Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
J Vasc Surg. 2022 Mar;75(3):884-892.e1. doi: 10.1016/j.jvs.2021.09.049. Epub 2021 Oct 22.
Although efforts such as the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act have improved access to abdominal aortic aneurysm (AAA) screening, certain high-risk populations are currently excluded from the guidelines yet may benefit from screening. We therefore examined all patients who underwent repair of ruptured AAA (rAAA) to characterize those who are ineligible for screening under current guidelines and evaluate the potential impact of these restrictions on their disease.
We identified patients undergoing rAAA repair in the Vascular Quality Initiative (VQI) database between 2003 and 2019. These patients were stratified by AAA screening eligibility according to the Centers for Medicare and Medicaid reimbursement guidelines. We then described baseline characteristics to identify high-risk features of these cohorts. Groups with disproportionate representation in the screening-ineligible cohort were identified as potential targets of screening expansion. Trends over time in screening eligibility and the proportion of AAA repairs performed for rAAA were also analyzed.
A total of 5340 patients underwent rAAA repair. The majority (66%) were screening-ineligible. When characterizing the screening-ineligible group by sex and risk factors (smoking history or family history of AAA), the largest contributors to screening ineligibility were males less than 65 years of age with a smoking history or family history of AAA (25%), males greater than 75 years of age with a smoking history (25%), and females older than 65 years of age with a smoking history (19%). In comparison with rAAAs prior to implementation of the SAAAVE act, the proportion of AAA repair performed for rupture among males undergoing AAA repair in the VQI decreased from 12% to 8% (P < .001), whereas in females, there was no change (P = .990). There was no statically significant difference in screening eligibility for either males (P = .762) or females (P = .335).
Most patients who underwent rAAA repair were ineligible for initial AAA screening or aged out of the screening window. Furthermore, rAAA rates and screening ineligibility have not improved as much as expected since the passage of the SAAAVE Act. Our data suggest that three high-risk populations may benefit from expansion of AAA screening guidelines: males with a smoking history or family history of AAA between ages 55 and 64 years, female smokers older than 65 years, and male smokers older than 75 years who are otherwise in good health. Increased efforts to screen these high-risk populations may increase elective AAA repair and minimize the morbidity and mortality associated with rAAAs.
尽管《高效筛查腹主动脉瘤法案》（SAAAVE）等努力提高了腹主动脉瘤（AAA）筛查的可及性，但某些高危人群目前仍被排除在指南之外，但他们可能受益于筛查。因此，我们检查了所有接受破裂性腹主动脉瘤（rAAA）修复的患者，以描述那些不符合当前指南筛查标准的患者，并评估这些限制对其疾病的潜在影响。
我们在血管质量倡议（VQI）数据库中确定了 2003 年至 2019 年期间接受 rAAA 修复的患者。根据医疗保险和医疗补助报销指南，根据 AAA 筛查资格对这些患者进行分层。然后，我们描述了基线特征，以确定这些队列的高危特征。在筛查不合格队列中比例不成比例的组被确定为筛查扩展的潜在目标。还分析了随时间推移筛查资格的趋势和 rAAA 修复的比例。
共有 5340 名患者接受了 rAAA 修复。大多数（66%）不符合筛查条件。当按性别和危险因素（吸烟史或 AAA 家族史）对筛查不合格组进行特征描述时，导致筛查不合格的最大因素是年龄小于 65 岁的有吸烟史或 AAA 家族史的男性（25%）、年龄大于 75 岁且有吸烟史的男性（25%）和年龄大于 65 岁且有吸烟史的女性（19%）。与 SAAAVE 法案实施前的 rAAAs 相比，VQI 中接受 AAA 修复的男性因破裂而行 AAA 修复的比例从 12%下降到 8%（P<.001），而女性则没有变化（P=.990）。男性（P=.762）或女性（P=.335）的筛查资格均无统计学显著差异。
大多数接受 rAAA 修复的患者最初不符合 AAA 筛查条件或已超出筛查窗口期。此外，自 SAAAVE 法案通过以来，rAAA 发生率和筛查不合格率并没有像预期的那样得到改善。我们的数据表明，三个高危人群可能受益于扩大 AAA 筛查指南：55 至 64 岁之间有吸烟史或 AAA 家族史的男性、65 岁以上的女性吸烟者以及其他健康状况良好的 75 岁以上的男性吸烟者。加大对这些高危人群的筛查力度，可能会增加择期 AAA 修复的比例，并最大限度地降低与 rAAAs 相关的发病率和死亡率。
