An unmeasured harm of screening.

1 recommends a 1-time screening for abdominal aortic aneurysm (AAA) by ultra-sonography in men aged 65 to 75 years who have ever smoked, on the basis of trials showing a reduction in death from AAA but not improvement in overall mortality. Mr R was such a patient. A 65-year-old, obese former smoker with a history of myocardial infarction and persistent risk factors (hypertension and hyperlipidemia), Mr R had undergone a total knee arthroplasty at age 60 years because of osteoarthritis. Thereafter, he was able to walk a mile at a stretch but could go no further because of persistent joint pain. A veteran of Vietnam, Mr R underwent screening ultrasonography for AAA when the clinical reminder system of the US Department of Veterans Affairs prompted his primary care physician. He was found to have an aneurysm of 6.0ϫ4.7 cm on the ultrasonogram. Mr R's primary care physician discussed the case with a vascular surgeon, who recommended a follow-up computed tomography (CT) scan with contrast and prompt follow-up in the vascular clinic. His vascular surgeon considered an open procedure to repair the aneurysm but ultimately decided on an en-dovascular repair, given Mr R's habitus and history of myo-cardial infarction. Mr R underwent a detailed informed consent process during which he consented to the procedure , acknowledging the risks of untreated aneurysm as well as those of surgery, including ischemia, bleeding , and infection. He was told in qualitative terms by both his primary care physician and vascular surgeon about a dilation of his aorta and the risk of rupture. Two weeks later, Mr R underwent placement of an en-dovascular aneurysm repair (EVAR) stent graft. The vas-cular closure device maldeployed on insertion but was fixed and correctly positioned, according to the operative note. Six months later, Mr R came back to his primary care physician reporting that his left leg was completely numb. The leg was found to be pulseless and cold. He had experienced a total occlusion of his EVAR graft. He underwent emergency thrombectomy and axillary-femoral bypass to his leg performed by a vascular surgeon. Despite this, Mr R's creatine kinase level began to increase, and his leg was noted to be taut. Three more operations followed, over the course of 2 months, to relieve compartment syndrome and later for wound de-bridement and dehiscence. Despite these efforts, Mr R was left with a persistent foot drop, requiring use of a …