How best to diagnose and manage abdominal aortic aneurysms

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doi:doi: 10.12788/jfp.0668

Applied Evidence

How best to diagnose and manage abdominal aortic aneurysms

J Fam Pract. 2023 October;72(8):325-331 | doi: 10.12788/jfp.0668

By

Nicholas LeFevre, MD, MSAM, FAAFP

Brandon Chase, MD

The evidence summarized here can help guide your approach to this life-threatening condition that often goes undetected until rupture.

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PRACTICE RECOMMENDATIONS

› Perform a one-time abdominal aortic aneurysm (AAA) screening ultrasound in men ages 65 to 75 years who have ever smoked. B

› Consider performing a one-time AAA screening ultrasound in women ages 65 to 75 years who have ever smoked. C

› Prescribe high-intensity statin therapy for men and women with atherosclerotic AAA. A

Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

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14. Chabok M, Nicolaides A, Aslam M, et al. Risk factors associated with increased prevalence of abdominal aortic aneurysm in women. Br J Surg. 2016;103:1132-1138. doi: 10.1002/bjs.10179

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16. Sweeting MJ, Thompson SG, Brown LC, et al; RESCAN collaborators. Meta-analysis of individual patient data to examine factors affecting growth and rupture of small abdominal aortic aneurysms. Br J Surg. 2012;99:655-665. doi: 10.1002/bjs.8707

17. Skibba AA, Evans JR, Hopkins SP, et al. Reconsidering gender relative to risk of rupture in the contemporary management of abdominal aortic aneurysms. J Vasc Surg. 2015;62:1429-1436. doi: 10.1016/j.jvs.2015.07.079

18. Guirguis-Blake JM, Beil TL, Senger CA, et al. Primary care screening for abdominal aortic aneurysm: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;322:2219-2238. doi: 10.1001/jama.2019.17021

19. Thompson SG, Ashton HA, Gao L, et al; Multicentre Aneurysm Screening Study (MASS) Group. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg. 2012;99:1649-1656. doi: 10.1002/bjs.8897

20. Ashton HA, Gao L, Kim LG, et al. Fifteen-year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg. 2007;94:696-701. doi: 10.1002/bjs.5780

21. Carnevale ML, Koleilat I, Lipsitz EC, et al. Extended screening guidelines for the diagnosis of abdominal aortic aneurysm. J Vasc Surg. 2020;72:1917-1926. doi: 10.1016/j.jvs.2020.03.047

22. Duncan A, Maslen C, Gibson C, et al. Ultrasound screening for abdominal aortic aneurysm in high-risk women. Br J Surg. 2021;108:1192-1198. doi: 10.1093/bjs/znab220

23. Shreibati JB, Baker LC, Hlatky MA, et al. Impact of the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act on abdominal ultrasonography use among Medicare beneficiaries. Arch Intern Med. 2012;172:1456-1462. doi: 10.1001/archinternmed.2012.4268

24. Hye RJ, Smith AE, Wong GH, et al. Leveraging the electronic medical record to implement an abdominal aortic aneurysm screening program. J Vasc Surg. 2014;59:1535-1542. doi: 10.1016/j.jvs.2013.12.016

25. Rubano E, Mehta N, Caputo W, et al., Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Acad Emerg Med. 2013. 20:128-138. doi: 10.1111/acem.12080

26. Blois B. Office-based ultrasound screening for abdominal aortic aneurysm. Can Fam Physician. 2012;58:e172-e178.

27. Arnold MJ, Jonas CE, Carter RE. Point-of-care ultrasonography. Am Fam Physician. 2020;101:275-285.

28. Nixon G, Blattner K, Muirhead J, et al. Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care. Rural Remote Health. 2019;19:5027. doi: 10.22605/RRH5027

29. Lederle FA, Wilson SE, Johnson GR, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1437-1444. doi: 10.1056/NEJMoa012573

30. Filardo G, Lederle FA, Ballard DJ, et al. Immediate open repair vs surveillance in patients with small abdominal aortic aneurysms: survival differences by aneurysm size. Mayo Clin Proc. 2013;88:910-919. doi: 10.1016/j.mayocp.2013.05.014

31. Lederle FA, Kyriakides TC, Stroupe KT, et al. Open versus endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2019;380:2126-2135. doi: 10.1056/NEJMoa1715955

32. Patel R, Sweeting MJ, Powell JT, et al., Endovascular versus open repair of abdominal aortic aneurysm in 15-years’ follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomised controlled trial. Lancet. 2016;388:2366-2374. doi: 10.1016/S0140-6736(16)31135-7

33. van Schaik TG, Yeung KK, Verhagen HJ, et al. Long-term survival and secondary procedures after open or endovascular repair of abdominal aortic aneurysms. J Vasc Surg. 2017;66:1379-1389. doi: 10.1016/j.jvs.2017.05.122

