How best to diagnose and manage abdominal aortic aneurysms

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doi:doi: 10.12788/jfp.0668

Applied Evidence

How best to diagnose and manage abdominal aortic aneurysms

J Fam Pract. 2023 October;72(8):325-331 | doi: 10.12788/jfp.0668

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References

1. CDC. Wide-ranging Online Data for Epidemiologic Research (WONDER) database. Accessed August 30, 2023. https://wonder.cdc.gov/ucd-icd10.html

2. Reimerink JJ, van der Laan MJ, Koelemay MJ, et al. Systematic review and meta-analysis of population-based mortality from ruptured abdominal aortic aneurysm. Br J Surg. 2013;100:1405-1413. doi: 10.1002/bjs.9235

3. Kent KC. Clinical practice. Abdominal aortic aneurysms. N Engl J Med. 2014;371:2101-2108. doi: 10.1056/NEJMcp1401430

4. 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.e2. doi: 10.1016/j.jvs.2017.10.044

5. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg. 2011;41 suppl 1:S1-S58. doi: 10.1016/j.ejvs.2010.09.011

6. Owens DK, Davidson KW, Krist AH, et al; US Preventive Services Task Force. Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement. JAMA. 2019;322:2211-2218. doi: 10.1001/jama.2019.18928

7. National Institute for Health and Care Excellence. Abdominal aortic aneurysm: diagnosis and management. NICE guideline [NG156]. March 19, 2020. Accessed June 30, 2023. www.nice.org.uk/guidance/ng156/chapter/recommendations

8. Canadian Task Force on Preventive Health Care. Recommendations on screening for abdominal aortic aneurysm in primary care. CMAJ. 2017;189:E1137-E1145. doi: 10.1503/cmaj.170118

9. Abdulameer H, Al Taii H, Al-Kindi SG, et al. Epidemiology of fatal ruptured aortic aneurysms in the United States (1999-2016). J Vasc Surg. 2019;69:378-384.e2. doi: 10.1016/j.jvs.2018.03.435

10. Kent KC, Zwolak RM, Egorova NN, et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg. 2010;52:539-548. doi: 10.1016/j.jvs.2010.05.090

11. [No authors listed] Smoking, lung function and the prognosis of abdominal aortic aneurysm. The UK Small Aneurysm Trial Participants. Eur J Vasc Endovasc Surg. 2000;19:636-642. doi: 10.1053/ejvs.2000.1066

12. Oliver-Williams C, Sweeting MJ, Turton G, et al. Lessons learned about prevalence and growth rates of abdominal aortic aneurysms from a 25-year ultrasound population screening programme. Br J Surg. 2018;105:68-74. doi: 10.1002/bjs.10715

13. Ulug P, Powell JT, Sweeting MJ, et al. Meta-analysis of the current prevalence of screen-detected abdominal aortic aneurysm in women. Br J Surg. 2016;103:1097-1104. doi: 10.1002/bjs.10225

14. Chabok M, Nicolaides A, Aslam M, et al. Risk factors associated with increased prevalence of abdominal aortic aneurysm in women. Br J Surg. 2016;103:1132-1138. doi: 10.1002/bjs.10179

15. Sweeting, MJ, Masconi KL, Jones E, et al. Analysis of clinical benefit, harms, and cost-effectiveness of screening women for abdominal aortic aneurysm. Lancet. 2018;392:487-495. doi: 10.1016/S0140-6736(18)31222-4

16. Sweeting MJ, Thompson SG, Brown LC, et al; RESCAN collaborators. Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms. Br J Surg. 2012;99:655-665. doi: 10.1002/bjs.8707

17. Skibba AA, Evans JR, Hopkins SP, et al. Reconsidering gender relative to risk of rupture in the contemporary management of abdominal aortic aneurysms. J Vasc Surg. 2015;62:1429-1436. doi: 10.1016/j.jvs.2015.07.079

18. Guirguis-Blake JM, Beil TL, Senger CA, et al. Primary care screening for abdominal aortic aneurysm: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;322:2219-2238. doi: 10.1001/jama.2019.17021

