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Task Force Screening
Task Force Screening
EVIDENCE ASSESSMENT Based on a review of the evidence, the USPSTF concludes with
moderate certainty that screening for AAA in men aged 65 to 75 years who have ever smoked
is of moderate net benefit. The USPSTF concludes with moderate certainty that screening for
AAA in men aged 65 to 75 years who have never smoked is of small net benefit. The USPSTF
concludes that the evidence is insufficient to determine the net benefit of screening for AAA
in women aged 65 to 75 years who have ever smoked or have a family history of AAA. The
USPSTF concludes with moderate certainty that the harms of screening for AAA in women
aged 65 to 75 years who have never smoked and have no family history of AAA outweigh the
benefits.
(Reprinted) 2211
© 2019 American Medical Association. All rights reserved.
Summary of Recommendations
The USPSTF recommends 1-time screening for abdominal aortic aneurysm B recommendation
(AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked.
The USPSTF recommends that clinicians selectively offer screening for AAA with C recommendation
ultrasonography in men aged 65 to 75 years who have never smoked rather than
routinely screening all men in this group. Evidence indicates that the net benefit
of screening all men in this group is small. In determining whether this service
is appropriate in individual cases, patients and clinicians should consider the
balance of benefits and harms on the basis of evidence relevant to the patient’s
medical history, family history, other risk factors, and personal values.
The USPSTF recommends against routine screening for AAA with D recommendation
ultrasonography in women who have never smoked and have no family
history of AAA. See the Figure for a more detailed
summary of the recommendation for
The USPSTF concludes that the current evidence is insufficient to assess the I statement
clinicians. See the “Practice
balance of benefits and harms of screening for AAA with ultrasonography in
Considerations” section for more
women aged 65 to 75 years who have ever smoked or have a family history
information on each of these
of AAA.
populations. USPSTF indicates US
Preventive Services Task Force.
2212 JAMA December 10, 2019 Volume 322, Number 22 (Reprinted) jama.com
December 2019
For women aged 65 to 75 years who have ever smoked or have a family history of AAA: I statement
Evidence is insufficient to assess the balance of benefits and harms of screening for AAA with ultrasonography in women
aged 65 to 75 years who have ever smoked or have a family history of AAA.
This recommendation is consistent with the 2014 USPSTF recommendation. Family history (first-degree relative) of AAA has
What’s new?
been added as a risk factor for screening decisions in women.
1. Assess risk. Risk factors for AAA include older age, male sex, smoking, and having a first-degree relative with an AAA.
The recommendation varies based on a patient’s sex, age, and smoking history. “Ever smoker” is commonly defined as
smoking 100 or more cigarettes.
2. Screen. Abdominal duplex ultrasonography is the standard approach for AAA screening.
How to implement this a. Screen men aged 65 to 75 years who have ever smoked.
recommendation? b. Selectively offer screening to men aged 65 to 75 years who have never smoked. Evidence shows that the overall benefit
for screening all men in this group is small. To determine whether this service is appropriate, patients and clinicians
should consider the patient’s medical history, family history, other risk factors, and personal values.
For those who screen positive, treatment of AAA will depend on aneurysm size, the risk of rupture, and the risk
of operative mortality.
What are other The USPSTF has made recommendations on screening for carotid artery stenosis and screening for peripheral arterial disease.
relevant USPSTF These recommendations are available at https://www.uspreventiveservicestaskforce.org.
recommendations?
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize
decision-making to the specific patient or situation.
AAA indicates abdominal aortic aneurysm; USPSTF, US Preventive Services Task Force.