34. Powell JT, Brady AR, Brown, LC, et al; United Kingdom Small Aneurysm Trial Participants. Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med. 2002;346:1445-1452. doi: 10.1056/NEJMoa013527

35. Paravastu SC, Jayarajasingam R, Cottam R, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev. 2014:CD004178. doi: 10.1002/14651858.CD004178.pub2

36. Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58:2020-2045. doi: 10.1016/j.jacc.2011.08.023

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38. Ouriel K, Clair DG, Kent KC, et al; Positive Impact of Endovascular Options for treating Aneurysms Early (PIVOTAL) Investigators. Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms. J Vasc Surg. 2010;51:1081-1087. doi: 10.1016/j.jvs.2009.10.113

39. Cao P, De Rango P, Verzini F, et al. Comparison of surveillance versus aortic endografting for small aneurysm repair (CAESAR): results from a randomised trial. Eur J Vasc Endovasc Surg. 2011;41:13-25. doi: 10.1016/j.ejvs.2010.08.026

40. Karthaus EG, Tong TML, Vahl A, et al; Dutch Society of Vascular Surgery, the Steering Committee of the Dutch Surgical Aneurysm Audit and the Dutch Institute for Clinical Auditing. Saccular abdominal aortic aneurysms: patient characteristics, clinical presentation, treatment, and outcomes in the Netherlands. Ann Surg. 2019;270:852-858. doi: 10.1097/SLA.0000000000003529

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Ruptured abdominal aortic aneurysms (AAAs) caused about 6000 deaths annually in the United States between 2014 and 2020¹ and are associated with a pooled mortality rate of 81%.² They result from a distinct degenerative process of the layers of the aortic wall.²An AAA is defined as an abdominal aorta whose dilation is > 50% normal (more commonly, a diameter > 3 cm).^3,4 The risk for rupture correlates closely with size; most ruptures occur in aneurysms > 5.5 cm^3,4 (TABLE 1⁵).

Most AAAs are asymptomatic and often go undetected until rupture, resulting in poor outcomes. Because of a low and declining prevalence of AAA and ruptured AAA in developed countries, screening recommendations target high-risk groups rather than the general population.^4,6-8 This review summarizes risk factors, prevalence, and current evidence-based screening and management recommendations for AAA.

Who’s at risk?

Age is the most significant nonmodifiable risk factor, with AAA rupture uncommon in patients younger than 55 years.⁹ One retrospective study found the odds ratio (OR) for diagnosing AAA was 9.41 in adults ages 65 to 69 years (95% CI, 8.76-10.12; P < .0001) and 14.46 (95% CI, 13.45-15.55; P < .0001) in adults ages 70 to 74 years, compared to adults younger than 55 years.¹⁰

Smoking is the most potent modifiable risk factor for AAA. Among patients with AAA, > 90% have a history of smoking.⁴ The association between smoking and AAA is dose dependent, with an OR of 2.61 (95% CI, 2.47-2.74) in patients with a pack-per-year history < 5 years and 12.13 (95% CI, 11.66-12.61) in patients with a pack-per-year history > 35 years, compared to nonsmokers.¹⁰ The risk for AAA increases with smoking duration but decreases with cessation duration.^4,10 Smoking cessation remains an important intervention, as active smokers have higher AAA rupture rates.¹¹

Other risk factors for AAA include concomitant cardiovascular disease (CVD) such as coronary artery disease (CAD), cerebrovascular disease, atherosclerosis, dyslipidemia, and hypertension.¹⁰ Factors associated with reduced risk for AAA include African American race, Hispanic ethnicity, Asian ethnicity, diabetes, smoking cessation, consuming fruits and vegetables > 3 times per week, and exercising more than once per week.^6,10

Prevalence declines but sex-based disparities in outcomes persist

The prevalence of AAA has declined in the United States and Europe in recent decades, correlating with declining rates of smoking.^4,12 Reports published between 2011 and 2019 estimate that AAA prevalence in men older than 60 years has declined over time, with a prevalence of 1.2% to 3.3%.⁶ The prevalence of AAA has also decreased in women,^6,13,14 estimated in 1 study to be as low as 0.74%.¹³ Similarly, deaths from ruptured AAA have declined markedly in the United States—by 70% between 1999 and 2016 according to 1 analysis.⁹

One striking difference in the male-female data is that although AAAs are more common in men, there is a 2- to 4-fold higher risk for rupture in women, who account for nearly half of all AAA-related deaths.^9,10,15-17 The reasons for this heightened risk to women despite lower prevalence are not fully understood but are likely multifactorial and related to a general lack of screening for AAA in women, tendency for AAA to rupture at smaller diameters in women, rupture at an older age in women, and a history of worse surgical outcomes in women than men (though the gap in surgical outcomes appears to be closing).^9,10,18

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