Kanter MH. Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program. J Vasc Surg 2014;59:1535-43. 47. Lederle FA, Johnson GR, Wilson SE, Ballard DJ, Jordan WD, Blebea J, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA 2002;287:2968-72. 48. Giles KA, Schermerhorn ML, O’Malley AJ, Cotterill P, Jhaveri A, Pomposelli FB, et al. Risk prediction for perioperative mortality of endovascular vs open repair of abdominal aortic aneurysms using the Medicare population. J Vasc Surg 2009;50:256-62.
Submitted Aug 14, 2019; accepted Oct 4, 2019.
ABSTRACT Both the U.S. Preventive Services Task Force and the UK National Institute for Health and Care Excellence are reevaluating their screening paradigms for abdominal aortic aneurysms (AAAs). Currently, most countries that screen for AAA do so only in male ever-smokers between the ages of 65 and 75 years and in patients with a family history of AAA. However, these recommendations are based primarily on screening trials predating the endovascular era. The wider applicability of endovascular aneurysm repair and its safety profile, especially in the elderly, have changed the risk-benefit of repair and, by extension, screening. This is despite the decreasing prevalence of AAA thanks to improved medical therapies and lower smoking rates. This evidence summary critically examines the evidence behind screening and the potential for expanded screening. (J Vasc Surg 2019;-:1-4.) Keywords: Abdominal aortic aneurysm; Screening; AAA; EVAR; Women; Guidelines
The first U.S. Preventive Services Task Force (USPSTF) recommendation on screening for abdominal aortic aneurysms (AAAs) was published in 2005. Based largely on four randomized trials, they recommended screening men between the ages of 65 and 75 years who had ever smoked, prompting the Centers for Medicare and Medicaid Services to reimburse a one-time screening ultrasound examination for this population.1-5 In 2014, the Centers for Medicare and Medicaid Services also approved screening for men and women with a family history of AAA. Similar screening programs exist in the United Kingdom, Canada, France, and Sweden.6-9 Despite significant advances in AAA repair, improved understanding of risk factors for AAA, and sophisticated computer modeling of screening strategies, when the USPSTF recently reviewed the evidence for AAA screening, their draft recommendation statement remained relatively unchanged.10 We contend that the available evidence supports a more expansive screening paradigm. Screening tests such as mammograms and colonoscopies identify potentially life-threatening conditions that are asymptomatic at the time of detection, for which intervention can improve outcomes. Screening paradigms consider four factors: the prevalence of the disease, the From the Department of Surgery, Massachusetts General Hospitala; the Division of Vascular and Endovascular Surgery,b and Division of General Medicine and Primary Care,c Beth Israel Deaconess Medical Center; and the Department of Health Care Policy, Harvard Medical School.d Author conflict of interest: none. Correspondence: Marc L. Schermerhorn, MD, FACS, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, 110 Francis St, Ste 5B, Boston, MA 02215 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.10.024
accuracy of the screening test, the risk of screening, and the potential benefit of screening. Lower smoking rates (possibly in conjunction with better blood pressure and lipid management) have decreased the prevalence of AAA to between 0.4% and 7.6%, depending on the population studied.11-19 Risk factors for AAA include age, smoking, hypertension, family history of AAA, atherosclerotic cardiovascular diseases (coronary artery disease, cerebrovascular disease, or peripheral artery disease), and male sex.12,15,17,19 Abdominal ultrasound is the principal screening modality for AAA as it is inexpensive and noninvasive, does not require contrast material or irradiation, and has a high sensitivity and specificity (both 94%100%).20 Whereas the risks of screening include the potential morbidity and mortality of surgery as well as the potential psychological impact on a patient, the benefits are clear: to prevent aneurysm rupture and death. At the time of the screening trials, open surgery was the only repair option, with perioperative mortality rates of 4.3% to 6%.1,3-6 However, the introduction of endovascular aneurysm repair (EVAR) dramatically changed the field of vascular surgery, with mortality rates of <2% even in patients unfit for open repair.1,35,21-23 The adoption of EVAR expanded the number of patients eligible for repair, and as more patients now undergo repair with low perioperative mortality, there has been a concomitant decrease in the number of aorta-related deaths.23-25 The shrinking fraction of patients who undergo open repair because of the patient’s preference or anatomic constraints also experience better outcomes in the modern era. Of the four screening trials, only one had perioperative mortality rates that would be considered even acceptable by the most recent Society for Vascular Surgery AAA guidelines, and several recent publications demonstrate that open repair is associated with acceptable results even in octagenarians.22,24-28 1
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With these improvements, the risk-benefit of repair and thus the potential benefits of expanded screening have changed significantly. Abdominal ultrasound scans cost only about $53, and the safety of EVAR has dramatically reduced the risks of surgery, making screening beneficial even in the face of decreasing prevalence.29 Markov modeling using contemporary data has demonstrated that screening for AAA would be cost-effective in populations with prevalence rates as low as 0.5%.30,31 This is echoed in the recent draft of the UK National Institute for Health and Care Excellence (NICE) guidelines, which concluded that screening would be cost-effective as long as the prevalence exceeded 0.35%.32 Even using the more conservative threshold of 0.5% would expand screening to patients with more than one of the following risk factors: age older than 65 years, smoking, male sex, family history, chronic obstructive pulmonary disease, atherosclerotic cardiovascular disease, hypertension, and hyperlipidemia. These populations all have a disease prevalence exceeding 1%, and their effect is additive.4,8,11,12,14-16,19,32 Indeed, the draft of the recent NICE guidelines encourages screening of men older than 66 years or women older than 70 years if they have at least one of these risk factors.32 In addition, patients with a family history of AAA experience aneurysm rupture a decade earlier on average than those with sporadic AAA.33 Expanding screening to all patients between the ages of 50 and 65 years may be excessive, but targeted early screening of patients with family history represents an appealing alternative. Expanded screening in line with the proposed NICE guidelines would increase the number of eligible patients, with