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Screening for AAA The 4A Study

International Union of Angiology Palermo. Screening for AAA The 4A Study. A. DIARD, F. BECKER, I. QUERE Société Française de Médecine Vasculaire. AAA, Definition.

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Screening for AAA The 4A Study

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  1. International Union of Angiology Palermo Screening for AAAThe 4A Study A. DIARD, F. BECKER, I. QUERE Société Française de Médecine Vasculaire

  2. AAA, Definition An aneurysm is a permanent localized (focal) dilation of an artery having at least a 50% increase in diameter compared to the expected normal diameter1, 2 of the artery in question. 1: cross sectional external diameter (adventitia-adventitia) 2: i.e., ratio 1.5 In most studies, AAA is defined as permanent localized aorta dilation > 30 mm3 of antero-posterior diameter (or any direction if AP measurement not possible). 3: i.e. 20 mm (normal 20 mm AA diameter in men + 50%) Arteriomegaly is diffuse arterial enlargement involving several arterial segments, (i.e., nonfocal) with increase in diameter of greater than 50% by comparison to the expected normal diameter. Ectasia is characterized by dilation less than 50% of the normal arterial diameter. Suggested standards for reporting on arterial aneurysms. J Vasc Surg 1991 FB.091026

  3. AAA, a silent and instant killer 14th leading cause of death in USA, the 10th among men (at least 9.000 deaths per year due to ruptured AAA). Almost 2% of all deaths in men over 60 yr in England and Wales (4028 deaths attributed to ruptured AAA in 2000). About 5% of the sudden deaths Yearly death rate from ruptured AAA comparable to yearly mortality from prostate cancer and breast cancer Mortalitity of ruptured AAA: 65 à 90 % 100 ruptured AAA 25 deaths before hospitalization 51 deaths before operating room 13 post-operative deaths 11 survivals FB.091026

  4. AAA, a common disease over 60 years, 4.3 to 8.3% of men 0.5 to 1.5% of women Boll et al Eur J Vasc Endovasc Surg 2003, Fleming C. et al Ann Intern Med 2005 « On a national level, over the past 19 years, there has been no change in the incidence rate of elective AAA repair. Moreover, the incidence of ruptured AAAs presenting to the nation’s hospitals has not changed. Advances in technology and critical care have not affected outcome. ». (Heller J.A. et al J Vasc Surg 2000) FB.091026

  5. Prevalence vs Age (AAA > 4 cm) n = 10.061 Men ≈ 5% ≈ 3.5% ≈ 2% Grimshaw G.M., Thompson J.M.. J Clin Ultrasound 1997 (Birmingham study) FB.091026

  6. Prevalence vs Age & Smoking (AAA > 3 cm) Prévalence AAA > 3 cm n = 126.696 US Veterans * * * * * * * Lederle FA. et al. Arch Intern Med 2000, Ann Intern Med 2005 FB.091026

  7. Prevalence and Risk Factors for AAA in a population-based Study. The TromsØ Study. Am J Epidemiol 2001 Age and smoking are key risk factors in both sexes Far from age and tobacco, Hypertension is mainly a RF in women FB.091026

  8. Family history of AAA • USPSTF ignored the importance of a family history of AAA, but • Investigation of first-degree relatives over 50 yrs of patients having AAA -> Probability of AA ectasia or of AAA > 30 mm:20% (45% if considering only men1) • Family AAA are earlier and at highter risk of rupture RR 3.56 2 15% if 2 FDRs, 29% if 3 FDRs, 36% if 4 FDRs 3 FDRs = First-Degree Relatives 1Kuivaniemi, J Vasc Surg 2003 - 2 Verloes, J Vasc Surg 1995 - 3 Darling, J Vasc Surg 1989. FB.091026

  9. AAA in Women USPSTF excludes women from screening, but compared to men, the ▪normal abdominal aorta diameter is smaller (16-18 mm vs 18-22 mm), so a 40 mm AAA in female is equivalent to 50 mm AAA in male ▪ AAA prevalence is lesser but the female smokers have the same AAA prevalence as male non-smokers (1.9% for 3 cm AAAs) ▪ progression of AAA is faster (from 40 mm, see next slide) ▪ risk of rupture is higher (RR = 3) ▪ operative risk is higher (RR = 1.5) ▪ arteriomegaly is nearly absent in women FB.091026

  10. AAA in Women Increased Growth Rate of Abdominal Aortic Aneurysms in Women. The TromsØ Study.SolBerg S. et al. Eur J Vasc Endovasc Surg 2005; 29: 145-49 FB.091026

  11. déc.2006 FB.091026

  12. AAA screening for men and women over 50 yrs Recommended (grade A) for men and women with a family history of AAA (first-degree parents or siblings) and more so for parents or siblings were or are involved. FB.091026

