Commentary on ‘Rupture of Abdominal Aortic Aneurysms in Patients under Screening Age and Elective Repair Threshold’

Abstract

patients and larger aneurysms, respectively. 3 Interestingly, 18.3% of all patients were younger than the universally accepted screening age of 65 years, demonstrating also a gender specific difference (21.4% of men and 3.0% of women were younger than 65 years). This proportion was even larger for smokers, who were more likely to present with an early RAAA than non-smokers, with 28.4% of smokers being under the screening age. These results come as no surprise. Our guidelines acknowledge the fact that a significant number of ruptures occur in individuals younger than 65 years, with the reported proportion varying from 5% to 18%. 2 In agreement with the authors’ findings (18.3% of all patients being below the generally accepted screening age of 65 years), in our personal unpublished series of RAAA, 17% of all patients were younger than 65 years (17.5% and 9.1% for the subgroup of men and women, respectively). In the landmark ADAM study, the mean unadjusted prevalence of AAA 4 cm in male smokers in the two age groups of 55e64 years and 65e79 years was 1.2% and 2.4%, respectively, 1 indicating that restricting AAA screening to the latter group of patients will miss 33% of all AAAs in this population; these observations fit perfectly with the 28.4% frequency of ruptured AAAs in smokers younger than 65 reported by the authors. According to the guidelines, screening should be considered at an earlier age for those at higher risk of AAA, 2,4 such as male smokers, males and also females with a family history of a AAA, or in the presence of any atherosclerotic vascular disease or other risk factors. Obviously a second screening scan would be required at a later stage. According to the authors’ study, 6% of men and 12% of women had a RAAA below the suggested repair diameter threshold of 55 mm and 52 mm, respectively. Since the mean AAA diameter was significantly lower in women than in men, females had an odds ratio of 3.2 compared with men for experiencing rupture of a small (O < 55 mm) AAA in a logistic regression analysis. In the UKSAT study, death was attributable to a ruptured AAA in 5% of men and 14% of women who died, 5 indicating firstly the need to lower the repair threshold for women, secondly the necessity for vigorous follow up of real world patients with a small AAA, and thirdly a commitment to more research on identifying markers predicting future rupture of small AAAs.