atherosclerosis is one of most common cause of aortic ds,screening of abdominal aorta in vulnerable population is very useful for prevention and early detection of future omplication.

1. ABDOMINAL AORTIC
ANEURYSM SCREENING
DR. KABILAN S J
SR, CARDIOLOGY
JIPMER
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2. AAA
• Definition – increase in size of abdominal aorta to > 3cm in diameter
• MC form of aortic aneurysms
• Incidence – 3.9% to 7.2% of men and 1.0% to 1.3% of women aged 50
years or older
• Prevalence - M > F
• Strong association with cigarette smoking
• 20 % familial
• MC site of AAA – infrarenal aorta ( >80%)
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3. WHY TO SCREEN ?
• Primary risk associated with AAA – rupture (sudden & fatal)
• The annual risk for rupture
SIZE OF AAA ANNUAL RISK OF RUPTURE
3 – 3.9 cm 0%
4– 4.9 cm 1%
5 – 5.9 cm 11%
Guirguis-Blake JM et al. Ultrasonography screening for abdominal aortic aneurysms: a systematic evidence
review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014;160:321-9
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4. • 59% to 83% of patients with AAA rupture die before
hospitalization
• 40% - Operative mortality (in- hospital or 30-day)
• 10% to 25% of persons with a ruptured AAA survive
• Almost all deaths from rupture occur after 65 years of age
• Most deaths in women occur after 80 years of age
Guirguis-Blake JM et al. Ultrasonography screening for abdominal aortic aneurysms: a systematic evidence
review for the U.S. Preventive Services Task Force. Ann Intern Med. 2014;160:321-9
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5. AAA IMAGING MODALITIES
• Abdominal ultrasound- almost 100% sensitive & specific in
detecting AAA
• Abdominal CT – extremely accurate in both detection and
measurement of AAA
• MRA – high accuracy in detection, measurement & planning
repair of AAA
• Screening of AAA- Ultrasound >> CT because of cost
effectiveness, avoidance of exposure to radiation & contrast
• CT – preferred for AAA variants (inflammatory AAAs & mycotic
aneurysms)
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7. RCT
S Svensjo et al. Eur J Vasc Endovasc Surg (2014) 48, 659
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8. • Meta analysis of the 4 RCTs  40 % reduction in AAA specific
mortality in elderly men
• 2.7 % reduction in all-cause mortality
Takagi H et al. The last judgment upon abdominal aortic aneurysm screening. Int J Cardiol
2013;167:2331e2
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9. MASS
• Multicenter aneurysm screening study
• 46 deaths from AAA were prevented by screening 10,000 men
• 217 men would have to be screened to prevent one death from AAA
• Screening reduced the risk of AAA death by 42%
• Number of elective AAA repairs conducted in the screening group
was twice that of the control group
• Number of emergency repairs - halved
Ashton HA et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of
abdominal aortic aneurysm screening on mortality in men: a randomised controlled
trial. Lancet 2002;360:1531
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10. ABDOMINAL ULTRASOUND SCREENING
• In MASS trial - inner to inner (ITI) wall measurement was used
• In Gloucestershire trial - outer margin of the anterior wall to
the inner margin of the posterior wall (leading edge to leading
edge (LELE) was measured
• In Huntingdon screening trial - outer to outer diameter (OTO)
was used
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11. 1.Statistics Sweden. Retrieved December 2013 from www.scb.se
2.Anjum A et al. Explaining the decrease in mortality from abdominal
aortic aneurysm rupture. Br J Surg 2012;99:637
• Reduced smoking rates seem to markedly coincide with falling rates of AAA prevalence
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• Increased rates of elective AAA repair- reduction in overall AAA related mortality2
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12. ETHICS AND HARMS OF SCREENING
• The risk of death from elective repair- 1 in 10,000 men invited
to screening
• The risk of death following repair in incidentally detected AAAs
- higher than for screening detected AAAs
• Mild transient reduction in quality of life
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13. Svensjo S et al. Screening for abdominal aortic aneurysm in 65-Year-old men remains cost-
effective with contemporary epidemiology and management. Eur J Vasc Endovasc Surg
2014;47:357
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19. OTHER RECOMMENDATIONS
• ACC & AHA - 1-time screening for AAA with physical examination
and ultrasonography in men aged 65 to 75 years who have ever
smoked and in men aged 60 years or older who are the sibling or
offspring of a person with AAA
• These organizations do not recommend screening for AAA in men
who have never smoked or in women
• Society for Vascular Surgery - 1-time ultrasonography screening for
AAA in men aged 55 years or older with a family history of AAA, all
men aged 65 years or older, and women aged 65 years or older who
have smoked or have a family history of AAA
• American College of Preventive Medicine - 1-time screening in men
aged 65 to 75 years who have ever smoked; it does not recommend
routine screening in women
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20. • Canadian Society for Vascular Surgery - Ultrasonography screening
for AAA in men aged 65 to 75 years who are candidates for surgery
and willing to participate
• In individualized cases, some women older than 65 years with
multiple risk factors (smoking history, cerebrovascular disease, or
family history) may be considered for screening
• European Society for Vascular Surgery - Men should be screened for
AAA with a single ultrasonography at age 65 years
• Screening should be considered at an earlier age in men at higher
risk (those who smoke, have other cardiovascular disease, or have a
family history)
• Screening in older women - does not reduce the incidence of
aneurysm rupture but that screening women who smoke may require
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21. TAKE HOME MESSAGE
• AAA – most dreaded complication is rupture
• Ultrasound- preferred modality for screening
• AAA is strongly associated with smoking
• Screening for AAA in elderly men and high risk women may be
beneficial for risk stratification for rupture risk
• For serial monitoring and planning early repair
• Cost effectiveness should be considered
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Thank you