Result card

  • SAF1: What harms can Screening for AAA cause to the screened subjects and what are the characteristics of the harms?
English

What harms can Screening for AAA cause to the screened subjects and what are the characteristics of the harms?

Authors: Iñaki Imaz, Sonia García-Pérez, Jesús González-Enríquez, Javiera Valdés, Andrés Fernández-Ramos, Carmen Bouza, Antonio Sarría-Santamera

Internal reviewers: Paolo Giorgi Rossi, Mirjana Huic, Aurora Llanos, Ingvil Sæterdal

Important harms of the implementation of an AAA screening programme derive from the expected increase in the number of detected AAAs (increase of incidence) and consequently in the number of surgical interventions to repair intact or non-ruptured AAAs suitable for repair. The surgical repair of an AAA, by EVAR or OAR, is a high-risk intervention. There are serious consequences, in terms of mortality, morbidity and psychological effects, for those in whom an AAA has been detected, which are mainly measured by quality of life (QoL) scales.

OVERALL MORTALITY

The European Society for Vascular Surgery reported data from 27,635 intact AAA surgical interventions performed in 386 hospitals in ten countries of Europe and Oceania between 2003 and 2007{1}. Most interventions were OAR (18,471), though EVAR accounted for 7,578, and the rest were unspecified. The mean age of patients was 72.1 years, and 13.5% of the patients were women. The overall mortality rate, which included in-hospital mortality or 30-day mortality, was 2.83%. The overall mortality rate for OAR was 3.5%, and for EVAR 1.15%.

Schermerhorn et al. reported data from 45,660 Medicare beneficiaries undergoing elective AAA repair in the USA during the 2001–2004 period, for whom the   overall 30-day mortality was 1.2% with EVAR and 4.8% with OAR {2}. The probability of survival after 5 years was around 64% in this latter study {2}, being similar between EVAR and OAR.

RELATED MORTALITY

Among 5612 patients with intact AAA repaired by EVAR between June 1996 and February 2004, 589 had died within 8 years of follow-up and 24% of those deaths were procedure-related (141 patients) {3}. Of the 141 procedure-related deaths, 88 (14.9% of the 589 total deaths) were within the 30 days after surgery, 28 (4.8% of the 589 total deaths) due to AAA-rupture and 25 due to graft infection (4.2% of the 589 total deaths). The non procedure-related deaths were caused by cancer (117 patients, 19.9%), other cardiovascular problems (27%), pulmonary problems (6.5%), renal problems (1.5%), multi-organ failure (1.4%), unknown reasons (10.7%) and other reasons (9.2%). (According to the Committee for Standardized Reporting Practices in Vascular Surgery {4}, all deaths within 30 days after the surgical intervention were considered procedure-related deaths. The definition of “mortality related to AAA repair” varies so it must be borne in mind that published figures on procedure-related mortality could be inaccurate.)

MORBIDITY

The Medicare database reported highly frequent complications from 45,660 elective AAA repairs performed by EVAR and OAR {2}, which are detailed in {SAF-2}. This Medicare database reported, after 4 years follow-up, rupture rates of 1.8% and 0.5%, respectively, after EVAR and OAR respectively. The re-intervention rates were 9% after EVAR and 1.7% after OAR.

QUALITY OF LIFE

Inconsistent results have been found regarding the psychological effects of an AAA screening programme. An appropriate design for measuring changes in QoL for participants versus non-participants has not been identified. Therefore, it is not possible to determine whether screening for AAA affects the health-related QoL among participants. However, other information can be highlighted from the literature related to QoL.

The Viborg trial, which measured QoL using the Screen QL scale, found significantly lower scores for those invited to an AAA screening when they compared scores before versus after the scan {5}. However, the Gloucestershire screening programme reported a statistically significant fall in anxiety levels between before and 1 month after screening {6}.

A cross-sectional case-control study within the West Australia trial compared QoL before and after screening only for those who attended screening. They found increased self-perceived general health from before to after screening {7}.

The MASS trial found higher anxiety scores, no difference in depression scores, and lower scores on the SF-36 mental and physical scales at 6 weeks post-screening for those who had an AAA compared with those who had a negative screening{8}. However, other studies found that poorer self-assessed health among those who have compared with those who do not have an aneurysm could be more predictive of an aneurysm rather than a consequence of an AAA screening programme {9}.

The ADAM trial found QoL benefits for early repair using OAR compared with surveillance for small AAAs {10}.

SEXUAL DYSFUNCTION

The ADAM trial compared immediate elective repair with surveillance for small AAAs {10}. In the elective immediate OAR group more patients became impotent compared with the surveillance group.

More information about quality of life effects can be found in result card RC-SOC5.

Critical
Completely
Imaz I et al. Result Card SAF1 In: Imaz I et al. Safety In: Jefferson T, Vicari N, Frønsdal K [eds.]. Abdominal Aorta Aneurysm Screening [Core HTA], Agenzia nationale per i servizi sanitari regionali (age.na.s), Italy; 2013. [cited 30 June 2022]. Available from: http://corehta.info/ViewCover.aspx?id=106

References