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Editorial| Volume 54, ISSUE 1, P1-2, July 2017

Update on Screening for Abdominal Aortic Aneurysm

Open ArchivePublished:May 16, 2017DOI:https://doi.org/10.1016/j.ejvs.2017.04.002
Update on Screening for Abdominal Aortic Aneurysm
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Next ArticleAntiplatelet Resistance in Ischaemic Stroke Patients
      The case for abdominal aortic aneurysm (AAA) screening in men was established from a series of randomised trials in the 1990s. The recently published late results of the randomised trial from Western Australia complete the evidence base,
      • McCaul K.A.
      • Lawrence-Brown M.
      • Dickinson J.A.
      • Norman P.E.
      Long term outcomes of the Western Australian trial of screening for abdominal aortic aneurysms.
      JAMA Int Med. 2016; 176: 1761-1767
      enabling meta-analysis of the late results of all the trials.
      • Takagi H.
      • Ando T.
      Umemoto T for the ALICE (All-Literature Investigation of Cardiovascular Evidence) Group
      Abdominal aortic aneurysm screening reduces all-cause mortality: make screening great again.
      Angiology. 2017 Jan 1; ([Epub ahead of print])https://doi.org/10.1177/0003319717693107
      This shows that inviting men for AAA screening reduces AAA related deaths (OR 0.66; 95% CI 0.47–0.93, p = .02), with a greater effect on men who attend (OR 0.40; 95% CI 0.31–0.51, p < .00001). There is also a reduction in overall mortality in invited men (HR 0.98; 95% CI 0.96–0.99, p = .003), something that is unusual in screening programmes which usually only affect disease related outcomes. There is unlikely to be any further evidence on population screening for AAA.
      • Lederle F.A.
      The last (randomized) word on screening for abdominal aortic aneurysms.
      JAMA Int Med. 2016; 176: 1767-1768
      The American Preventive Services Task Force now recommends ultrasound screening for AAA in men aged 65–74 who have ever smoked.
      • LeFevre M.L.
      on behalf of the U.S. Preventive Services Task Force
      Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement.
      Ann Intern Med. 2014; 161: 281-290
      It should, however, be recognised that there is a disadvantage to men who do not accept the offer of screening: they have increased mortality both for AAA and non-AAA related diseases over the next decade. Focusing on improving the profile of AAA disease and the reasons for AAA screening might be a way to reach these men who may otherwise not focus on their health.
      Interestingly, the final outcome of the Western Australia screening study was negative: invitation for screening did not affect AAA related mortality.
      • McCaul K.A.
      • Lawrence-Brown M.
      • Dickinson J.A.
      • Norman P.E.
      Long term outcomes of the Western Australian trial of screening for abdominal aortic aneurysms.
      JAMA Int Med. 2016; 176: 1761-1767
      This is possibly the effect of a high background rate of abdominal investigation in Australian men, such that many of their AAAs were already diagnosed. The meta-analysis
      • Takagi H.
      • Ando T.
      Umemoto T for the ALICE (All-Literature Investigation of Cardiovascular Evidence) Group
      Abdominal aortic aneurysm screening reduces all-cause mortality: make screening great again.
      Angiology. 2017 Jan 1; ([Epub ahead of print])https://doi.org/10.1177/0003319717693107
      was heavily influenced by the larger Multicentre Aneurysm Screening Study (MASS) from the UK,
      • Thompson S.G.
      • Ashton H.A.
      • Gao L.
      • Buxton M.J.
      • Scott R.A.P.
      on behalf of the Multicentre Aneurysm Screening study
      Final follow-up of the Multicentre Aneurysm Screening Study randomized trial of abdominal aortic aneurysm screening.
      Br J Surg. 2012; 99: 1649-1656
      where it is probable the background rate of abdominal investigation was lower. This is the first indication that the benefits of AAA screening may vary according to the risk profile in individual countries.
      Population screening programmes are now up and running successfully in the UK
      • Jacomelli J.
      • Summers L.
      • Stevenson A.
      • Lees T.
      • Earnshaw J.J.
      Results of the first five years of the NHS Abdominal Aortic Aneurysm Screening Programme in England.
      Br J Surg. 2016; 103: 1125-1131
      and Sweden,
      • Wanhainen A.
      • Hultgren R.
      • Linne A.
      • Holst J.
      • Gottsater A.
      • Langenskiold M.
      • et al.
      Outcome of the Swedish nationwide abdominal aortic aneurysm screening programme.
      Circulation. 2016; 134: 1141-1148