  13. AAA screening for men and women 60-75 yrs old Recommended (grade A) for all men 60-75 yrs smokers or former smokers. Recommended (grade B) for all men 60-75 yrs non-smokers. Recomended (grade B) for women 60-75 yrs smokers or with hypertension FB.091026

  14. AAA screening for men and women over 75 yrs Recommended (grade B) for men over 75 yrs without severe co-morbidity and with life expectancy substantially normal for age. Recommended (grade B) for women over 75 yrs smokers, without severe co-morbidity and with life expectancy substantially normal for age. FB.091026

  15. Impact of AAA screening on Mortality (1) Pooled mid-term (3.5 - 5 yrs) results: the offer of screening causes a significant reduction in ▪ AAA related mortality, OR = 0.56(95% IC = 0.44 – 0.72) and ▪ emergency operations, OR = 0.55(95% IC = 0.39 – 0.76) Overall mortality is reduced but not significantly, OR = 0.94 (95% IC = 0.86 – 1.02). Lindolt J.S., Norman P. - Eur J Vasc Endovasc Surg 2008 (Pooled data of Australian study (BMJ 2004) - MASS (Lancet 2002) - Viborg study (Eur J Vasc Endovasc Surg 2002) - Chichester study (Br J Surg 2002). Total = 125.576 individuals. Attenders 74%. AAA prevalence 5.5% FB.091026

  16. Impact of AAA screening on Mortality (2) Long term results (7-15 yrs)shows significant reduction in ▪ AAA-related mortality: OR 0.47(95% IC: 0.25 – 0.90) ▪ Emergency operations: OR 0.48(95% IC: 0.28 – 0.83) ▪ Overall mortality: OR 0.94(95% IC: 0.92 – 0.97) with a significant increase of elective operations: OR = 3.27(95% IC = 2.14 – 5.00) at mid term, OR = 2.81(95% IC : 2.40 – 3.30) at long term. Lindolt J.S., Norman P. - Eur J Vasc Endovasc Surg 2008 (Pooled data of Australian study (BMJ 2004) - MASS (Lancet 2002) - Viborg study (Eur J Vasc Endovasc Surg 2002) - Chichester study (Br J Surg 2002). Total = 125.576 individuals. Attenders 74%. AAA prevalence 5.5% FB.091026

  17. Screening, but then ... « The success of a screening program largely depends on how patients are managed after the screening test. Of great concern for patients with small AAAs detected at screening is the risk of unnecessary procedures » F.A. LEDERLE (ADAM Study), Ann Intern Med 2003 FB.091026

  18. Mortality of patients followed for AAA The caliber of the abdominal aorta is not the only parameter to consider in patients followed for AAA, The over-mortality is mainly linked to CV risk factors (especially tobacco and hypertension) and related diseases, cardiovascular and other! Bergqvist D, Br J Surg 1999 Lindholt JS, Br J Surg 2001 Newman AB, Ann Inter Med 2001 MASS group, Lancet 2002 ADAM group N Engl J Med 2002 FB.091026

  19. Causes of death of patients with AAA FB.091026

  20. Important questions remain ... « The presence of AAA indicates an increased risk of cardiovascular death, Now we should move forward to screening in a manner that increases the evidence base and answers some of the questions about cardiovascular health care and changes in life-style in those with AAA detected at screening ». Greenhalgh R.M. BMJ 2002;325:1123-1124 ( 16 November ) Editorials FB.091026

  21. The 4A study4A: Atherothrombotic Aneurysm of Abdominal AortaSociété Française de Médecine Vasculaire Recruitement of Vascular Medicine daily practice AAA with AP diameter > 30 mm or Diameters Ratio > 1.5 FB.091026

  22. 4A study Two phases 4A phase I (Nov.2008 – May.2009) ended, under analysis Validation of the SFMV guidelines in private and in hospital daily practice of Vascular Medicine. Evaluation of CV risk factors, of associated diseases and of potential for phase II 4A study. 4A phase II (2010-2012) Validation Medical Management approach for « small » AAA (< 50 mm) Evaluation of the progression of the « small » AAA, Impact at mid and long term of a better management on patients with « small » AAA including on post-operative morbi-mortality if open / EVAR surgery in the follow-up. FB.091026

  23. Rate of AAA* according SFMV guidelines(* AP diameter > 30 mm or Diameters ratio > 1.5) 5160 patients examined, 305 screened or known AAA according to SFMV criteria for screening, whatever the reason for examination is, i.e. 5,9% ic.95%: 5,3 – 6,5 % Males: 10,3% Females: 1,9% No any difference between private and hospital practice 78% of the recruitement was from private practice FB.091026

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