Primary Care Screening for Abdominal Aortic Aneurysm

Importance: Ruptured abdominal aortic aneurysms (AAAs) have mortality estimated at 81%. Objective: To systematically review the evidence on benefits and harms of AAA screening and small aneurysm treatment to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed (publisher supplied only), Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through September 2018. Surveillance continued through July 2019. Study Selection: Trials of AAA screening benefits and harms; trials and cohort studies of small (3.0-5.4 cm) AAA treatment benefits and harms. Data Extraction and Synthesis: Two investigators independently reviewed abstracts and full-text articles and extracted data. The Peto method was used to pool odds ratios (ORs) for AAA-related mortality, rupture, and operations; the DerSimonian and Laird random-effects model was used to pool calculated risk ratios for all-cause mortality. Main Outcomes and Measures: AAA and all-cause mortality; AAA rupture; treatment complications. Results: Fifty studies (N = 323 279) met inclusion criteria. Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65 years or older was associated with a reduction in AAA-related mortality over 12 to 15 years (OR, 0.65 95% CI, 0.57-0.74; 4 RCTs n = 124 926), AAA-related ruptures over 12 to 15 years (OR, 0.62 95% CI, 0.55-0.70; 4 RCTs n = 124 929), and emergency surgical procedures over 4 to 15 years (OR, 0.57 95% CI, 0.48-0.68; 5 RCTS n = 175 085). In contrast, no significant association with all-cause mortality benefit was seen at 12- to 15-year follow-up (relative risk, 0.99 95% CI 0.98-1.00; 4 RCTs n = 124 929). One-time screening was associated with significantly more procedures over 4 to 15 years in the invited group compared with the control group (OR, 1.44 95% CI, 1.34-1.55; 5 RCTs n = 175 085). Four trials (n = 3314) of small aneurysm surgical treatment demonstrated no significant difference in AAA-related mortality or all-cause mortality compared with surveillance over 1.7 to 12 years. These 4 early surgery trials showed a substantial increase in procedures in the early surgery group. For small aneurysm treatment, registry data (3 studies n = 14 424) showed that women had higher surgical complications and postoperative mortality compared with men. Conclusions and Relevance: One-time AAA screening in men 65 years or older was associated with decreased AAA-related mortality and rupture rates but was not associated with all-cause mortality benefit. Higher rates of elective surgery but no long-term differences in quality of life resulted from screening.