Screening guidelines for AAA may be inadequate
More than two-thirds of patients who required abdominal aortic aneurysm repair would not have been captured by the U.S. Preventive Service Task Force AAA screening guidelines, according to data from the Vascular Quality Initiative.
The rate of capture was slightly higher with existing Society for Vascular Surgery screening guidelines and much higher with expanded SVS screening guidelines, researchers reported.
Not fitting in
“We had read a few papers about patients dying from AAA that didn’t meet established screening criteria,” Matthew L. Carnevale, MD, vascular surgery resident at Montefiore Einstein Center for Heart and Vascular Care, told Healio. “This made us ask the broader question of how many patients are actually treated for this condition that may not fit into the current criteria of AAA screening guidelines.”
The USPSTF guidelines call for one-time abdominal ultrasound screening of men aged 65 to 75 years with a history of smoking and/or a family history of AAA. The SVS guidelines call for one-time abdominal ultrasound screening of men and women aged 65 to 75 years with a history of smoking. The expanded SVS guidelines add screening any candidate with AAA’s first-degree relatives and anyone not previously screened who is older than 75 years and has a history of tobacco use.
Carnevale, Jeffrey E. Indes, MD, associate professor in the department of cardiothoracic and vascular surgery at Montefiore Einstein Center for Heart and Vascular Care, and colleagues analyzed 55,197 patients from the Vascular Quality Initiative database who underwent AAA repair from 2003 to 2019. Most had endovascular aneurysm repair.
Among the cohort, only 33% of those who had surgical repair and 32% of those who had EVAR would have been identified by the USPSTF guidelines, the researchers found.
When the standard SVS screening guidelines were applied, 38% of the EVAR group and 45% of the surgical repair group would have been identified, according to the researchers.
Adopting the expanded SVS guidelines, only 27% of the EVAR group and 33% of the surgical repair group would have been missed, the researchers wrote.
Those who did not meet screening criteria were twice as likely to have a ruptured AAA as those who did (8.5% vs. 4.4%; P .0001).
Expanding the net
“Many patients with AAA that require treatment are not necessarily captured by the screening criteria put forth by the USPSTF,” Carnevale said in an interview. “Using the SVS guidelines, which include screening certain women as well as patients with a family history of AAA, expands the net and allows for more patients to be captured; however, a significant proportion of patients remain that do not fit any screening criteria. Importantly, these patients that don’t meet any screening criteria are at higher risk for presenting with ruptured AAA, which carries a high risk of mortality.”
He told Healio: “Further work is necessary to identify risk factors for patients presenting with ruptured AAA. This is particularly important for younger patients who smoke or elderly patients with no smoking history who would otherwise fall through the cracks of current screening guidelines.”
According to the researchers, in the EVAR group, among those who did not meet screening criteria, 52% were younger than 65 years and almost all of them had a history of smoking.
For more information:
Matthew L. Carnevale, MD, can be reached at Division of Vascular and Endovascular Surgery, Montefiore Medical Center and The Albert Einstein College of Medicine, 1250 Waters Place, Tower 2, 7th Floor, Bronx, NY 10461.