From the Guidelines
Abdominal aortic aneurysm (AAA) screening is recommended for men aged ≥65 years with a history of smoking to reduce the risk of death from ruptured AAA, as stated in the 2024 ESC guidelines 1. This recommendation is based on the latest evidence, which suggests that screening for AAA with duplex ultrasound (DUS) can reduce AAA-related mortality by enabling elective repair before rupture occurs. The benefits of screening outweigh the harms, particularly in men aged 65-75 who have ever smoked, as they are at higher risk of developing AAA. Key points to consider when implementing AAA screening include:
- Men aged ≥65 years with a history of smoking should be screened for AAA with DUS, as recommended by the 2024 ESC guidelines 1.
- Screening may also be considered in men aged ≥75 years (irrespective of smoking history) or in women aged ≥75 years who are current smokers, hypertensive, or both, as stated in the 2024 ESC guidelines 1.
- Family AAA screening with DUS is recommended for first-degree relatives of patients with AAA aged ≥50, unless an acquired cause can be clearly identified, as recommended by the 2024 ESC guidelines 1.
- Regular follow-up ultrasounds are recommended for AAAs that are detected but below the intervention threshold, with frequencies depending on the aneurysm size. Overall, AAA screening is an important tool for reducing AAA-related mortality, and the latest guidelines provide clear recommendations for implementing screening in high-risk populations, as supported by the 2024 ESC guidelines 1.
From the Research
AAA Screening Overview
- AAA screening is typically performed using ultrasonography, which is considered the screening modality of choice due to its high sensitivity and specificity, as well as its safety and relatively lower cost 2.
- The United States Preventive Services Task Force (USPSTF) recommends one-time screening for AAA with ultrasonography in men aged 65 to 75 years who have ever smoked 3.
- The USPSTF also recommends that clinicians selectively offer screening for AAA with ultrasonography in men aged 65 to 75 years who have never smoked, rather than routinely screening all men in this group 3.
Risk Factors for AAA
- Tobacco use, hypertension, a family history of AAA, and male sex are clinical risk factors for the development of an aneurysm 4.
- Smoking, male sex, and a positive family history are the most important risk factors for AAA, and AAA is most common in men over 65 years of age 5.
- A strategy combining smoking, presence of coronary artery disease (CAD), or both was associated with the optimal balance between sensitivity and specificity in detecting AAAs 6.
Screening Strategies
- Targeted screening of men at high risk of AAA, focusing on smoking history for inclusion, may be a safe and effective alternative to general population screening 6.
- A simplified strategy of targeting ever smokers resulted in detecting 85.0% of all AAAs by screening 61.0% of the population 6.
- The USPSTF concludes that the evidence is insufficient to determine the net benefit of screening for AAA in women aged 65 to 75 years who have ever smoked or have a family history of AAA 3.
Management and Treatment
- Management options for patients with an asymptomatic AAA include reduction of risk factors, medical therapy with beta-blockers, watchful waiting, endovascular stenting, and surgical repair depending on the size and expansion rate of the aneurysm and underlying comorbidities 2.
- Repair is indicated when the aneurysm becomes greater than 5.5 cm in diameter or grows more than 0.6 to 0.8 cm per year 4.
- Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible 5.