Family History (RCTs) of AAA screening used a 1-time screening approach; 7 fair-
Family history of AAA in a first-degree relative doubles the risk of to good-quality cohort studies and 1 fair-quality case-control study
developing AAA.25 The risk of developing an AAA is stronger with a (n = 6785) show that AAA-associated mortality over 5 to 12 years is
female first-degree relative (odds ratio [OR], 4.32) than with a male rare (<3%) in men with initially normal results on ultrasonography
first-degree relative (OR, 1.61).1,25 However, evidence is lacking on (defined as an AAA <3 cm in diameter).1
whether persons with family history experience a different natural
history or surgical outcomes than those without such a history.1 Treatment
Treatment of AAA depends on aneurysm size, the risk of rupture,
Screening Tests and the risk of operative mortality. Larger size is associated with an
The primary method of screening for AAA is conventional abdomi- increased risk of rupture. The annual risk for rupture is nearly 0%
nal duplex ultrasonography.26 Screening with ultrasonography is non- for persons with AAAs between 3.0 and 3.9 cm in diameter, 1% for
invasive, is simple to perform, has high sensitivity (94%-100%) and those with AAAs between 4.0 and 4.9 cm in diameter, and 11% for
specificity (98%-100%) for detecting AAA,1,27-31 and does not ex- those with AAAs between 5.0 and 5.9 cm in diameter.1 Surgical re-
pose patients to radiation. Computed tomography is an accurate tool pair is standard practice for men with an AAA of 5.5 cm or larger in
for identifying AAA; however, it is not recommended as a screen- diameter or an AAA larger than 4.0 cm in diameter that has rapidly
ing method because of the potential for harms from radiation increased in size (defined as an increase of 1.0 cm in diameter over
exposure.1 Physical examination has been used in practice but has a 1-year period). Endovascular aneurysm repair (EVAR) has be-
low sensitivity (39%-68%) and specificity (75%) and is not recom- come the most common approach for elective AAA repair. Open re-
mended for screening.32 pair is a time-tested, effective treatment for AAA. In the United
States, 80% of intact AAA repairs and 52% of ruptured AAA re-
Screening Intervals pairs are performed using EVAR.1
Evidence is adequate to support 1-time screening for men who have The majority of screen-detected AAAs (ⱖ90%) are between 3.0
ever smoked. All of the population-based randomized clinical trials and 5.5 cm in diameter and thus below the usual threshold for
jama.com (Reprinted) JAMA December 10, 2019 Volume 322, Number 22 2213
Men Women
Never Smoked and No Family
Rationale Ever Smoked Never Smoked Ever Smoked or Family History History
Detection There is adequate evidence There is adequate evidence There is adequate evidence There is adequate evidence
that ultrasonography is a safe that ultrasonography is a safe that ultrasonography is a safe that ultrasonography is a safe
and accurate screening test and accurate screening test and accurate screening test and accurate screening test
for AAA for AAA for AAA for AAA
Benefits of early detection and There is adequate evidence There is adequate evidence There is inadequate evidence There is adequate evidence
treatment (based on direct or that 1-time screening for AAA that 1-time screening for AAA to conclude whether 1-time that 1-time screening for AAA
indirect evidence) with ultrasonography results with ultrasonography results screening for AAA with with ultrasonography results
in a moderate benefit in men in a small benefit in men aged ultrasonography is beneficial in no benefit in women who
aged 65 to 75 y who have ever 65 to 75 y who have never in women aged 65 to 75 y who have never smoked and have
smoked smoked have ever smoked or have a no family history of AAA
family history of AAA
Harms of early detection and There is adequate evidence There is adequate evidence There is adequate evidence There is adequate evidence
treatment that the harms associated with that the harms associated with that the harms associated with that the harms associated with
1-time screening for AAA with 1-time screening for AAA with 1-time screening for AAA with 1-time screening for AAA with
ultrasonography are small to ultrasonography are small to ultrasonography are small to ultrasonography are small to
moderate moderate moderate moderate
USPSTF assessment There is moderate certainty There is moderate certainty The benefits and harms of There is moderate certainty
that screening for AAA with that screening for AAA with screening for AAA with that the harms of screening
ultrasonography in men aged ultrasonography in men aged ultrasonography in women for AAA with ultrasonography
65 to 75 y who have ever 65 to 75 y who have never aged 65 to 75 y who have ever in women who have never
smoked has a moderate net smoked has a small net smoked or have a family smoked and have no family
benefit benefit history of AAA are uncertain, history of AAA outweigh the
and the balance of benefits benefits
and harms cannot be
determined
a
Abbreviations: AAA, abdominal aortic aneurysm; USPSTF, US Preventive See the eFigure in the Supplement for explanation of USPSTF grades and
Services Task Force. levels of evidence.
surgery. The current standard of care for patients with stable smaller The standard of care for elective repair is that patients with an
aneurysms is to maintain ultrasound surveillance at regular inter- AAA of 5.5 cm or larger in diameter should be referred for surgical
vals because the risk of rupture is small. Recommended surveil- intervention with either open repair or EVAR.1 This recommenda-
lance intervals for monitoring the growth of small AAAs vary across tion is based on RCTs conducted in men. The AAA size needed for
guideline groups, and adherence with surveillance guidelines has surgical intervention in women may differ. As a result, guidelines from
been reported to be as low as 65%.1 Repairing smaller aneurysms the Society for Vascular Surgery recommend repairing AAAs be-
with a lower risk of rupture increases the harms and reduces the ben- tween 5.0 and 5.4 cm in diameter in women.26 However, concerns
efits of screening. about poorer surgical outcomes in women, who have more com-
plex anatomy and smaller blood vessels, have led some to caution
Suggestions for Practice Regarding the I Statement against lowering the threshold for surgical intervention in women.1
Potential Preventable Burden
The estimated prevalence of AAA in women is reportedly less than
that in men.1 The Chichester trial reported a prevalence in women
Update of Previous USPSTF Recommendation
that was one-sixth of the prevalence in men (1.3% vs 7.6%), and most
AAA-related deaths occurred in women 80 years or older (70% vs This recommendation incorporates new evidence and replaces the
<50% in men).33 In women, small AAAs have an increased risk of rup- 2014 USPSTF recommendation.35 It is consistent with the 2014
ture, and rupture at an older age than in men.1 Studies estimate that USPSTF recommendation, which was a B recommendation for 1-time
one-fourth to one-third of women have an AAA with a diameter be- screening for AAA with ultrasonography in asymptomatic men aged
low the current 5.5-cm threshold at the time of rupture.1 65 to 75 years who have ever smoked, a C recommendation for se-
lective screening in men aged 65 to 75 years who have never smoked,
Potential Harms a D recommendation against routine screening in asymptomatic
Operative mortality associated with AAA is higher in women than women who have never smoked, and an I statement for women aged
in men. Women had higher 30-day mortality rates (2.31%) than men 65 to 75 years who have ever smoked.