19. Thompson SG, Ashton HA, Gao L, et al; Multicentre Aneurysm Screening Study (MASS) Group. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg. 2012;99:1649-1656. doi: 10.1002/bjs.8897

20. 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. doi: 10.1002/bjs.5780

21. Carnevale ML, Koleilat I, Lipsitz EC, et al. Extended screening guidelines for the diagnosis of abdominal aortic aneurysm. J Vasc Surg. 2020;72:1917-1926. doi: 10.1016/j.jvs.2020.03.047

22. Duncan A, Maslen C, Gibson C, et al. Ultrasound screening for abdominal aortic aneurysm in high-risk women. Br J Surg. 2021;108:1192-1198. doi: 10.1093/bjs/znab220

23. 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. doi: 10.1001/archinternmed.2012.4268

24. Hye RJ, Smith AE, Wong GH, et al. Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program. J Vasc Surg. 2014;59:1535-1542. doi: 10.1016/j.jvs.2013.12.016

25. Rubano E, Mehta N, Caputo W, et al., Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013. 20:128-138. doi: 10.1111/acem.12080

26. Blois B. Office-based ultrasound screening for abdominal aortic aneurysm. Can Fam Physician. 2012;58:e172-e178.

27. Arnold MJ, Jonas CE, Carter RE. Point-of-care ultrasonography. Am Fam Physician. 2020;101:275-285.

28. Nixon G, Blattner K, Muirhead J, et al. Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care. Rural Remote Health. 2019;19:5027. doi: 10.22605/RRH5027

29. Lederle FA, Wilson SE, Johnson GR, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1437-1444. doi: 10.1056/NEJMoa012573

30. Filardo G, Lederle FA, Ballard DJ, et al. Immediate open repair vs surveillance in patients with small abdominal aortic aneurysms: survival differences by aneurysm size. Mayo Clin Proc. 2013;88:910-919. doi: 10.1016/j.mayocp.2013.05.014

31. Lederle FA, Kyriakides TC, Stroupe KT, et al. Open versus endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2019;380:2126-2135. doi: 10.1056/NEJMoa1715955

32. Patel R, Sweeting MJ, Powell JT, et al., Endovascular versus open repair of abdominal aortic aneurysm in 15-years’ follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 2016;388:2366-2374. doi: 10.1016/S0140-6736(16)31135-7

33. van Schaik TG, Yeung KK, Verhagen HJ, et al. Long-term survival and secondary procedures after open or endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2017;66:1379-1389. doi: 10.1016/j.jvs.2017.05.122

34. Powell JT, Brady AR, Brown, LC, et al; United Kingdom Small Aneurysm Trial Participants. Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1445-1452. doi: 10.1056/NEJMoa013527

35. Paravastu SC, Jayarajasingam R, Cottam R, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev. 2014:CD004178. doi: 10.1002/14651858.CD004178.pub2

36. Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58:2020-2045. doi: 10.1016/j.jacc.2011.08.023

37. Bhak RH, Wininger M, Johnson GR, et al. Factors associated with small abdominal aortic aneurysm expansion rate. JAMA Surg. 2015;150:44-50. doi: 10.1001/jamasurg.2014.2025

38. Ouriel K, Clair DG, Kent KC, et al; Positive Impact of Endovascular Options for treating Aneurysms Early (PIVOTAL) Investigators. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms. J Vasc Surg. 2010;51:1081-1087. doi: 10.1016/j.jvs.2009.10.113

39. Cao P, De Rango P, Verzini F, et al. Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from a randomised trial. Eur J Vasc Endovasc Surg. 2011;41:13-25. doi: 10.1016/j.ejvs.2010.08.026

40. Karthaus EG, Tong TML, Vahl A, et al; Dutch Society of Vascular Surgery, the Steering Committee of the Dutch Surgical Aneurysm Audit and the Dutch Institute for Clinical Auditing. Saccular abdominal aortic aneurysms: patient characteristics, clinical presentation, treatment, and outcomes in the Netherlands. Ann Surg. 2019;270:852-858. doi: 10.1097/SLA.0000000000003529

41. Nathan DP, Xu C, Pouch AM, et al. Increased wall stress of saccular versus fusiform aneurysms of the descending thoracic aorta. Ann Vasc Surg. 2011;25:1129-2237. doi: 10.1016/j.avsg.2011.07.008

42. Durojaye MS, Adeniyi TO, Alagbe OA. Multiple saccular aneurysms of the abdominal aorta: a case report and short review of risk factors for rupture on CT Scan. Ann Ib Postgrad Med. 2020;18:178-180.