      and are being considered elsewhere in Europe. They have proved it is possible to design and conduct population screening of 65 year old men in an efficient and effective way. In the two largest national programmes, uptake rates around 80% are reported, and large numbers of men with large AAA are found and referred for treatment with low mortality rates.
      • Jacomelli J.
      • Summers L.
      • Stevenson A.
      • Lees T.
      • Earnshaw J.J.
      Results of the first five years of the NHS Abdominal Aortic Aneurysm Screening Programme in England.
      Br J Surg. 2016; 103: 1125-1131
      , 
      • Wanhainen A.
      • Hultgren R.
      • Linne A.
      • Holst J.
      • Gottsater A.
      • Langenskiold M.
      • et al.
      Outcome of the Swedish nationwide abdominal aortic aneurysm screening programme.
      Circulation. 2016; 134: 1141-1148
      The early reports from these programmes also describe a declining prevalence of AAA in 65 year old men, just over 1% compared with 4% in MASS, commensurate with a reduction in smoking habits in the UK and Sweden over the past decade. Despite this, because of the catastrophic outcome of ruptured AAA, the programme remains cost effective in England down to a prevalence as low as 0.35%, using standard willingness to pay thresholds.
      • Glover M.J.
      • Kim L.G.
      • Sweeting M.J.
      • Thompson S.G.
      • Buxton M.J.
      Cost-effectiveness of the National Health Service abdominal aortic aneurysm screening programme in England.
      Br J Surg. 2014; 101: 976-982
      It would therefore be expected that population screening for AAA will be worthwhile in countries where smoking rates remain high.
      The ongoing AAA screening programmes also raise new issues, such as the management of men with small (3.0–4.4 cm) and medium (4.5–5.4 cm) AAA. In the NHS AAA Screening Programme (NAAASP), there are currently almost 13,000 of these men who are offered regular surveillance and advice from a vascular nurse. Rupture rates are reassuringly low (<0.5%) in these men (unpublished data), but they are at risk of cardiovascular complications,
      • Bath M.F.
      • Saratzis A.
      • Saedon M.
      • Sidloff D.
      • Sayers R.
      • Bown M.J.
      for the UKAGS Investigators
      Patients with small abdominal aortic aneurysm are at significant risk of cardiovascular events and this risk is not addressed sufficiently.
      Eur J Vasc Endovasc Surg. 2017; 53: 255-260
      and their optimal management is unknown. It is suggested that men in surveillance who are taking antiplatelet and statin therapy have a lower risk of death from cardiovascular complications.
      • Bahia S.S.
      • Vidal-Diez A.
      • Seshasai S.R.
      • Shpitser I.
      • Brownrigg J.R.
      • Paterson B.O.
      • et al.
      Cardiovascular risk prevention and all-cause mortality in primary care patients with an abdominal aortic aneurysm.
      Br J Surg. 2016; 103: 1626-1633
      Ensuring men in surveillance are optimally managed should affect their long-term outcome. Another issue is that in the majority of younger men with a medium sized AAA, the AAA will eventually grow to 5.5 cm and require intervention. It makes sense to make these men as fit as possible to undergo treatment. It is becoming recognised that prehabilitation raises the possibility of improving treatment outcomes. It remains to be proved which prehabilitation interventions have the greatest impact.
      • Moorthy K.
      • Wyntyer-Blyth V.
      Prehabilitation in perioperative care.
      Br J Surg. 2017 Mar 16; ([Epub ahead of print])https://doi.org/10.1002/bjs.10516
      In NAAASP, there is still room for improvement as two thirds of men who have been in surveillance and are referred for treatment of a large AAA remain overweight, and one third are still current smokers (unpublished data). The search for medications to reduce AAA growth rates has been disappointing: the potential benefit of antihypertensive drugs has been unproven in a series of randomised trials. There is emerging evidence, however, that metformin can affect AAA growth rates and this may justify a randomised trial.
      Introducing a national screening programme for AAA remains challenging. It is difficult to organise, and expensive to run, particularly if the costs of increased elective activity are also considered. The estimated cost of NAAASP is £25 million per year. The existing model seems to work best in health services that are publically funded. Other large health economies with a self funded element have difficulty organising the systematic invitation of men, and have tended simply to use existing guidelines to recommend providers offer this service to relevant groups. In the US SAAAVE programme, new Medicare applicants who are over 65 and smoke are offered an ultrasound scan. The advantage of nationally funded and organised programmes is that quality assurance of the imaging method can be built in. Alternative options, such as targeted screening using medical data already held on central databases to identify high risk groups, are being considered.
