In a highly anticipated move, the U.S. Preventative Services Task Force (USPSTF)  released a new recommendation that ultrasound screening be performed for abdominal aortic aneurysms (AAAs). New evidence has shown that screening and surgery are effective at reducing death from this condition, updating the guidelines originally published in 1996.

Task Force Recommendations

The recommendations call for ultrasonography of men between 65-75 who are or have been smokers. The task force found evidence that “abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. The absence of quality assurance is likely to lower test accuracy. Abdominal palpation has poor accuracy and is not an adequate screening test.”

The recommendation is grade B, meaning that the evidence supports screening as a tool that improves health outcomes and that benefits outweigh the harms. The USPSTF recommends that clinicians provide the service to eligible patients.

The task force did not make a recommendation for or against the screening of men between 65-75 who were nonsmokers, but did recognize the strong association of aneurysms among first-degree relatives. Clinicians must individualize recommendations depending on a patient’s risk and likelihood of benefit. According to the task force, “Clinicians may choose to discuss screening with men and women who have a strong first-degree family history of AAA that required surgery.”

National Reaction and Legislation for Medicare Reimbursement

Robert Zwolak, M.D., the chair of the National Aneurysm Alliance (NAA) and the government relations director for the Society of Vascular Surgery, said, “Vascular surgeons and all other physicians who face the tragedy of patients dying needlessly from ruptured aortic aneurysms are excited about the Task Force’s recommendations. With this recommendation, we believe that we will have a significantly improved chance of identifying and saving those who are at risk.”

The NAA is a coalition of medical professional organizations, patient advocates and medical technology manufacturers dedicated to promoting public awareness for AAAs. AAAs are one of the nation’s least recognized yet most deadly conditions. It is estimated that 15,000 Americans will die of AAA rupture each year. This annual death rate is comparable to the death rates of AIDS and many forms of cancer. Fortunately, for this disease, most deaths are preventable if the AAAs are discovered through screening prior to rupture.

AbdominalLast summer, the NAA supported the introduction of bipartisan legislation known as the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act, which would provide a Medicare benefit for a one-time ultrasound screening of individuals at high risk for AAA. “The SAAAVE Act will provide easy, affordable exams for seniors most vulnerable to this deadly condition,” said Rep. Ron Lewis (R-KY), the bill’s co-sponsor. “This is a very personal matter for my family and I. Two years ago, my mother died after suffering a sudden aortic aneurysm rupture. Had it been available, this simple preventative screening may very well have saved her life.”

The NAA noted that the existing data also supports the screening for patients with a family history of ruptured AAA in a first-degree relative. Ultrasonography for scheduled surveillance of smaller aneurysms allows for identification of aneurysm that could potentially rupture.

“This screening benefit should also encompass women and men with a family history of AAA,” Dr. Zwolak added. “We look forward to correcting this omission during consideration of the SAAAVE legislation this year.”

The screening of patients at risk is now the obligation of the primary care physician. Failure to offer ultrasonography to these patients may result in adverse legal implications if unscreened patients at risk have ruptured aneurysms. Currently, under the best of conditions, mortality from ruptured AAAs is between 50 and 90 percent. Nonruptured aneurysm repair with the advent of minimally invasive technique has lowered the elective mortality rate to less than 3 percent. Clearly, a simple, noninvasive test such as ultrasonography has great potential to save lives.

Quality Standards for Screening

The recommendation also reflects the significance of ensuring quality standards for ultrasonography, such as the accreditation of the testing facilities and the credentialing of the technical personnel used to perform the screening. Certification by the Intersocial Commission for the Accreditation of Vascular Laboratories (ICAVL) represents one of the important components of a quality laboratory. Many community laboratories are unable to meet such high standards, yet provide ultrasound services without the same standards of quality. Ultimately, this makes some community studies suspect.

“In order to make the screening effective, it has to be performed in a setting with the appropriate quality standards in place, and we applaud the Task Force for recognizing that fact,” observes Anne Jones, RVT, from the Society for Vascular Ultrasound.

Important Literature

Drug Therapy: Medical Treatment of Peripheral Arterial Disease and Claudication. Hiatt, W. The New England Journal of Medicine, 344, May 24, 2001, p.1608.

Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: insights from the University of Michigan Peripheral Vascular Disease Quality Improvement Initiative (PVD-Q12) Mukherjee, D. Circulation, Oct 8, 2002; 106(15) 1909-12

Multicenter Study of Perioperative Ischemia Research Group: Effect of Atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Mangano, DT. The New England Journal of Medicine 335: 1713-1720, 1996.

By Charles S. Thompson, M.D.

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