43. Bertges DJ, Neal D, Schanzer A, et al. The Vascular Quality Initiative Cardiac Risk Index for prediction of myocardial infarction after vascular surgery. J Vasc Surg. 2016;64:1411-1421.e4. doi: 10.1016/j.jvs.2016.04.045

44. Mach F, Baigent C, Catapano AL, et al. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41:111-188. doi: 10.1093/eurheartj/ehz455

45. Twine CP, Williams IM. Systematic review and meta-analysis of the effects of statin therapy on abdominal aortic aneurysms. Br J Surg. 2011;98:346-353. doi: 10.1002/bjs.7343

46. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140:e596-e646. doi: 10.1161/CIR.0000000000000678

47. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35:2873-2926. doi: 10.1093/eurheartj/ehu281

48. Lederle FA, Noorbaloochi S, Nugent S, et al. Multicentre study of abdominal aortic aneurysm measurement and enlargement. Br J Surg. 2015;102:1480-1487. doi: 10.1002/bjs.9895

49. Itoga NK, Rothenberg KA, Suarez P, et al. Metformin prescription status and abdominal aortic aneurysm disease progression in the U.S. veteran population. J Vasc Surg. 2019;69:710-716.e3. doi: 10.1016/j.jvs.2018.06.19

While declines in AAA and AAA-related death are largely attributed to lower smoking rates, other likely contributing factors include the implementation of screening programs, incidental detection during cross-sectional imaging, and improved surgical techniques and management of CV risk factors (eg, hypertension, hyperlipidemia).^9,10

The benefits of screening older men

Randomized controlled trials (RCTs) have demonstrated the benefits of AAA screening programs. A meta-analysis of 4 populationbased RCTs of AAA screening in men ≥ 65 years demonstrated statistically significant reductions in AAA rupture (OR = 0.62; 95% CI, 0.55-0.70) and death from AAA (OR = 0.65; 95% CI, 0.57-0.74) over 12 to 15 years, with a number needed to screen (NNS) of 305 (95% CI, 248-411) to prevent 1 AAA-related death.¹⁸ The study also found screening decreases the rate of emergent surgeries for AAA (OR = 0.57; 95% CI, 0.48-0.68) while increasing the number of elective surgeries (OR = 1.44; 95% CI, 1.34-1.55) over 4 to 15 years.¹⁸

Only 1 study has demonstrated an improvement in all-cause mortality with screening programs, with a relatively small benefit (OR = 0.97; 95% CI, 0.94-0.99).¹⁹ Only 1 of the studies included women and, while underpowered, showed no difference in AAA-related death or rupture.²⁰ Guidelines and recommendations of various countries and professional societies focus screening on subgroups at highest risk for AAA.^4,6-8,18

Screening recommendations from USPSTF and others

The US Preventive Services Task Force (USPSTF) currently recommends one-time ultrasound screening for AAA in men ages 65 to 75 years who have ever smoked (commonly defined as having smoked > 100 cigarettes) in their lifetime.⁶ This grade “B” recommendation, initially made in 2005 and reaffirmed in the 2014 and 2019 USPSTF updates, recommends screening the highest-risk segment of the population (ie, older male smokers).⁶

In men ages 65 to 75 years with no smoking history, rather than routine screening, the USPSTF recommends selectively offering screening based on the patient’s medical history, family history, risk factors, and personal values (with a “C” grade).⁶ The USPSTF continues to recommend against screening for AAA in women with no smoking history and no family history of AAA.⁶ According to the USPSTF, the evidence is insufficient to recommend for or against screening women ages 65 to 75 years who have ever smoked or have a family history of AAA (“I” statement).⁶

Continue to: One critique of the USPSTF recommendations