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Method of AAA Detection is Associated With Differences in Presentation and EVAR Outcomes
William E. Beckerman, MD, Ajit Rao, MD, Daniel K. Han, MD, Sean P. Wengerter, MD, Melissa Baldwin, MD, Rami O. Tadros, MD, Michael L. Marin, MD, Peter L. Faries, MD.
Mount Sinai Medical Center, New York, NY, USA.

Objective: Ultrasound screening identifies patients at high risk for abdominal aortic aneurysms (AAA), but limit data exists regarding how AAAs necessitating treatment with endovascular aneurysm repair (EVAR) initially present. This study aimed to evaluate how AAAs requiring EVAR are detected as well as differences in presentation and outcome based on method of detection.
Methods: Retrospective analysis of a prospectively maintained database at a single health system was performed for all patients undergoing EVAR. Patients with a recorded method of AAA detection were identified and categorized as incidental, symptomatic, screened by ultrasound, or found on physical exam. Demographics, comorbidities, maximum AAA diameter at time of detection as well as time of treatment with EVAR, and postoperative outcomes were identified and analyzed.
Results: Of 232 patients identified as meeting inclusion criteria, most AAAs were detected incidentally (n=180; 77.6%) with far fewer discovered by ultrasound screening (n=27; 11.6%), physical exam (n=20; 8.6%) or symptomatically (n=5; 2.2%). Symptomatic AAAs were larger on detection (60.3mm vs. 43.9mm; p=.034) compared with asymptomatic AAAs (Table 1). Patient demographics and comorbidities based on method of detection were comparable, although symptomatic patients were more likely to be female (60% vs 22.5%; p=0.034). Notably, only 35.6% of patients with incidentally detected AAA met Medicare's one-time ultrasound screening guidelines. Symptomatic AAA patients had more intraoperative complications (40% vs 10.7%; p=.039), required more perioperative transfusions (40% vs 5.6%; p=0.002), and had longer lengths of stay (5.2 vs 1.5 days, p<.001). Incidentally detected AAA patients had fewer intraoperative complications (8.9% vs 10.7%; p=.037). Rates of endoleak, re-intervention, and AAA-related mortality were not different between the study groups.
Conclusions: Most AAA patients requiring EVAR are detected incidentally. Greater awareness and compliance with Medicare's screening guidelines for AAA is vital as a sizeable percentage of incidentally detected AAA patients were candidates for one-time screening ultrasounds. Finally, as many studied patients requiring EVAR fell outside Medicare's guidelines, this study supports liberalizing and individualizing the decision to screen patients at risk of AAA.

Mean Size at Detection and Treatment by Method of Detection
Method of DetectionNumber of Patients (Percentage of Total)Mean Size at Detection, mm (P-value)Mean Size at Treatment, mm (P-value)
Incidental180 (77.6%)42.3 (.571)57.8 (.510)
Screening27 (11.6%)47.1 (.631)54.6 (.693)
Physical Exam20 (8.6%)53.5 (.120)62.9 (.544)
Symptomatic5 (2.2%)60.3 (.034)60.3 (.115)
Total232 (100%)44.158.3

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