Screening for abdominal aortic aneurysm: a consensus statement.

Abstract

Treatment of abdominal aortic aneurysm (AAA) with minimally invasive techniques has recently gained tremendous national and international attention. However, enthusiasm for this new technique has diverted attention from an equally important issue, that of early detection or screening for aneurysms. Over the past 20 years, despite advances in diagnostic imaging and in general medical care of patients, there has been essentially no change in the number of patients seen in US hospitals with ruptured AAA.1Heller J.A. Weinberg A. Arons R. Krishnasastry K.V. Lyon R.T. Deitch J.S. et al.Two decades of abdominal aortic aneurysm repair have we made any progress?.J Vasc Surg. 2000; 32: 1091-2000Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar Approximately 15,000 persons die of ruptured AAA and dissections each year.2National Center for Health Statistics. Deaths, percent of total deaths and death rates for the 15 leading causes of death: United States and each state, 2000. Atlanta, Ga: CDC/NCHS, National Vital Statistics System; 2001Google Scholar However, this may be the tip of the iceberg. It is estimated that 300,000 persons per year die suddenly without receiving medical care.3American Heart AssociationHeart disease and stroke statistics 2003 update. The Association, Dallas, Tex2002Google Scholar Furthermore, studies have shown that the incidence of ruptured AAA in cases of sudden death ranges from 4% to 5%.4Cheng CT, Tai GK. Sudden, unexpected deaths in adults: clinical-pathological correlations and legal considerations. Legal Med 1992:31-48Google Scholar, 5O'Sullivan J.P. The coroner's necropsy in sudden death an under-used source of epidemiological information.J Clin Pathol. 1996; 49: 737-740Crossref PubMed Scopus (25) Google Scholar, 6Owada M. Aizawa Y. Kurihara K. Tanabe N. Aizaki T. Izumi T. Risk factors and triggers of sudden death in the working generation an autopsy proven case-control study.Tohoku J Exp Med. 1999; 189: 245-258Crossref PubMed Scopus (22) Google Scholar Thus the yearly death rate from ruptured AAA could be as high as 30,000. This is comparable to a yearly mortality of 32,000 for prostate cancer and 42,000 for breast cancer.2National Center for Health Statistics. Deaths, percent of total deaths and death rates for the 15 leading causes of death: United States and each state, 2000. Atlanta, Ga: CDC/NCHS, National Vital Statistics System; 2001Google Scholar The foregoing data strongly emphasize the increasingly recognized7Beard J.D. Screening for abdominal aortic aneurysm.Br J Surg. 2003; 90: 515-516Crossref PubMed Scopus (28) Google Scholar need for a strategy that will enable early detection of aneurysms. When evaluating the cost and effectiveness of screening programs, four important issues must be considered: cost, invasiveness, and accuracy of the screening test; prevalence of the disease; efficacy of interventions to treat the disease; and cost of these interventions. Screening for AAA can be performed with a simple noninvasive ultrasound study. It is well-documented that a limited ultrasound examination is extremely accurate in identifying the presence of AAA.8Lee T.Y. Korn P. Heller J.A. Kilaru S. Beavers F.P. Bush H.L. et al.The cost-effectiveness of a “quick-screen” program for abdominal aortic aneurysms.Surgery. 2002; 132: 399-407Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar The prevalence of AAA is quite high if selected populations are screened. For example, the incidence of AAA larger than 3 cm in all men older than 60 years is 4% to 8%.9Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Hye R.J. Makaroun M.S. et al.The aneurysm detection and management study screening program validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.Arch Intern Med. 2000; 160: 1425-1430Crossref PubMed Scopus (503) Google Scholar, 10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar, 11Lawrence-Brown M.M. Norman P.E. Jamrozik K. Semmens J.B. Donnelly N.J. Spencer C. et al.Initial results of ultrasound screening for aneurysm of the abdominal aorta in Western Australia relevance for endoluminal treatment of aneurysm disease.Cardiovasc Surg. 2001; 9: 234-240Crossref PubMed Scopus (46) Google Scholar, 12Wilmink A.B. Quick C.R. Epidemiology and potential for prevention of abdominal aortic aneurysm.Br J Surg. 1998; 85: 155-162Crossref PubMed Scopus (155) Google Scholar, 13Wilmink T.B. Quick C.R. Hubbard C.S. Day N.E. The influence of screening on the incidence of ruptured abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 203-208Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 14Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Hospital costs and benefits of screening for abdominal aortic aneurysms results from a randomised population screening trial.Eur J Vasc Endovasc Surg. 2002; 23: 55-60Abstract Full Text PDF PubMed Scopus (142) Google Scholar If patients have cardiovascular risk factors, such as smoking, hypertension, or history of peripheral arterial disease, the incidence of AAA increases two to five times.15Alcorn H.G. Wolfson Jr, S.K. Sutton-Tyrrell K. Kuller L.H. O'Leary D. Risk factors for abdominal aortic aneurysms in older adults enrolled in The Cardiovascular Health Study.Arterioscl Thromb Vasc Biol. 1996; 16: 963-970Crossref PubMed Scopus (274) Google Scholar The prevalence of AAA larger than 3 cm in women older than 60 years is only 1.5%.9Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Hye R.J. Makaroun M.S. et al.The aneurysm detection and management study screening program validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.Arch Intern Med. 2000; 160: 1425-1430Crossref PubMed Scopus (503) Google Scholar, 16Bengtsson H. Bergqvist D. Sternby N.H. Increasing prevalence of abdominal aortic aneurysms a necropsy study.Eur J Surg. 1992; 158: 19-23PubMed Google Scholar, 17Singh K. Bonaa K.H. Jacobsen B.K. Bjork L. Solberg S. Prevalence of and risk factors for abdominal aortic aneurysms in a population-based study The Tromso Study.Am J Epidemiol. 2001; 154: 236-244Crossref PubMed Scopus (457) Google Scholar, 18McFarlane M.J. The epidemiologic necropsy for abdominal aortic aneurysm.JAMA. 1991; 265: 2085-2088Crossref PubMed Scopus (72) Google Scholar, 19Scott R.A. Wilson N.M. Ashton H.A. Kay D.N. Influence of screening on the incidence of ruptured abdominal aortic aneurysm 5-year results of a randomized controlled study.Br J Surg. 1995; 82: 1066-1070Crossref PubMed Scopus (388) Google Scholar However, in female patients with a family history of aneurysm or with multiple cardiovascular risk factors the incidence of AAA is also two to three times higher than in those without these factors.20Lederle FA, Johnson GR, Wilson SE. Abdominal aortic aneurysm in women. Veterans Affairs Cooperative Study Investigators. J Vasc Surg 2001;34:122-6Google Scholar The efficacy of treatment of large aneurysms is profound. The yearly incidence of rupture and death in patients with AAA larger than 5.5 cm is 16%, compared with periopoerative mortality of 2% to 6% for open repair.1Heller J.A. Weinberg A. Arons R. Krishnasastry K.V. Lyon R.T. Deitch J.S. et al.Two decades of abdominal aortic aneurysm repair have we made any progress?.J Vasc Surg. 2000; 32: 1091-2000Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar, 10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar, 13Wilmink T.B. Quick C.R. Hubbard C.S. Day N.E. The influence of screening on the incidence of ruptured abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 203-208Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 14Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Hospital costs and benefits of screening for abdominal aortic aneurysms results from a randomised population screening trial.Eur J Vasc Endovasc Surg. 2002; 23: 55-60Abstract Full Text PDF PubMed Scopus (142) Google Scholar, 19Scott R.A. Wilson N.M. Ashton H.A. Kay D.N. Influence of screening on the incidence of ruptured abdominal aortic aneurysm 5-year results of a randomized controlled study.Br J Surg. 1995; 82: 1066-1070Crossref PubMed Scopus (388) Google Scholar, 21Scott R.A. Bridgewater S.G. Ashton H.A. Randomized clinical trial of screening for abdominal aortic aneurysm in women.Br J Surg. 2002; 89: 283-285Crossref PubMed Scopus (251) Google Scholar, 22Heather B.P. Poskitt K.R. Earnshaw J.J. Whyman M. Shaw E. Population screening reduces mortality rate from aortic aneurysm in men.Br J Surg. 2000; 87: 750-753Crossref PubMed Scopus (80) Google Scholar, 23Irvine C.D. Shaw E. Poskitt K.R. Whyman M.R. Earnshaw J.J. Heather B.P. A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally.Eur J Vasc Endovasc Surg. 2000; 20: 374-378Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 24Lederle F.A. Johnson G.R. Wilson S.E. Ballard D.J. Jordan Jr, W.D. Blebea J. et al.Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair.JAMA. 2002; 287: 2968-2972Crossref PubMed Scopus (441) Google Scholar Moreover, recent data suggest that the mortality rate for endovascular AAA repair may be as low as 1%.25Anderson P.L. Arons R.R. Moskowitz A.J. Gelijns A. Magnell C. Clair D. et al.A statewide experience with endovascular AAA repair—rapid diffusion with excellent early results.J Vasc Surg. 2004; 39: 10-19Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar Thus patients with large aneurysms clearly benefit from repair. As of yet, there is no definitive treatment for “small” aneurysms, and a screening program will identify many of these. Nevertheless, rate of growth of small AAAs is relatively predictable. With appropriate surveillance, early identification of small aneurysms is quite beneficial for those patients with aneurysms that enlarge and reach treatment thresholds. In addition, emerging data suggest that medicines such as doxycycline, and risk factor modification may retard aneurysm expansion.26Baxter B.T. Pearce W.H. Waltke E.A. Littooy F.N. Hallett Jr, J.W. Kent K.C. et al.Prolonged administration of doxycycline in patients with small asymptomatic abdominal aortic aneurysms report of a prospective (phase II) multicenter study.J Vasc Surg. 2002; 36: 1-12Abstract Full Text PDF PubMed Scopus (279) Google Scholar, 27Vardulaki K.A. Walker N.M. Day N.E. Duffy S.W. Ashton H.A. Scott R.A. Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm.Br J Surg. 2000; 87: 195-200Crossref PubMed Scopus (205) Google Scholar, 28Wilmink T.B. Quick C.R. Day N.E. The association between cigarette smoking and abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 1099-1105Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar, 29Vammen S. Lindholt J.S. Ostergaard L. Fasting H. Henneberg E.W. Randomized double-blind controlled trial of roxithromycin for prevention of abdominal aortic aneurysm expansion.Br J Surg. 2001; 88: 1066-1072Crossref PubMed Scopus (131) Google Scholar Early identification of aneurysms will enable application of these treatments and analysis of their efficacy. Although AAA repair with open or endovascular techniques is expensive, the cost more than doubles if repair is performed emergently.1Heller J.A. Weinberg A. Arons R. Krishnasastry K.V. Lyon R.T. Deitch J.S. et al.Two decades of abdominal aortic aneurysm repair have we made any progress?.J Vasc Surg. 2000; 32: 1091-2000Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar When these various factors were incorporated into a Markov decision analysis model, AAA screening was found to be cost-effective.8Lee T.Y. Korn P. Heller J.A. Kilaru S. Beavers F.P. Bush H.L. et al.The cost-effectiveness of a “quick-screen” program for abdominal aortic aneurysms.Surgery. 2002; 132: 399-407Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar The cost per quality-adjusted life year saved for screening men older than 60 years was $11,285. This number compares favorably with the cost-effectiveness of other well-accepted interventions, such as coronary artery bypass grafting ($26,117)30Hlatky M.A. Rogers W.J. Johnstone I. Boothroyd D. Brooks M.M. Pitt B. et al.Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery.Bypass Angioplasty Revascularization Investigation (BARI) Investigators. N Engl J Med. 1997; 336: 92-99Google Scholar or hemodialysis ($54,400).31Winkelmayer W.C. Weinstein M.C. Mittleman M.A. Glynn R.J. Pliskin J.S. Health economic evaluations the special case of end-stage renal disease treatment.Med Decision Making. 2002; 22: 417-430PubMed Google Scholar Of interest, the cost-effectiveness of AAA screening appears to be similar to that of screening mammography ($16,000-$20,000).32Lindfors K.K. Rosenquist C.J. The cost-effectiveness of mammographic screening strategies.JAMA. 1995; 274: 881-884Crossref PubMed Scopus (121) Google Scholar As might be anticipated, AAA screening is not cost-effective in patients older than 84 years.8Lee T.Y. Korn P. Heller J.A. Kilaru S. Beavers F.P. Bush H.L. et al.The cost-effectiveness of a “quick-screen” program for abdominal aortic aneurysms.Surgery. 2002; 132: 399-407Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar The benefit of screening for AAA has been demonstrated in six prospective randomized studies.10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar, 11Lawrence-Brown M.M. Norman P.E. Jamrozik K. Semmens J.B. Donnelly N.J. Spencer C. et al.Initial results of ultrasound screening for aneurysm of the abdominal aorta in Western Australia relevance for endoluminal treatment of aneurysm disease.Cardiovasc Surg. 2001; 9: 234-240Crossref PubMed Scopus (46) Google Scholar, 13Wilmink T.B. Quick C.R. Hubbard C.S. Day N.E. The influence of screening on the incidence of ruptured abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 203-208Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 14Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Hospital costs and benefits of screening for abdominal aortic aneurysms results from a randomised population screening trial.Eur J Vasc Endovasc Surg. 2002; 23: 55-60Abstract Full Text PDF PubMed Scopus (142) Google Scholar, 19Scott R.A. Wilson