(1.37%) after EVAR procedures (OR, 1.67 [95% CI, 1.38-2.04]) and
open repair (5.37% vs 2.82%; OR, 1.76 [95% CI, 1.35-2.30]).1,34
Women also experience higher rates of other harms, such as major
Supporting Evidence
surgical complications and hospital readmission, after elective open
repair or EVAR compared with men.1 Scope of Review
The USPSTF commissioned a systematic evidence review to up-
Current Practice date its 2014 recommendation on screening for AAA. The USPSTF
Evidence is insufficient to accurately characterize current practice examined evidence regarding the effectiveness of 1-time and re-
patterns related to screening for AAA in women. peated screening for AAA, the associated harms of screening, and
2214 JAMA December 10, 2019 Volume 322, Number 22 (Reprinted) jama.com
the benefits and harms of available treatments for small AAAs 0.58 [95% CI, 0.49-0.69] and 0.34 [95% CI, 0.20-0.57],
(3.0-5.4 cm in diameter) identified through screening. respectively).13,36 The Chichester trial reported an HR of less than 1
(HR, 0.89 [95% CI, 0.60-1.32]), but it was not statistically
Accuracy of Screening Tests and Risk Assessment significant.1,37 Pooled analysis of all available trials also showed no
Ultrasonography is the primary method used to screen for AAA in effect on all-cause mortality (relative risk, 0.99 [95% CI, 0.98-
primary care because of its high sensitivity (94%-100%) and speci- 1.00]; I2 = 0%).1 Of the individual trials, only MASS showed a sta-
ficity (98%-100%).1 It is also noninvasive, is simple to perform, and tistically significant benefit of screening for all-cause mortality at
does not expose patients to radiation. up to 15-year follow-up (HR, 0.97 [95% CI, 0.95-0.99]).1 Invitation
to screening was associated with a statistically significant reduced
Benefits of Early Detection and Treatment rate of rupture in the pooled analysis of the 4 trials (Peto OR, 0.62
Screening [95% CI, 0.55-0.70]; I2 = 53%).1 The number needed to screen
Four large, population-based RCTs (n = 134 271) that predomi- was 246 men (95% CI, 207-311) to prevent 1 AAA rupture. Pooled
nantly enrolled men 65 years or older examined the effectiveness results of the trials showed a reduction in emergency surgery in
of 1-time screening for AAA: the good-quality Multicenter Aneu- the invited-to-screening group (Peto OR, 0.57 [95% CI, 0.48-
rysm Screening Study (MASS) (n = 67 800)36; the good-quality 0.68]; I2 = 27%).1 Screening 1000 men for AAA would decrease
Viborg County, Denmark, screening trial (n = 12 639)13; the fair- the number of emergency operations by 2 (95% CI, 2-2).1
quality Chichester, United Kingdom, screening trial (n = 15 382)37;
and the fair-quality Western Australia screening trial (n = 38 480).38 Treatment
Reported mean (or median) ages ranged from 67.7 to 72.6 years; the Four trials evaluated early surgical intervention compared with
oldest participants were aged 83 years.1 The Western Australia surveillance of smaller aneurysms (4-5.4 cm in diameter).41-44
screening trial38 reported outcomes by smoking status in the Two good-quality open repair trials (n = 2226) and 2 fair-quality
screened group. The trial was underpowered to detect differences EVAR trials (n = 1088) showed no differences in all-cause and
in subpopulations. No comparisons in the unscreened group were AAA-related mortality. However, there was a reduction in rupture
reported.1,39 None of the 4 population-based screening RCTs re- rate with early open surgery compared with surveillance for small
ported family history of AAA in the trial populations.1 AAAs 12,16,37,38 in the Aneurysm Detection and Management
The prevalence of AAA in male screening participants ranged (ADAM) Veterans Affairs trial (relative risk, 0.18 [95% CI, 0.04-
from 4.0% to 7.6% across the studies. Most screen-detected AAAs 0.81]) and the UK Small Aneurysm Trial (UKSAT) (relative risk,
were small (ⱕ4 to 4.5 cm in diameter); 0.3% to 0.6% of screened 0.51 [95% CI, 0.26-0.99]).1,41,42 Individual patient data meta-
participants had an AAA measuring 5 cm or larger or 5.5 cm or larger analysis of the 2 early open vs surveillance trials (ADAM and
in diameter.1 Two of the population-based screening trials ana- UKSAT) reported no differences in all-cause mortality effect by
