An abdominal aortic aneurysm is a ballooning of the body's main artery below the diaphragm. It grows slowly and silently, usually without a single symptom, until the day it bursts. A ruptured aneurysm is one of the most lethal emergencies in medicine. Yet the condition is easy to find: a few minutes of ultrasound, no needles, no radiation. Since 2018, German statutory health insurance has paid for one such scan in men from the age of 65. The evidence behind that offer is solid — but it was gathered in another era, and a new generation of Scandinavian studies has reopened the question of how much screening still achieves.

What the scan looks for

A normal abdominal aorta is about 2 to 2.5 cm wide. Once it measures 3 cm or more, doctors call it an aneurysm. The widest diameter is measured with a standard abdominal ultrasound — a single number that decides almost everything that follows.

The evidence: four trials, one clear signal in men

A Cochrane review pooled four randomised trials, run mostly in the 1990s, with almost 128,000 men and 9,300 women. In men, screening reduced deaths from aneurysms by about 40% (odds ratio 0.60). The price was roughly twice as many aneurysm operations. In the one trial that included women, no benefit was found.

The largest trial, the British MASS study, followed 67,770 men aged 65–74 for 13 years. There were 224 aneurysm-related deaths in the invited group and 381 in the control group — a 42% reduction. Overall mortality fell by a small but measurable 3%. To prevent one aneurysm death over 13 years, 216 men had to be invited. Across all trials, the US Preventive Services Task Force (USPSTF) estimated that about 305 men need to be screened to prevent one aneurysm death, and that pooled all-cause mortality did not change.

42%Fewer aneurysm deaths over 13 years (MASS)
≈3 in 1,000Aneurysm deaths prevented over 13 years (G-BA leaflet)
≈10 of 20Detected aneurysms that would never have caused problems

The same evidence, per 1,000 men

The official German information leaflet from the Federal Joint Committee (G-BA) translates the trials into absolute numbers. Of 1,000 men aged 65 or older who are screened:

  • about 980 have no aneurysm;
  • about 20 have one — 18 measuring 3 to 5.4 cm, which are monitored, and 2 measuring 5.5 cm or more, for which surgery is usually recommended;
  • over 13 years, ruptures fall from about 7 to about 4, and aneurysm deaths from about 6 to about 3;
  • of the 20 men told they have an aneurysm, about 10 would never have had any problem from it.

That last line is the hidden cost: repeated scans, worry, and for a few men an operation they did not need.

The German programme

The G-BA decided on 20 October 2016 to make ultrasound screening for abdominal aortic aneurysms a statutory benefit. It could be offered from 1 January 2018. Men with statutory insurance are entitled to one scan from the age of 65 — once in a lifetime. It is performed by GPs and specialists with the required ultrasound approval. Women are not included: the G-BA found no indication of benefit for women, and the condition is far less common in women of the same age.

Women, smokers and the US view

Smoking is the strongest modifiable risk factor for aneurysms, and the US rules reflect this. In the US, the USPSTF (2019) recommends one-time screening for men aged 65–75 who have ever smoked (grade B, usually defined as 100 or more cigarettes in a lifetime). For men who never smoked, screening is offered selectively (grade C). For women aged 65–75 who have ever smoked or have a family history of aneurysm, the evidence is judged insufficient (grade I). For women who never smoked and have no family history, the Task Force recommends against screening (grade D). Germany does not distinguish by smoking status: every man from 65 is eligible. Outside the programme, a doctor can order an ultrasound when risk factors or symptoms justify it — a close relative with an aneurysm counts (see family history as a diagnostic tool).

What happens if something is found

Most aneurysms found by screening are small, and the initial response is to watch, not to operate. The 2024 guideline of the European Society for Vascular Surgery (ESVS) suggests ultrasound surveillance for men at these intervals:

  • 2.5–2.9 cm (enlarged but not yet an aneurysm): every five years
  • 3.0–3.9 cm: every three years
  • 4.0–4.9 cm: every year
  • 5.0 cm or more: every six months

For women, whose aortas are smaller, the intervals tighten earlier: yearly from 4.0 cm and six-monthly from 4.5 cm. Repair — either open surgery or an endovascular stent graft placed through the groin arteries — should be considered from 5.5 cm in men (ESVS class IIa, level C). For women the threshold for considering repair remains 5.0 cm; below that, elective repair in women without symptoms is not recommended. Equally important is what happens alongside surveillance: the ESVS recommends cardiovascular risk management, including stopping smoking.

