Perspective:

This update to the 2014 USPSTF recommendations provides an opportunity to review the criteria for AAA screening in asymptomatic adults. Clinicians familiar with the previous criteria will not need to update their screening practices based on this report, however, because the recommendations themselves have not changed. Unfortunately, many of the research needs and gaps also seem familiar. Public comments to the draft version of the recommendation statement urged more research in diverse populations, but that gap persists and gender disparities related to both screening and treatment outcomes remain. Insufficient evidence to support screening versus not for women who are smokers and/or have a family history of AAA leaves clinicians treating these patients (many of whom may have been anticipating an update for this subgroup) without a recommendation.

The updated evidence review includes several interesting observations that may reflect gaps between recommendations and existing clinical practice. Reduction in AAA-related mortality was observed from all four screening trials included, but it is interesting to note that pooled analysis did not reflect an effect on all-cause mortality. Other benefits associated with screening included reduction in emergency surgery. Results were mixed in terms of impacts of screening on quality of life (QOL), perhaps reflecting the fact that asymptomatic, undiagnosed AAAs likely do not impact QOL while diagnosis and repair of AAA potentially have negative impacts (at least in the short term).

Public comments also included concerns about the harms of screening related to overdiagnosis and overtreatment. Higher rates of reintervention were identified in registry studies of endovascular aneurysm repair (EVAR) versus randomized clinical trials, perhaps reflecting the limitations of EVAR when anatomic criteria and indications are more flexible, especially if EVAR is undertaken outside device-specific instructions for use.