      • Jones G.T.
      • Hill B.G.
      • Curtis N.
      • Kabir T.D.
      • Wong L.E.
      • Tilyard M.W.
      • et al.
      Comparison of three targeted approaches to screening for abdominal aortic aneurysm based on cardiovascular risk.
      Br J Surg. 2016; 103: 1139-1146
      Monitoring the ongoing efforts of European countries to develop AAA screening, and providing mutual support from existing programmes has been a valuable function of the ESVS.
      • Björck M.
      • Bown M.J.
      • Choke E.
      • Earnshaw J.
      • Flørenes T.
      • Glover M.
      • et al.
      for the International AAA Screening Group
      International update on screening for abdominal aortic aneurysms: issues and opportunities.
      Eur J Vasc Endovasc Surg. 2015; 49: 113-115
      Existing AAA screening programmes should not be complacent. There are a number of options for improvement. (i) Costs might be reduced by reducing the number of surveillance scans, something which has been shown to be entirely safe, particularly in men with a small AAA who only need a surveillance scan every 2–3 years, instead of annually.
      The RESCAN Collaborators
      Surveillance intervals for small abdominal aortic aneurysms: a meta-analysis.
      JAMA. 2013; 309: 806-813
      (ii) It is a consistent finding that uptake of screening varies with social deprivation and ethnicity.
      • Crilly M.
      • Mundie A.
      • Bachoo P.
      • Nimmo F.
      Influence of rurality, deprivation and distance-from-clinic on the uptake by men of abdominal aortic aneurysm screening.
      Br J Surg. 2015; 102: 916-923
      , 
      • Jacomelli J.
      • Summers L.
      • Stevenson A.
      • Lees T.
      • Earnshaw J.J.
      Inequalities in abdominal aortic aneurysm screening in England: effects of social deprivation and ethnicity.
      Eur J Vasc Endovasc Surg. 2017; 53: 837-843
      A major initiative is planned for 2018 in the UK, with local programmes encouraged to employ bespoke methods to improve penetration of screening to these hard to reach groups. (iii) Men with an AAA who were aged over 65 years when the programme started will never be invited, and these men are now targeted through a self referral option, and a programme of communication encouraging high risk men to self refer.
      • Meecham L.
      • Jacomelli J.
      • Pherwani A.
      • Earnshaw J.J.
      Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme.
      Eur J Vasc Endovasc Surg. 2016; 52: 317-321
      Another potential reservoir of AAA is in men with an aorta just below the threshold for referral at age 65 (subaneurysmal aorta 2.6–2.9 cm). They have a significant risk of developing an AAA eventually.
      • Wild J.B.
      • Stather P.W.
      • Biancari F.
      • Choke E.C.
      • Earnshaw J.J.
      • Grant S.W.
      • et al.
      A multicentre observational study of the outcomes of screening-detected sub-aneurysmal aortic dilatation.
      Eur J Vasc Endovasc Surg. 2013; 45: 128-134
      There is not sufficient evidence to justify their inclusion in surveillance as yet, but ongoing modelling studies, counterbalanced by investigation into possible reduction in quality of life for men in surveillance may help inform the issue. These men will not get their AAA until they are in their 80s, which raises questions about the value of preventive treatment in the elderly person.
      • Hinchliffe R.J.
      • Earnshaw J.J.
      Vascular interventions in the elderly.
      Br J Surg. 2016; 103: e16-e18
      Whether or not to screen women also remains a hot topic. Ongoing investigations will enable a final decision about population screening for women in the near future.
      It is ironic that population screening programmes started at a time when the prevalence of AAA was reducing. Nevertheless, AAA screening is going to make a major contribution to the eradication of deaths from AAA rupture for at least a generation, and maybe more so in countries where smoking remains prevalent. It is unlikely that the need for AAA screening will disappear completely; existing programmes will need constant monitoring, and could even evolve into more general cardiovascular risk programmes. This is the end of the era of randomised trials of AAA screening, and the start of the opportunity to use emerging data from ongoing screening programmes to inform changes and improvements.