lyzed AAA-associated mortality by age. The Viborg trial found simi- sex or age.1,36,37 The UKSAT trial reported no difference in all-
lar risk reduction in AAA-related mortality in screening men aged 64 cause mortality by smoking status; there were no analyses strati-
to 65 years compared with men aged 66 to 73 years.13 The West- fying by family history or race/ethnicity.1
ern Australia trial found no AAA-associated mortality benefit in men Seven pharmacotherapy RCTs (n = 1553) of antibiotics, antihy-
aged 65 to 74 years (rate ratio, 0.92 [95% CI, 0.62-1.36]) at 12.8- pertensive medications (eg, angiotensin-converting enzyme inhibi-
year follow-up; results were similar to findings for men aged 64 to tors, calcium channel blockers, and propranolol), and a mast cell
83 years.1,38 stabilizer showed no significant effect on AAA growth compared
As noted previously, only the Chichester trial included women with placebo.1
(aged 65-80 years). It found a low prevalence of AAA in women
(1.3%), and 75% of screen-detected AAAs in women were 3.0 to Harms of Screening and Treatment
3.9 cm in diameter. Rupture rates (0.2% in both groups), AAA- An individual’s risk for death related to elective surgery for AAA is
specific mortality (0.06% vs 0.04% in both groups), and all-cause lower than that related to emergency surgery for aneurysm rup-
mortality (10.7% vs 10.2%) at 5 years did not statistically signifi- ture. However, the increase in the overall rates of detection and sur-
cantly differ between the invitation-to-screening and control gery in the screening groups still potentially represents a harm. The
groups.1,33 The trial was underpowered to draw definitive conclu- extent of overdiagnosis and overtreatment is difficult to estimate.
sions about health outcomes in women. Although the risk for rup- Each of the 4 older screening trials and a more recent
ture at a smaller aneurysm diameter seems to be higher in women population-based screening RCT (n = 18 614), the Viborg Vascular
than in men,1,40 the overall rupture rate in women is low. In the (VIVA) trial, showed an increase in elective operations in the inter-
Chichester trial, more than two-thirds of deaths from AAA occurred vention vs control group.1,45 There were approximately 40% more
in women 80 years or older.1,33 operations in the invitation-to-screen group than in the control
Pooled analysis of AAA-related mortality from the 4 trials group (5 studies; n = 175 085; Peto OR, 1.44 [95% CI, 1.34-1.55]),
showed a statistically significant 35% reduction associated with driven primarily by an increase in elective operations (5 studies;
invitation to screening (Peto OR, 0.65 [95% CI, 0.57-0.74]; n = 175 085; Peto OR, 1.75 [95% CI, 1.61-1.90]).1 There was no sta-
I2 = 80%).1 The number needed to screen was 305 men (95% CI, tistically significant difference in 30-day mortality rates between
248-411) to prevent 1 AAA death. The MASS and Viborg trials the invited and control groups for either elective or emergency
each found a statistically significant reduction in AAA-related operations at 12- to 15-year follow-up.1
mortality in the groups invited to screening compared with the Five studies (n = 2734) reported mixed results on quality-of-
control groups up to 13 years after screening (hazard ratio [HR], life outcomes.1 Overall, there were no substantial differences on
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2216 JAMA December 10, 2019 Volume 322, Number 22 (Reprinted) jama.com
ARTICLE INFORMATION Disclaimer: Recommendations made by the aneurysm in New Zealand. Br J Surg. 2011;98(5):
Accepted for Publication: October 30, 2019. USPSTF are independent of the US government. 645-651. doi:10.1002/bjs.7461
They should not be construed as an official position 8. Wanhainen A, Hultgren R, Linné A, et al; Swedish
The US Preventive Services Task Force (USPSTF) of AHRQ or the US Department of Health and
members: Douglas K. Owens, MD, MS; Karina W. Aneurysm Screening Study Group (SASS). Outcome
Human Services. of the Swedish Nationwide Abdominal Aortic
Davidson, PhD, MASc; Alex H. Krist, MD, MPH;
Michael J. Barry, MD; Michael Cabana, MD, MA, Additional Contributions: We thank Iris Aneurysm Screening Program. Circulation. 2016;134
MPH; Aaron B. Caughey, MD, PhD; Chyke A. Mabry-Hernandez, MD, MPH (AHRQ), who (16):1141-1148. doi:10.1161/CIRCULATIONAHA.116.
