As research data into the pathological behaviour of aneurysms of the abdominal aorta continue to be gathered, more countries implement screening programmes to test predisposed patients for the presence of AAA. Patients with AAA were significantly more often male and were older in age (Table 1). This is in line with previous literature [11], showing that our study population is representative for the AAA population.
Screening usually involves ultrasonography, which is a costly and complex investigation that is generally impossible to perform in a primary care facility or a family practice. In addition, several countries have now implemented cardiovascular risk management in primary care facilities which means that screening for AAA could be performed in a similar setting. The introduction of a simple handheld screening device would enable AAA screening to be moved from vascular clinics and general hospitals towards primary care facilities and outpatient clinics, quite similar to the screening, diagnostics and treatment of diabetes by family practitioners and specialized nurses [12]. Such developments would benefit health care cost-effectiveness and would promote more patients to participate in screening for a host of pathologies, including AAA. While screening always comes at great financial expense, costly treatment and morbidity may be spared through the early detection of AAA.
In this study, we tested a handheld aortic scanning device and determined its accuracy in detecting the presence and absence of AAA. We confirmed that the accuracy of this device is sufficient to be used as a screening tool for the general population at risk, in particular those patients with a WHC < 115 cm. In such cases, we would recommend using the Aorta Scan or a similarly certified device to screen for AAA.
Nine patients who were diagnosed with AAA during our study visited our out-clinic department for peripheral artery disease, and would in daily practice not have been subjected to examination of their aorta. Their AAA would have remained undiagnosed if they had not participated in the study. A screening programme for AAA in predisposed patients as suggested by the Dutch National Health Council should be considered. The incidence of 13.2% is high compared to the general population (which has an AAA incidence of approximately 2%), but comparable to the incidence of AAA in patients with peripheral artery disease (7.3–15%) [2].
As we wanted to study the effectiveness of the Aorta Scan in diagnosing true-positive cases (people with an actual AAA as proven by ultrasound), we selected patients from our outpatient clinic with a known history of AAA up to a percentage of 50% of our study population. While this creates a selection bias (the study group does not reflect the general population), the advantage is that we included the largest number of AAAs in any study known to date. Because we implemented such a high incidence of AAA (58 out of 117), we were able to very accurately study the results in the rare case of an AAA, and determine the outcome parameters within statistical significance. If a standard screening group was used, with a normal incidence of AAA of between 2 and 2.5%, only 2 or 3 patients in our group would have been diagnosed with AAA, which would have compromised our ability to reach significance without greatly increasing the study population. The accuracy of the Aorta Scan was tested by other researchers as well, such as Nguyen et al., however because they had such a low incidence of AAA, their results might be easily disturbed by a false result in the Aorta Scan (for instance, a negative result by accident regardless of the test subject) [13]. Kappa measurement corrects for precisely such chance results. Furthermore, Nguyen mentioned that there were several unspecified technical problems with the device which need improvement [13]. We used the same device in our study, but we did not investigate technical problems.
As alternative to using a cheaper device such as the Aorta Scan, it has been suggested by others that novice trainees might be as good at detecting AAAs as an experienced ultrasonographer and thereby reduce costs as well (salary) [14]. However, this solution would not extend the amount of patients that could be screened in primary practices. In addition, others have shown as well that a small sized ultrasound paired with relatively short training in about 2 h enables effective screening for AAA in a clinical setting [15, 16].
In our study, the exam was performed by a single certified radiologist and the accuracy results are probably representing a higher performance obtainable. The results with the Aorta Scan can be less accurate when performed by health practitioner with less experience [17].
In summary, these data confirm and strengthen existing data that the Aorta Scan BVI 9600 is an easy, cost-effective, and reliable tool for measuring the aortic diameter, especially in patients with WHC ≤ 115 cm. We support the opinion that screening for AAA is important in selected patient populations, and we suggest the use of a handheld device such as the Aorta Scan, as it cuts costs and time, while preserving accuracy and precision of AAA diagnostics. Furthermore, new cases of AAA can be identified earlier and treated, which we believe is advantageous to the health care we continue to provide.
