Even when the aneurysm grows to more than 5.5 cm, what happens next is not always straightforward. Although in an otherwise healthy patient the risk of rupture is greater than that of surgery, aneurysm patients are seldom “otherwise healthy.” An aneurysm is a disease of an artery, and arterial disease rarely exists in isolation. Most patients will have hypertension or a history of myocardial infarction or stroke. Some are diabetic. More often they are heavy smokers and have pulmonary disease. Often comorbidity is discovered during the work-up for aortic surgery, and sometimes the coronary artery disease or lung cancer has to be dealt with first.
So aneurysm screening will turn up much more than aortic aneurysms, and the cost of dealing with the comorbidity needs to be included in the cost-benefit analysis. Many patients will not be fit enough to have a repair and will be left knowing that the time bomb in their abdomen doesn’t just have a remote possibility of exploding but is quite likely to do so soon. Admittedly some, probably more than half, of these high risk patients can be treated with an aortic stent6
—a lesser surgical procedure which simply requires access to the femoral arteries by incisions in both groins. The cost effectiveness of this form of treatment is, however, uncertain.7
There is also long term uncertainty about the security of the devices and persistent leaks into the aneurysmal sac (endoleaks).8
So patients with endovascular repairs have a new time bomb in the abdomen—a prosthesis that may come loose or leak (thus revascularising the aneurysm).
In a minority of patients, the configuration of the aneurysm or the condition of the patient makes even endovascular repair impossible. In any case NHS commissioners take very different views about the extent to which they are prepared to purchase endovascular repair saying (incorrectly9
) that it is still experimental.
In short, many patients will be left with the knowledge that they have a life threatening condition that is liable to cause sudden death and that nothing can be done about it. It doesn’t affect the arithmetic of lives saved but it is a serious social consequence that needs to be thought through. At the very least, as with HIV, any member of the public taking the test will need intensive counselling about the possible consequences that screening might have for their future lives and psychological wellbeing.