Doubeni, MD, MPH; John W. Epling Jr, MD, MSEd; contributed to the writing of the manuscript, and 022305
Martha Kubik, PhD, RN; C. Seth Landefeld, MD; Lisa Nicolella, MA (AHRQ), who assisted with 9. Johansson M, Zahl PH, Siersma V, Jørgensen KJ,
Carol M. Mangione, MD, MSPH; Lori Pbert, PhD; coordination and editing. Marklund B, Brodersen J. Benefits and harms of
Michael Silverstein, MD, MPH; Melissa A. Simon, Additional Information: The USPSTF makes screening men for abdominal aortic aneurysm in
MD, MPH; Chien-Wen Tseng, MD, MPH, MSEE; recommendations about the effectiveness of Sweden: a registry-based cohort study. Lancet.
John B. Wong, MD. specific preventive care services for patients 2018;391(10138):2441-2447. doi:10.1016/S0140-6736
Affiliations of The US Preventive Services Task without obvious related signs or symptoms. It (18)31031-6
Force (USPSTF) members: Veterans Affairs bases its recommendations on the evidence of both 10. Grøndal N, Søgaard R, Lindholt JS. Baseline
Palo Alto Health Care System, Palo Alto, California the benefits and harms of the service and an prevalence of abdominal aortic aneurysm,
(Owens); Stanford University, Stanford, California assessment of the balance. The USPSTF does not peripheral arterial disease and hypertension in men
(Owens); Feinstein Institute for Medical Research, consider the costs of providing a service in this aged 65-74 years from a population screening study
Northwell Health, Manhasset, New York assessment. The USPSTF recognizes that clinical (VIVA trial). Br J Surg. 2015;102(8):902-906. doi:
(Davidson); Fairfax Family Practice Residency, decisions involve more considerations than 10.1002/bjs.9825
Fairfax, Virginia (Krist); Virginia Commonwealth evidence alone. Clinicians should understand the
evidence but individualize decision-making to the 11. Reimerink JJ, van der Laan MJ, Koelemay MJ,
University, Richmond (Krist); Harvard Medical Balm R, Legemate DA. Systematic review and
School, Boston, Massachusetts (Barry); University specific patient or situation. Similarly, the USPSTF
notes that policy and coverage decisions involve meta-analysis of population-based mortality from
of California, San Francisco (Cabana); Oregon ruptured abdominal aortic aneurysm. Br J Surg.
Health & Science University, Portland (Caughey); considerations in addition to the evidence of clinical
benefits and harms. 2013;100(11):1405-1413. doi:10.1002/bjs.9235
Mayo Clinic, Rochester, Minnesota (Doubeni);
Virginia Tech Carilion School of Medicine, Roanoke 12. US Preventive Services Task Force. Procedure
(Epling Jr); Temple University, Philadelphia, REFERENCES Manual. https://www.uspreventiveservicestaskforce.
Pennsylvania (Kubik); University of Alabama at 1. Guirguis-Blake JM, Beil TL, Senger CA, org/Page/Name/procedure-manual. Published June
Birmingham (Landefeld); University of California, Coppola EL. Primary Care Screening for Abdominal 2018. Accessed October 15, 2019.
Los Angeles (Mangione); University of Aortic Aneurysm: Updated Systematic Review for 13. Lindholt JS, Juul S, Fasting H, Henneberg EW.
Massachusetts Medical School, Worcester (Pbert); the US Preventive Services Task Force: Evidence Screening for abdominal aortic aneurysms: single
Boston University, Boston, Massachusetts Synthesis No. 184. Rockville, MD: Agency for centre randomised controlled trial. BMJ. 2005;330
(Silverstein); Northwestern University, Evanston, Healthcare Research and Quality; 2019. AHRQ (7494):750. doi:10.1136/bmj.38369.620162.82
Illinois (Simon); University of Hawaii, Honolulu publication 19-05253-EF-1. 14. Kent KC, Zwolak RM, Egorova NN, et al.