N.M. Ashton H.A. Kay D.N. Influence of screening on the incidence of ruptured abdominal aortic aneurysm 5-year results of a randomized controlled study.Br J Surg. 1995; 82: 1066-1070Crossref PubMed Scopus (388) Google Scholar, 21Scott R.A. Bridgewater S.G. Ashton H.A. Randomized clinical trial of screening for abdominal aortic aneurysm in women.Br J Surg. 2002; 89: 283-285Crossref PubMed Scopus (251) Google Scholar, 22Heather B.P. Poskitt K.R. Earnshaw J.J. Whyman M. Shaw E. Population screening reduces mortality rate from aortic aneurysm in men.Br J Surg. 2000; 87: 750-753Crossref PubMed Scopus (80) Google Scholar, 23Irvine C.D. Shaw E. Poskitt K.R. Whyman M.R. Earnshaw J.J. Heather B.P. A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally.Eur J Vasc Endovasc Surg. 2000; 20: 374-378Abstract Full Text PDF PubMed Scopus (50) Google Scholar Although these studies were performed in multiple countries, with variable patient cohorts, the findings are surprisingly similar. Male patients of various ages were invited to participate in ultrasound screening, and subsequently aneurysm-related mortality rates in the screened and unscreened populations were compared. Patient response to the request for screening was high (74%-84%), and follow-up ranged from 4 to 10 years.10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar, 13Wilmink T.B. Quick C.R. Hubbard C.S. Day N.E. The influence of screening on the incidence of ruptured abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 203-208Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 14Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Hospital costs and benefits of screening for abdominal aortic aneurysms results from a randomised population screening trial.Eur J Vasc Endovasc Surg. 2002; 23: 55-60Abstract Full Text PDF PubMed Scopus (142) Google Scholar, 19Scott R.A. Wilson N.M. Ashton H.A. Kay D.N. Influence of screening on the incidence of ruptured abdominal aortic aneurysm 5-year results of a randomized controlled study.Br J Surg. 1995; 82: 1066-1070Crossref PubMed Scopus (388) Google Scholar, 21Scott R.A. Bridgewater S.G. Ashton H.A. Randomized clinical trial of screening for abdominal aortic aneurysm in women.Br J Surg. 2002; 89: 283-285Crossref PubMed Scopus (251) Google Scholar, 22Heather B.P. Poskitt K.R. Earnshaw J.J. Whyman M. Shaw E. Population screening reduces mortality rate from aortic aneurysm in men.Br J Surg. 2000; 87: 750-753Crossref PubMed Scopus (80) Google Scholar, 23Irvine C.D. Shaw E. Poskitt K.R. Whyman M.R. Earnshaw J.J. Heather B.P. A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally.Eur J Vasc Endovasc Surg. 2000; 20: 374-378Abstract Full Text PDF PubMed Scopus (50) Google Scholar In screened patients the authors observed a remarkable 45% to 49% reduction in incidence of ruptured AAA10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar, 13Wilmink T.B. Quick C.R. Hubbard C.S. Day N.E. The influence of screening on the incidence of ruptured abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 203-208Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar and a 21% to 68% decrease in aneurysm-related deaths.10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar, 13Wilmink T.B. Quick C.R. Hubbard C.S. Day N.E. The influence of screening on the incidence of ruptured abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 203-208Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 14Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Hospital costs and benefits of screening for abdominal aortic aneurysms results from a randomised population screening trial.Eur J Vasc Endovasc Surg. 2002; 23: 55-60Abstract Full Text PDF PubMed Scopus (142) Google Scholar, 19Scott R.A. Wilson N.M. Ashton H.A. Kay D.N. Influence of screening on the incidence of ruptured abdominal aortic aneurysm 5-year results of a randomized controlled study.Br J Surg. 1995; 82: 1066-1070Crossref PubMed Scopus (388) Google Scholar, 21Scott R.A. Bridgewater S.G. Ashton H.A. Randomized clinical trial of screening for abdominal aortic aneurysm in women.Br J Surg. 2002; 89: 283-285Crossref PubMed Scopus (251) Google Scholar The largest of these studies was a recently published randomized trial in the United Kingdom that involved 70,495 men ages 65 to 74 years.10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar Eighty percent of patients responded to the request for screening. Mortality associated with elective AAA repair was 6%. At 4 years the authors found a 42% reduction in deaths from AAA in the invited group. Moreover, the mortality curves for screened and unscreened patients in this trial continue to diverge after 4 years. Several concerns have