At what age should a woman with a family history of abdominal aortic aneurysm (AAA) in her mother and grandmother, including a ruptured AAA in her grandmother, be considered for AAA screening?

From the Guidelines

Screening for abdominal aortic aneurysm (AAA) in a female patient with a strong family history (mother and grandmother both affected, with rupture in grandmother) should be considered starting at age 55, or 10 years earlier than the youngest affected relative's age at diagnosis, considering the high risk of AAA in this patient. For this specific patient with significant family history, I recommend initiating screening with abdominal ultrasound, which is non-invasive and has high sensitivity for detecting AAA, as suggested by recent guidelines 1. If the initial scan is negative, consider repeating every 5-10 years depending on other risk factors. Additional risk factors that would warrant earlier or more frequent screening include smoking, hypertension, and certain connective tissue disorders like Marfan syndrome. The recommendation for screening women differs from men because AAA is less common in females, but your patient's strong family history significantly increases her risk, with family history of AAA in first-degree relatives increasing risk approximately four-fold, and the history of rupture suggests potentially aggressive disease progression 1. Early detection allows for monitoring of aneurysm size and timely intervention before complications occur, which is crucial given the high mortality and morbidity associated with AAA rupture, estimated to be between 75% and 90% 1.

Some key points to consider in this patient's care include:

• The natural history of AAA is progressive expansion and potential rupture, which is a medical emergency with high mortality 1
• Indications for open or endovascular repair of nonruptured AAA include an aortic diameter >5.5 cm in men or >5.0 cm in women, onset of symptoms portending rupture, and rapid aneurysm growth 1
• Imaging is required to confirm the diagnosis and characterize the aneurysm to inform management planning, with abdominal ultrasound being a suitable initial screening modality 1
• The patient's strong family history and potential for aggressive disease progression warrant close monitoring and consideration of earlier intervention, if necessary, to prevent complications and improve quality of life.

Given the most recent and highest quality study available 1, initiating screening at age 55 is a reasonable approach for this patient, balancing the benefits of early detection with the potential risks and harms of screening.

From the Research

Screening for Abdominal Aortic Aneurysm (AAA) in Women

• The U.S. Preventive Services Task Force recommends one-time screening with ultrasonography for men 65 to 75 years of age with a history of smoking 2.
• For women, there is inconclusive evidence to recommend screening for abdominal aortic aneurysm in those 65 to 75 years of age with a smoking history, and women without a smoking history should not undergo screening because the harms likely outweigh the benefits 2.
• However, a family history of abdominal aortic aneurysm is a significant risk factor, and women with a strong family history may benefit from screening 2, 3.

Family History as a Risk Factor

• A family history of aortic aneurysm is an independent risk factor for more rapid growth of small abdominal aortic aneurysms 3.
• Women with a family history of AAA, particularly those with a first-degree relative (such as a mother or grandmother) who has had an AAA, may be at increased risk 2, 3.
• In the case of a woman whose mother and grandmother both have AAA, with one rupture in the grandmother, the risk of AAA and rupture may be higher due to the strong family history 3.

Considerations for Scanning

• Given the strong family history, it may be reasonable to consider scanning this patient, even if she is younger than 65 years old or does not have a smoking history 2, 3.
• The decision to scan should be individualized, taking into account the patient's overall risk factor profile, family history, and other medical conditions 2, 4.
• If scanning is performed, ultrasonography is a reasonable initial test, as it is non-invasive and can accurately measure the diameter of the aorta 2, 4.