(Tseng); Pacific Health Research and Education 2. Guirguis-Blake JM, Beil TL, Senger CA, Analysis of risk factors for abdominal aortic
Institute, Honolulu, Hawaii (Tseng); Tufts University Coppola EL. Primary care screening for abdominal aneurysm in a cohort of more than 3 million
School of Medicine, Boston, Massachusetts (Wong). aortic aneurysm: evidence report and systematic individuals. J Vasc Surg. 2010;52(3):539-548. doi:
Author Contributions: Dr Owens had full access to review for the US Preventive Services Task Force 10.1016/j.jvs.2010.05.090
all of the data in the study and takes responsibility [published December 10, 2019]. JAMA. doi:10.1001/ 15. Wilmink AB, Hubbard CS, Day NE, Quick CR.
for the integrity of the data and the accuracy of the jama.2019.17021 The incidence of small abdominal aortic aneurysms
data analysis. The USPSTF members contributed 3. Svensjö S, Björck M, Gürtelschmid M, Djavani and the change in normal infrarenal aortic diameter:
equally to the recommendation statement. Gidlund K, Hellberg A, Wanhainen A. Low implications for screening. Eur J Vasc Endovasc Surg.
Conflict of Interest Disclosures: Authors followed prevalence of abdominal aortic aneurysm among 2001;21(2):165-170. doi:10.1053/ejvs.2000.1285
the policy regarding conflicts of interest described 65-year-old Swedish men indicates a change in the 16. Vardulaki KA, Walker NM, Day NE, Duffy SW,
at https://www.uspreventiveservicestaskforce.org/ epidemiology of the disease. Circulation. 2011;124 Ashton HA, Scott RA. Quantifying the risks of
Page/Name/conflict-of-interest-disclosures. All (10):1118-1123. doi:10.1161/CIRCULATIONAHA.111. hypertension, age, sex and smoking in patients with
members of the USPSTF receive travel 030379 abdominal aortic aneurysm. Br J Surg. 2000;87(2):
reimbursement and an honorarium for participating 4. Benson RA, Poole R, Murray S, Moxey P, 195-200. doi:10.1046/j.1365-2168.2000.01353.x
in USPSTF meetings. Dr Barry reported receiving Loftus IM. Screening results from a large United
grants and personal fees from Healthwise, a 17. van Vlijmen-van Keulen CJ, Pals G,
Kingdom abdominal aortic aneurysm screening Rauwerda JA. Familial abdominal aortic aneurysm:
nonprofit, outside the submitted work. No other center in the context of optimizing United Kingdom
disclosures were reported. a systematic review of a genetic background. Eur J
National Abdominal Aortic Aneurysm Screening Vasc Endovasc Surg. 2002;24(2):105-116. doi:10.
Funding/Support: The USPSTF is an independent, Programme protocols. J Vasc Surg. 2016;63(2):301- 1053/ejvs.2002.1692
voluntary body. The US Congress mandates that 304. doi:10.1016/j.jvs.2015.08.091
the Agency for Healthcare Research and Quality 18. MacSweeney ST, O’Meara M, Alexander C,
5. Choke E, Vijaynagar B, Thompson J, Nasim A, O’Malley MK, Powell JT, Greenhalgh RM. High
(AHRQ) support the operations of the USPSTF. Bown MJ, Sayers RD. Changing epidemiology of prevalence of unsuspected abdominal aortic
Role of the Funder/Sponsor: AHRQ staff assisted abdominal aortic aneurysms in England and Wales: aneurysm in patients with confirmed symptomatic
in the following: development and review of the older and more benign? Circulation. 2012;125(13): peripheral or cerebral arterial disease. Br J Surg.
research plan, commission of the systematic 1617-1625. doi:10.1161/CIRCULATIONAHA.111.077503 1993;80(5):582-584. doi:10.1002/bjs.1800800510
evidence review from an Evidence-based Practice 6. Anjum A, Powell JT. Is the incidence of
Center, coordination of expert review and public 19. Lederle FA, Johnson GR, Wilson SE, et al; The
abdominal aortic aneurysm declining in the Aneurysm Detection and Management (ADAM)
comment of the draft evidence report and draft 21st century? mortality and hospital admissions for
recommendation statement, and the writing and Veterans Affairs Cooperative Study Investigators.
England & Wales and Scotland. Eur J Vasc Endovasc Relationship of age, gender, race, and body size to
preparation of the final recommendation statement Surg. 2012;43(2):161-166. doi:10.1016/j.ejvs.2011.11.