      Conflict of Interest

      None.

      Funding

      The NHS AAA Screening Programme is funded by the Department of Health and provided through Public Health England.

      References

        • McCaul K.A.
        • Lawrence-Brown M.
        • Dickinson J.A.
        • Norman P.E.
        Long term outcomes of the Western Australian trial of screening for abdominal aortic aneurysms.
        JAMA Int Med. 2016; 176: 1761-1767
        View in Article
        • Takagi H.
        • Ando T.
        • Umemoto T for the ALICE (All-Literature Investigation of Cardiovascular Evidence) Group
        Abdominal aortic aneurysm screening reduces all-cause mortality: make screening great again.
        Angiology. 2017 Jan 1; ([Epub ahead of print])https://doi.org/10.1177/0003319717693107
        View in Article
        • Lederle F.A.
        The last (randomized) word on screening for abdominal aortic aneurysms.
        JAMA Int Med. 2016; 176: 1767-1768
        View in Article
        • LeFevre M.L.
        • on behalf of the U.S. Preventive Services Task Force
        Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2014; 161: 281-290
        View in Article
        • Thompson S.G.
        • Ashton H.A.
        • Gao L.
        • Buxton M.J.
        • Scott R.A.P.
        • on behalf of the Multicentre Aneurysm Screening study
        Final follow-up of the Multicentre Aneurysm Screening Study randomized trial of abdominal aortic aneurysm screening.
        Br J Surg. 2012; 99: 1649-1656
        View in Article
        • Jacomelli J.
        • Summers L.
        • Stevenson A.
        • Lees T.
        • Earnshaw J.J.
        Results of the first five years of the NHS Abdominal Aortic Aneurysm Screening Programme in England.
        Br J Surg. 2016; 103: 1125-1131
        View in Article
        • Wanhainen A.
        • Hultgren R.
        • Linne A.
        • Holst J.
        • Gottsater A.
        • Langenskiold M.
        • et al.
        Outcome of the Swedish nationwide abdominal aortic aneurysm screening programme.
        Circulation. 2016; 134: 1141-1148
        View in Article
        • Glover M.J.
        • Kim L.G.
        • Sweeting M.J.
        • Thompson S.G.
        • Buxton M.J.
        Cost-effectiveness of the National Health Service abdominal aortic aneurysm screening programme in England.
        Br J Surg. 2014; 101: 976-982
        View in Article
        • Bath M.F.
        • Saratzis A.
        • Saedon M.
        • Sidloff D.
        • Sayers R.
        • Bown M.J.
        • for the UKAGS Investigators
        Patients with small abdominal aortic aneurysm are at significant risk of cardiovascular events and this risk is not addressed sufficiently.
        Eur J Vasc Endovasc Surg. 2017; 53: 255-260
        View in Article
        • Bahia S.S.
        • Vidal-Diez A.
        • Seshasai S.R.
        • Shpitser I.
        • Brownrigg J.R.
        • Paterson B.O.
        • et al.
        Cardiovascular risk prevention and all-cause mortality in primary care patients with an abdominal aortic aneurysm.
        Br J Surg. 2016; 103: 1626-1633
        View in Article
        • Moorthy K.
        • Wyntyer-Blyth V.
        Prehabilitation in perioperative care.
        Br J Surg. 2017 Mar 16; ([Epub ahead of print])https://doi.org/10.1002/bjs.10516
        View in Article
        • Jones G.T.
        • Hill B.G.
        • Curtis N.
        • Kabir T.D.
        • Wong L.E.
        • Tilyard M.W.
        • et al.
        Comparison of three targeted approaches to screening for abdominal aortic aneurysm based on cardiovascular risk.
        Br J Surg. 2016; 103: 1139-1146
        View in Article
        • Björck M.
        • Bown M.J.
        • Choke E.
        • Earnshaw J.
        • Flørenes T.
        • Glover M.
        • et al.
        • for the International AAA Screening Group
        International update on screening for abdominal aortic aneurysms: issues and opportunities.
        Eur J Vasc Endovasc Surg. 2015; 49: 113-115
        View in Article
        • The RESCAN Collaborators
        Surveillance intervals for small abdominal aortic aneurysms: a meta-analysis.
        JAMA. 2013; 309: 806-813
        View in Article
        • Crilly M.
        • Mundie A.
        • Bachoo P.
        • Nimmo F.
        Influence of rurality, deprivation and distance-from-clinic on the uptake by men of abdominal aortic aneurysm screening.
        Br J Surg. 2015; 102: 916-923
        View in Article
        • Jacomelli J.
        • Summers L.
        • Stevenson A.
        • Lees T.
        • Earnshaw J.J.
        Inequalities in abdominal aortic aneurysm screening in England: effects of social deprivation and ethnicity.
        Eur J Vasc Endovasc Surg. 2017; 53: 837-843
        View in Article
        • Meecham L.
        • Jacomelli J.
        • Pherwani A.
        • Earnshaw J.J.
        Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme.
        Eur J Vasc Endovasc Surg. 2016; 52: 317-321
        View in Article
        • Wild J.B.
        • Stather P.W.
        • Biancari F.
        • Choke E.C.
        • Earnshaw J.J.
        • Grant S.W.
        • et al.
        A multicentre observational study of the outcomes of screening-detected sub-aneurysmal aortic dilatation.
        Eur J Vasc Endovasc Surg. 2013; 45: 128-134
        View in Article
        • Hinchliffe R.J.
        • Earnshaw J.J.
        Vascular interventions in the elderly.
        Br J Surg. 2016; 103: e16-e18
        View in Article

      Article info

      Publication history

      Published online: May 16, 2017

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      DOI: https://doi.org/10.1016/j.ejvs.2017.04.002

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      © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd.

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