Editorial
Angiology
Abdominal Aortic Aneurysm Screening:
Do We Need to Shift Toward
a Targeted Strategy?
Konstantinos Spanos, MSc, MD, PhD1,
Nicos Labropoulos, MSc, PhD, RVT2, and
Athanasios Giannoukas, MSc, MD, PhD, FEBVS1
Keywords
abdominal aortic aneurysm, screening, rupture
Several abdominal aortic aneurysm (AAA) screening programs
have been developed worldwide, aiming at early identification
of individuals with an unknown AAA.1 This became possible
because of the high accuracy (sensitivity and specificity of
nearly 100%) of duplex scan, a noninvasive investigation per-
formed by portable scanners.2 Early detection of AAA allows a
timely elective repair leading to a reduced AAA-related
mortality and complications associated with an urgent
intervention.3,4 A recent systematic evidence review for the
US Preventive Services Task Force suggested that onetime
invitation for AAA screening in men aged 65 years or older
was associated with decreased AAA rupture and AAA-related
mortality rates.5 Another study highlighted the significant risk
of AAA patients for developing cardiovascular (CV) events
and thus the identification of those patients even with small
AAA may contribute to CV risk reduction. 6 A recent
meta-analysis showed that invitation to AAA screening in
64-year-old men significantly reduced both all-cause and
AAA-related mortality.7
The Society for Vascular Surgery (SVS) has recommended
onetime duplex scan screening for AAAs in men aged 55 years
or older with a family history of AAA, all men aged 65 years or
older, and women aged 65 years or older who have smoked or
have a family history of AAA.8 In the United States, Medicare
covers 1 ultrasound scan screening of men aged 65 to 75 years
who ever smoked in their lifetime or men and women who have
a family history of AAA disease as part of a “Welcome to
Medicare” package.9 The European Society for Vascular Sur-
gery has recommended that men should be screened for AAAs
with a single duplex scan at the age of 65 years or younger men
who may be at increased risk (eg, those who smoke or have a
family history).10 On the other hand, although the American
College of Preventive Medicine has recommended onetime
screening in men aged 65 to 75 years who have ever smoked,
it has not recommended routine screening in women.11
Recent literature has highlighted the association of clinical
factors with the increased incidence of AAA, which are not
included in the indications of guidelines for AAA screening.
1-3
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A total of 22 studies involving 13 388 patients concluded that
AAA prevalence was significantly higher in patients with cor-
onary artery disease versus patients without (odds ratio [OR]
2.42, 95% confidence interval [CI], 2.08-2.81).12 Another
meta-analysis showed that serum low-density lipoprotein cho-
lesterol is higher in patients with AAA (mean differences
[MD], 0.25 mmol/L; 95% CI, 0.08-0.42 mmol/L; P ¼ .004)
than control patients while the serum high-density lipoprotein
cholesterol is likely lower.13 Additionally, a significant associ-
ation between AAA and other factors has been demonstrated,
such as body mass index (OR 1.20; 95% CI, 1.17-1.22),14
chronic obstructive pulmonary disease (adjusted OR 3.0;
95% CI 1.6-5.5, P < .001),15 primary abdominal wall hernia
(OR 2.32; 95% CI, 1.72-3.14; P for effect <.00001; P for het-
erogeneity <.00001),16 and the presence of simple renal cysts
(OR 2.54; 95%CI, 1.93-3.34; P < .00001).17 In contrast, dia-
betes mellitus (DM) appears to be inversely associated with
prevalence of AAA, as shown in a pooled analysis of 13 studies
which demonstrated that DM was significantly associated
with lower prevalence of AAA (OR 0.59; 95% CI, 0.52-0.67;
P < .00001).18
Female gender has been neglected from most of the AAA
screening programs except from the Chichester trial in which
the AAA prevalence in females was 1.3%.19 Apparently, this
was based on the notion that the prevalence of AAA in females
is too low to deserve inclusion in screening despite the fact that
in the UK Small Aneurysm Trial (patients with AAA between
4.0 and 5.4 cm) women had a 3-fold increased rupture rate
compared with men with equal diameter of AAA.20 In a recent
1
Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences,
University Hospital of Larissa, University of Thessaly, Larissa, Greece
2
Division of Vascular Surgery, Stony Brook Medical Center, New York,
NY, USA
Corresponding Author:
Konstantinos Spanos, 13 Sinopoulou str, 41335 Larissa, Greece.
Email: spanos.kon@gmail.com
2 Angiology XX(X)
review, it was suggested that women undergo EVAR less often,
mostly due to unfavorable neck anatomy, and tend to have a
worse long-term outcome than in men.21 Women were also less
likely to undergo repair if their AAA ruptured; mortality was
higher after repair, and ruptures occurred later in life.21 It is of
interest that the SVS recommends that women aged 65 years or
older who have smoked or have a family history of AAA
should be included in AAA screening programs.6 In this
context, a recent meta-analysis of the current prevalence of
screen-detected AAA in women suggested that in women ever
smokers and those >70 years of age the prevalence is >1%.22
Therefore, it may be reasonable to this group of women.
The most recent screening programs with current indica-
tions have reported a lower incidence of AAA compared with
the older ones. The incidence of AAA was 1.8% in the National
Health Service (NHS) AAA screening program and 1.5% in the
Swedish AAA screening program,23 although a recent Belgian
screening study showed the overall AAA prevalence to be
3.6%.24 However, even with lower incidence, the screening
programs have been shown to be effective in the detection and
treatment of AAA and offer a clear balance of good over
harm.25 Thus, a population screening program is ethically jus-
tified, as long as men are given adequate information at every
stage of the process.26 However, using the current criteria for
AAA screening, half of those with an AAA would never be
eligible for inclusion in screening programs.27
The existing data of the screening programs may not demon-
strate the global truth of the AAA incidence as ethnic differ-
ences in CV risk factors exist.28 Additionally, risk factor
prevention strategies have not been developed with the same
intensity worldwide. In many low- and middle-income coun-
tries (LMICs), morbidity and mortality associated with cardi-
ovascular diseases (CVDs) have grown exponentially over the
recent years. It is estimated that about 80% of CVD deaths
occur in LMICs. 29 HEalthy LIfe in an Urban Setting
(HELIUS), a multiethnic study, showed large treatment gaps
in secondary prevention of CVD among 6 ethnic groups.28
There are several ongoing AAA screening trials listed on
ClinicalTrials.gov, for example, ultrasound AAA screening in
Israeli Arab men who smoke (NCT02306304), population-
based screening study is evaluating the effect on mortality in
an Asian population (NCT01205945), screening study in
65-year-old males in Norway (NCT01248533), and a rando-
mized preventive vascular screening trial of 65- to 74-year-old
men in Denmark (NCT00662480). However, none suggested
targeted screening criteria in their protocol.
Future screening studies may also evaluate genetic factors in
association with presence of AAA, as it has been suggested that
polymorphisms in some genes had strong or moderate
association with AAA.30
While the cost-effectiveness of the current screening pro-
grams is obvious, population stratification to identify the most
vulnerable based on novel risk factors may further increase
their efficacy and reduce costs, especially in consideration with
the need for rescreening because of the aging population.
Future screening programs may benefit from the inclusion of
more targeted criteria in order to increase the number of
detected AAAs.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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