and its submission for publication. AHRQ staff had infrarenal aortic diameter. J Vasc Surg. 1997;26
014 (4):595-601. doi:10.1016/S0741-5214(97)70057-0
no role in the approval of the final recommendation
statement or the decision to submit for publication. 7. Sandiford P, Mosquera D, Bramley D. Trends in 20. Li X, Zhao G, Zhang J, Duan Z, Xin S. Prevalence
incidence and mortality from abdominal aortic and trends of the abdominal aortic aneurysms
jama.com (Reprinted) JAMA December 10, 2019 Volume 322, Number 22 2217
epidemic in general population—a meta-analysis. aortic aneurysm? JAMA. 1999;281(1):77-82. doi:10. aneurysm repair (CAESAR): results from a
PLoS One. 2013;8(12):e81260. doi:10.1371/journal. 1001/jama.281.1.77 randomised trial. Eur J Vasc Endovasc Surg. 2011;41
pone.0081260 33. Scott RA, Bridgewater SG, Ashton HA. (1):13-25. doi:10.1016/j.ejvs.2010.08.026
21. De Rango P, Farchioni L, Fiorucci B, Lenti M. Randomized clinical trial of screening for abdominal 44. Ouriel K, Clair DG, Kent KC, Zarins CK; Positive
Diabetes and abdominal aortic aneurysms. Eur J aortic aneurysm in women. Br J Surg. 2002;89(3): Impact of Endovascular Options for Treating
Vasc Endovasc Surg. 2014;47(3):243-261. doi:10. 283-285. doi:10.1046/j.0007-1323.2001.02014.x Aneurysms Early (PIVOTAL) Investigators.
1016/j.ejvs.2013.12.007 34. Ulug P, Sweeting MJ, von Allmen RS, Endovascular repair compared with surveillance for
22. Lederle FA, Johnson GR, Wilson SE, et al; Thompson SG, Powell JT; SWAN Collaborators. patients with small abdominal aortic aneurysms.
Aneurysm Detection and Management Veterans Morphological suitability for endovascular repair, J Vasc Surg. 2010;51(5):1081-1087. doi:10.1016/j.jvs.
Affairs Cooperative Study Investigators. The non-intervention rates, and operative mortality in 2009.10.113
aneurysm detection and management study women and men assessed for intact abdominal 45. Lindholt JS, Søgaard R. Population screening
screening program: validation cohort and final aortic aneurysm repair: systematic reviews with and intervention for vascular disease in Danish men
results. Arch Intern Med. 2000;160(10):1425-1430. meta-analysis. Lancet. 2017;389(10088):2482-2491. (VIVA): a randomised controlled trial. Lancet. 2017;
doi:10.1001/archinte.160.10.1425 doi:10.1016/S0140-6736(17)30639-6 390(10109):2256-2265. doi:10.1016/S0140-6736(17)
23. Takagi H, Umemoto T; ALICE (All-Literature 35. LeFevre ML; US Preventive Services Task Force. 32250-X
Investigation of Cardiovascular Evidence) Group. Screening for abdominal aortic aneurysm: U.S. 46. Hirsch AT, Haskal ZJ, Hertzer NR, et al;
Negative association of diabetes with rupture of Preventive Services Task Force recommendation American Association for Vascular Surgery; Society
abdominal aortic aneurysm. Diab Vasc Dis Res. statement. Ann Intern Med. 2014;161(4):281-290. for Vascular Surgery; Society for Cardiovascular
2016;13(5):341-347. doi:10.1177/1479164116651389 doi:10.7326/M14-1204 Angiography and Interventions; Society for Vascular
24. Xiong J, Wu Z, Chen C, Wei Y, Guo W. 36. Ashton HA, Buxton MJ, Day NE, et al; Medicine and Biology; Society of Interventional
Association between diabetes and prevalence and Multicentre Aneurysm Screening Study Group. The Radiology; ACC/AHA Task Force on Practice
growth rate of abdominal aortic aneurysms: Multicentre Aneurysm Screening Study (MASS) into Guidelines Writing Committee to Develop
a meta-analysis. Int J Cardiol. 2016;221:484-495. the effect of abdominal aortic aneurysm screening Guidelines for the Management of Patients With
doi:10.1016/j.ijcard.2016.07.016 on mortality in men: a randomised controlled trial. Peripheral Arterial Disease; American Association of
Lancet. 2002;360(9345):1531-1539. doi:10.1016/ Cardiovascular and Pulmonary Rehabilitation;
25. Joergensen TM, Houlind K, Green A, National Heart, Lung, and Blood Institute; Society
Lindholt JS. Abdominal aortic diameter is increased S0140-6736(02)11522-4
for Vascular Nursing; TransAtlantic Inter-Society
in males with a family history of abdominal aortic 37. Norman PE, Jamrozik K, Lawrence-Brown MM, Consensus; Vascular Disease Foundation. ACC/AHA
aneurysms: results from the Danish VIVA-trial. Eur J et al. Population based randomised controlled trial 2005 Practice Guidelines for the management of