the most pronounced impact on women and the elderly (patients older than 75 years). Women with AAA experience higher risk than men, as aneurysms in women rupture at greater frequency and at smaller diameters.34,35 This may be due to the fact that when indexed to body size, women actually undergo repairs at relatively larger diameters than men do.36,37 Previously, arguments against screening of women centered around the low prevalence of disease and the inferior outcomes after repair compared with men. However, although AAA is less common in the overall population of women, the prevalence in select subgroups is comparable to that in men. For example, female smokers have a prevalence of 1.7%, and risk factors such as atherosclerotic cardiovascular disease, hypertension, and family history of AAA carry similar risk.11,13,15,19 In fact, the rate of AAA in these subpopulations is comparable to that in male smokers, for whom screening is currently reimbursed.11,13,15,19 The effect of these risk factors is additive; female smokers with heart disease had a prevalence of 3.4%, and those with three risk factors had a prevalence of 6.8%.15 In addition, with advancements in endovascular
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techniques, the outcomes gap between the sexes has been narrowed.38 Elderly patients have the highest risk of aneurysmrelated mortality but are not eligible for screening under current U.S. recommendations. AAA prevalence and rupture risk increase with age, and two-thirds of patients who present with rupture are older than 75 years.24 The upper limit for screening eligibility under every current international paradigm is 75 years, despite the fact that current life expectancy is 11 years for a 75year-old man and 13 years for a woman.39 In addition, elderly patients derive the greatest benefit from undergoing elective repair as emergent repair in the elderly carries substantial morbidity and mortality.40,41 Only one-third to one-half of patients who present with a rupture ever undergo surgery, and mortality rates even after repair in the elderly population exceed 50% in some reports.40,41 In contrast, elective aneurysm repairs in the elderly have more than doubled, and as of 2012, octogenarians represented almost a quarter of the annual repairs.42 As operative mortality has fallen and the number of repairs performed in elderly patients increased, AAA-related mortality in patients older than 80 years has fallen by more than half.24 In the Society for Vascular Surgery Vascular Quality Initiative, perioperative mortality for patients older than 75 years undergoing EVAR is only 1.4%, a stark contrast to the roughly 5% mortality experienced by younger patients during the screening trials.43 In addition to the low perioperative risk of EVAR, elderly patients have excellent longer term life expectancy after repair. The Vascular Quality Initiative study showed 5-year survival of 79% after repair, and even the highest risk group (only 4% of the patients) experienced 50% 5-year survival.43 As such, we would argue that our approach to screening elderly patients for AAA should mirror that of colorectal cancer, eschewing hard age limits in favor of individualizing screening on the basis of life expectancy. The potential impact of these changes is significant. Currently, there are roughly 8 million male eversmokers between 65 and 75 years of age in the United States, plus hundreds of thousands with a family history of AAA. Extending the age range for male ever-smokers would add another approximately 3 million eligible men, and adding female smokers would add another 12 million or so. In addition, >40 million patients older than 65 years have at least one form of atherosclerotic cardiovascular disease, and two-thirds of adults older than 65 years have at least one risk factor for AAA.44 Even accounting for the 25% to 40% of eligible patients who already underwent abdominal imaging for other reasons, this proposal would expand screening considerably.16 In addition to expanding the number of patients eligible for screening, more effective programs are needed to ensure that eligible patients actually undergo
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screening. The first year in which screening ultrasound was reimbursed, only 1% of eligible beneficiaries were screened, and despite progress, current estimates suggest that number is still only 15%.45,46 Several groups have used the electronic health record to increase the proportion of patients screened, but significant gaps remain.46 We believe that the best approach to screening is a liberal approach, as ultrasound scans detect not only the presence or absence of an aneurysm but its size and therefore its rupture risk. These data, in combination with currently available models for both perioperative and long-term mortality after AAA repair, provide patients with important information to aid in individualized decision-making. A patient with limited life expectancy but a 10-cm aneurysm has a 30% chance of rupture per year and therefore may actually benefit from repair.47 Although expanded screening holds the potential to prevent many deaths from aneurysm-related mortality, a note of caution is warranted. More than a third of the repairs in the United States are currently performed for aneurysms that do not meet the diameter criteria set forth in guidelines (although many may have been for other indications, such as saccular aneurysms, rapid growth, symptoms, tenderness, concomitant iliac aneurysms, or other concerns).42 Strong guidance from professional societies, stakeholders, and thought leaders is critical to guard against overuse and to ensure that the patient’s interests remain at the forefront. In addition, currently available risk models for perioperative risk and long-term survival could aid clinicians in deciding who to screen and who to repair.26,43,48 The field of vascular surgery has changed dramatically since the time of the screening trials and the original USPSTF guidelines. We contend that the recently drafted NICE guidelines for AAA screening more accurately reflect the currently available data than the USPSTF guidelines. Patients older than 65 years (including women and those older than 75 years) with at least one risk factor and a life expectancy of >5 years as well as patients older than 50 years with a strong family history should be offered a one-time screening ultrasound examination. The cost of screening is low, and those populations have sufficiently high prevalence of the disease and experience relatively low morbidity and mortality after elective repair, especially with EVAR.
AUTHOR CONTRIBUTIONS Conception and design: TO, BL, MS Analysis and interpretation: TO, BL, MS Data collection: TO Writing the article: TO, MS Critical revision of the article: TO, BL, MS Final approval of the article: TO, BL, MS
Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: MS
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Submitted Aug 14, 2019; accepted Oct 4, 2019.