been raised about the utility of population-based screening for AAA. It has been proposed that patients who are found to have “small” aneurysms will experience a diminished quality of life related to concern about rupture.33Cheatle T.R. The case against a national screening programme for aortic aneurysms.Ann R Coll Surg Engl. 1997; 79: 90-95PubMed Google Scholar, 34Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm Trial Participants. Lancet 1998;352:1649-55Google Scholar, 35Lindholt J.S. Vammen S. Fasting H. Henneberg E.W. Psychological consequences of screening for abdominal aortic aneurysm and conservative treatment of small abdominal aortic aneurysms.Eur J Vasc Endovasc Surg. 2000; 20: 79-83Abstract Full Text PDF PubMed Scopus (110) Google Scholar Level of anxiety, however, appears to diminish when a prudent plan of treatment is provided.35Lindholt J.S. Vammen S. Fasting H. Henneberg E.W. Psychological consequences of screening for abdominal aortic aneurysm and conservative treatment of small abdominal aortic aneurysms.Eur J Vasc Endovasc Surg. 2000; 20: 79-83Abstract Full Text PDF PubMed Scopus (110) Google Scholar, 36Khaira H.S. Herbert L.M. Crowson M.C. Screening for abdominal aortic aneurysms does not increase psychological morbidity.Ann R Coll Surg Engl. 1998; 80: 341-342PubMed Google Scholar As with any screening program, there will be patients who do not participate. However, similar screening programs within and outside the United States enjoy acceptance rates that range from 75% to 88%.10Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. 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: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (932) Google Scholar, 14Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Hospital costs and benefits of screening for abdominal aortic aneurysms results from a randomised population screening trial.Eur J Vasc Endovasc Surg. 2002; 23: 55-60Abstract Full Text PDF PubMed Scopus (142) Google Scholar, 37Coughlin S.S. Thompson T.D. Seeff L. Richards T. Stallings F. Breast, cervical, and colorectal carcinoma screening in a demographically defined region of the southern U.S.Cancer. 2002; 95: 2211-2222Crossref PubMed Scopus (66) Google Scholar, 38Hewitt M. Devesa S. Breen N. Papanicolaou test use among reproductive-age women at high risk for cervical cancer analyses of the 1995 National Survey of Family Growth.Am J Public Health. 2002; 92: 666-669Crossref PubMed Scopus (35) Google Scholar Moreover, very little cost is incurred for patients who do not participate in screening. Aortic aneurysm disease is one of the least-known killers in American society. Initiation of an educational program to inform seniors and their physicians of this disease will increase the rate of response to screening and constitute an important step in a strategy to prevent death from aneurysm rupture. Last, critics have suggested that screening may identify a large number of patients who are unfit for surgery.33Cheatle T.R. The case against a national screening programme for aortic aneurysms.Ann R Coll Surg Engl. 1997; 79: 90-95PubMed Google Scholar However, Irvine et al23Irvine C.D. Shaw E. Poskitt K.R. Whyman M.R. Earnshaw J.J. Heather B.P. A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally.Eur J Vasc Endovasc Surg. 2000; 20: 374-378Abstract Full Text PDF PubMed Scopus (50) Google Scholar found that patients identified through screening were healthier than those in whom aneurysms were discovered incidentally. Moreover, endovascular techniques will also likely reduce the percentage of patients who are unfit for aneurysm repair. On the basis of available data we recommend baseline ultrasound screening for AAA in the following patient cohorts: •All men aged 60 to 85 years•Women aged 60 to 85 years with cardiovascular risk factors•Men and women older than 50 years with a family history of AAA. Patients who appear unfit for any intervention should not be screened. On the basis of available data we recommend subsequent surveillance of screened patients as follows: •Aortic diameter less than 3 cm, no further testing•AAA 3 to 4 cm in diameter, yearly ultrasound examination•AAA 4 to 4.5 cm in diameter, ultrasound examination every 6 months•AAA greater than 4.5 cm in diameter, referral to a vascular specialist. There are compelling data that in appropriately selected patient cohorts identification of AAA can save lives at a cost to society that compares favorably with other well-accepted interventions. Inasmuch as reimbursement remains the major impediment to acceptance of aneurysm screening, we strongly encourage that insurers adopt a policy that allows payment for this life-saving test.