Vasc Endovasc Surg. 2014;48(6):669-675. doi:10. on impact of screening on mortality from patients with peripheral arterial disease (lower
1016/j.ejvs.2014.09.005 abdominal aortic aneurysm. BMJ. 2004;329(7477): extremity, renal, mesenteric, and abdominal aortic):
26. Chaikof EL, Dalman RL, Eskandari MK, et al. 1259. doi:10.1136/bmj.329.7477.1259 a collaborative report from the American
The Society for Vascular Surgery practice guidelines 38. Scott RA, Wilson NM, Ashton HA, Kay DN. Association for Vascular Surgery/Society for
on the care of patients with an abdominal aortic Influence of screening on the incidence of ruptured Vascular Surgery, Society for Cardiovascular
aneurysm. J Vasc Surg. 2018;67(1):2-77. doi:10. abdominal aortic aneurysm: 5-year results of a Angiography and Interventions, Society for Vascular
1016/j.jvs.2017.10.044 randomized controlled study. Br J Surg. 1995;82(8): Medicine and Biology, Society of Interventional
27. Lederle FA, Walker JM, Reinke DB. Selective 1066-1070. doi:10.1002/bjs.1800820821 Radiology, and the ACC/AHA Task Force on Practice
screening for abdominal aortic aneurysms with 39. McCaul KA, Lawrence-Brown M, Dickinson JA, Guidelines (Writing Committee to Develop
physical examination and ultrasound. Arch Intern Norman PE. Long-term outcomes of the Western Guidelines for the Management of Patients With
Med. 1988;148(8):1753-1756. doi:10.1001/archinte. Australian trial of screening for abdominal aortic Peripheral Arterial Disease): endorsed by the
1988.00380080049015 aneurysms: secondary analysis of a randomized American Association of Cardiovascular and
clinical trial. JAMA Intern Med. 2016;176(12):1761-1767. Pulmonary Rehabilitation; National Heart, Lung,
28. Lindholt JS, Vammen S, Juul S, Henneberg EW, and Blood Institute; Society for Vascular Nursing;
Fasting H. The validity of ultrasonographic scanning doi:10.1001/jamainternmed.2016.6633
TransAtlantic Inter-Society Consensus; and Vascular
as screening method for abdominal aortic 40. Svensjö S, Björck M, Wanhainen A. Disease Foundation. Circulation. 2006;113(11):
aneurysm. Eur J Vasc Endovasc Surg. 1999;17(6): Current prevalence of abdominal aortic aneurysm e463-e654.
472-475. doi:10.1053/ejvs.1999.0835 in 70-year-old women. Br J Surg. 2013;100(3):367-
372. doi:10.1002/bjs.8984 47. Chaikof EL, Brewster DC, Dalman RL, et al;
29. Costantino TG, Bruno EC, Handly N, Dean AJ. Society for Vascular Surgery. The care of patients
Accuracy of emergency medicine ultrasound in the 41. Lederle FA, Wilson SE, Johnson GR, et al; with an abdominal aortic aneurysm: the Society for
evaluation of abdominal aortic aneurysm. J Emerg Aneurysm Detection and Management Veterans Vascular Surgery practice guidelines. J Vasc Surg.
Med. 2005;29(4):455-460. doi:10.1016/j. Affairs Cooperative Study Group. Immediate repair 2009;50(4)(suppl):S2-S49. doi:10.1016/j.jvs.2009.
jemermed.2005.02.016 compared with surveillance of small abdominal 07.002
30. Tayal VS, Graf CD, Gibbs MA. Prospective study aortic aneurysms. N Engl J Med. 2002;346(19):
1437-1444. doi:10.1056/NEJMoa012573 48. Lim LS, Haq N, Mahmood S, Hoeksema L;
of accuracy and outcome of emergency ultrasound ACPM Prevention Practice Committee; American
for abdominal aortic aneurysm over two years. 42. Powell JT, Brady AR, Brown LC, et al; College of Preventive Medicine. Atherosclerotic
Acad Emerg Med. 2003;10(8):867-871. doi:10.1197/ The UK Small Aneurysm Trial Participants. Mortality cardiovascular disease screening in adults:
aemj.10.8.867 results for randomised controlled trial of early American College of Preventive Medicine position
31. Rubano E, Mehta N, Caputo W, Paladino L, elective surgery or ultrasonographic surveillance for statement on preventive practice. Am J Prev Med.
Sinert R. Systematic review: emergency small abdominal aortic aneurysms. Lancet. 1998; 2011;40(3):381.e1-381.e10. doi:10.1016/j.amepre.
department bedside ultrasonography for 352(9141):1649-1655. doi:10.1016/S0140-6736(98) 2010.11.021
diagnosing suspected abdominal aortic aneurysm. 10137-X
Acad Emerg Med. 2013;20(2):128-138. doi:10.1111/ 43. Cao P, De Rango P, Verzini F, Parlani G, Romano
acem.12080 L, Cieri E; CAESAR Trial Group. Comparison of
32. Lederle FA, Simel DL. The rational clinical surveillance versus aortic endografting for small
examination: does this patient have abdominal
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