What are the guidelines for abdominal aortic aneurysm (AAA) screening in men over 65 years old with a history of smoking and women over 65 with a history of smoking or a first-degree relative with AAA?

AAA Screening Guidelines

Men aged 65-75 who have ever smoked should receive one-time ultrasound screening for abdominal aortic aneurysm, as this reduces AAA-specific mortality by approximately 50%. 1

Screening Recommendations by Population

Men Ages 65-75 Years

Ever Smokers (≥100 cigarettes lifetime):

• One-time ultrasound screening is strongly recommended (Grade B). 2, 1, 3, 4
• This population has the highest risk and derives the greatest mortality benefit from screening. 1

Never Smokers:

• Selective screening may be offered rather than routine screening for all men in this group (Grade C). 1, 3, 4
• Consider screening if other risk factors are present, particularly family history of AAA. 5
• The prevalence of large AAAs is substantially lower in never-smokers, resulting in smaller potential benefit. 3

Men ≥50 Years with First-Degree Relative with AAA:

• The European Society of Cardiology recommends screening regardless of smoking status (Class I recommendation). 6
• Family history is an independent risk factor that warrants screening outside standard age-based guidelines. 6

Women Ages 65-75 Years

Never Smokers without Family History:

• Do not screen routinely (Grade D recommendation). 1, 3, 4
• AAA is rare in this population and harms outweigh benefits. 3, 4

Ever Smokers or Those with Family History of AAA:

• Current evidence is insufficient to recommend for or against screening (I statement). 1, 4
• The European Society of Cardiology suggests opportunistic screening in women ≥75 years during transthoracic echocardiography, particularly if current smokers or hypertensive. 1

Screening Method and Quality Assurance

Ultrasonography is the screening modality of choice:

• Sensitivity and specificity approach 100%. 1, 7
• Safe, painless, and takes less than 10 minutes per patient. 7
• Must be performed in an accredited facility with credentialed technologists. 1, 3
• Fails to visualize the aorta adequately in only 1-2% of cases due to bowel gas or anatomical challenges. 1
• Color Doppler is not required but may be used as an adjunct. 1

Common Pitfall: Screening rates in eligible populations are only 13-26% despite clear mortality benefit—actively identify and offer screening to eligible patients. 1

Management Based on Screening Results

Small Aneurysms (<5.5 cm diameter):

• Periodic monitoring with ultrasound surveillance is recommended. 2, 1, 3
• No difference in outcomes between early elective surgical repair and surveillance for aneurysms 4.0-5.4 cm. 7

Large Aneurysms (≥5.5 cm) or Rapidly Growing:

• Surgical intervention is generally recommended. 1, 3
• Options include open surgical repair or endovascular stenting. 8
• Elective repair leads to an estimated 43% reduction in AAA-specific mortality. 6
• Operative mortality for elective repair is 5-7%, compared to 80-90% mortality for ruptured AAA. 8, 7

Negative Initial Screen:

• One-time screening is sufficient. 6
• There is negligible health benefit in rescreening those with normal aortic diameter on initial screening. 6

Risk Factor Modification

All patients with detected AAA should receive:

• Smoking cessation counseling. 8
• Blood pressure control. 8
• Management of dyslipidemia. 8
• Continued smoking and persistent hypertension increase rupture risk. 8