A warning sign that cannot wait

Anyone known to have an aneurysm who develops sudden, severe pain in the abdomen, back or flank — especially with faintness — needs emergency care immediately (in Germany, call 112).

The debate: is the benefit shrinking?

The classic trials enrolled men when smoking was far more common. Since then, aneurysms have become rarer. A Swedish registry study found that aneurysm deaths in men aged 65–74 fell from 36 to 10 per 100,000 between the early 2000s and 2015 — at the same pace in counties with and without screening. Its estimate: about 2 aneurysm deaths avoided per 10,000 men offered screening (with a confidence interval that included zero), against 49 overdiagnosed men and 19 avoidable operations per 10,000. The authors attributed most of the decline to less smoking.

Two Danish trials tested broader packages. VIVA invited 50,156 men aged 65–74 to combined screening for aneurysm, peripheral artery disease and high blood pressure. After about five years, 10.2% of invited men had died versus 10.8% of controls (hazard ratio 0.93); one death was prevented for every 169 men screened. DANCAVAS went further, adding a CT scan for coronary calcium, among other tests, in 46,611 men. The reduction in all-cause mortality was not statistically significant (hazard ratio 0.95, 95% CI 0.90–1.00), although men under 70 appeared to benefit (0.89). Neither trial isolates the effect of the aneurysm scan alone.

The ESVS 2024 guideline reflects this shift. Citing a "dramatically changed epidemiology", mainly falling prevalence, it now recommends screening in high-risk populations (class I), with target groups to be defined locally, rather than for all men at 65.

What this means for you

  • Man, 65 or older, statutory insurance: you are entitled to one free scan. Ask your GP; it is often combined with the general health check-up (Gesundheits-Check-up).
  • Current or former smoker: your expected benefit is greater. Of everything in this article, stopping smoking does the most to protect you.
  • Woman who smoked, or with a parent or sibling who had an aneurysm: there is no screening programme for you, but discuss an indicated ultrasound with your doctor.
  • If an aneurysm is found, ask: What is the exact diameter? When is the next scan, and who arranges it? Are my blood pressure, cholesterol and smoking being addressed? At what size would repair be discussed, and where?

Bottom line

For men aged 65 and over, a single ultrasound scan reliably finds aneurysms and reduces deaths from rupture, at the cost of some overdiagnosis. The benefit is probably smaller today than in the original trials because fewer men smoke, so it matters most for current and former smokers. Routine screening of women who have never smoked is not recommended. Evidence: ★★★ High (men, aneurysm-related deaths) · — Not recommended (women who never smoked).

References

  1. Thompson SG, Ashton HA, et al. Final follow-up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening. Br J Surg. 2012;99(12):1649-1656. doi:10.1002/bjs.8897.
  2. Cosford PA, Leng GC, Thomas J. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;(2):CD002945.
  3. US Preventive Services Task Force. Abdominal aortic aneurysm: screening. Final recommendation statement. 10 December 2019.
  4. Gemeinsamer Bundesausschuss (G-BA). Ultraschall-Screening auf Bauchaortenaneurysmen: Versicherteninformation (Merkblatt). 2017.
  5. Gemeinsamer Bundesausschuss (G-BA). Ultraschallscreening auf Bauchaortenaneurysmen für Männer ab 65 Jahren. Pressemitteilung, 20. Oktober 2016.
  6. Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. European Society for Vascular Surgery (ESVS) 2024 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms. Eur J Vasc Endovasc Surg. 2024;67:192-331. doi:10.1016/j.ejvs.2023.11.002.
  7. Johansson M, Zahl PH, Siersma V, Jørgensen KJ, Marklund B, Brodersen J. Benefits and harms of screening men for abdominal aortic aneurysm in Sweden: a registry-based cohort study. Lancet. 2018;391(10138):2441-2447. doi:10.1016/S0140-6736(18)31031-6.
  8. Lindholt JS, Søgaard R. Population screening and intervention for vascular disease in Danish men (VIVA): a randomised controlled trial. Lancet. 2017;390(10109):2256-2265. doi:10.1016/S0140-6736(17)32250-X.
  9. Lindholt JS, Søgaard R, Rasmussen LM, et al. Five-year outcomes of the Danish Cardiovascular Screening (DANCAVAS) trial. N Engl J Med. 2022;387:1385-1394.
Prof. Dr. med. Markus Guba

Head of Liver Surgery and Transplantation at LMU University Hospital Munich. Edits this independent journal in a private capacity; views are his own. About →

This article is general information and not individual medical advice. Decisions about tests and treatment belong in a conversation with your own physician.