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Screening Guidelines and Treatment Options for Abdominal Aortic Aneurysms

Harvard Medical School. B eth I srael D eaconess M edical C enter. Screening Guidelines and Treatment Options for Abdominal Aortic Aneurysms. Allen Jeremias, MD Division of Cardiology. AAA. Normal size: 2 cm AAA: 3 cm Prevalence: 1.3% in men aged 45-54 BUT 12.5% in age 75-84

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Screening Guidelines and Treatment Options for Abdominal Aortic Aneurysms

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  1. Harvard Medical School Beth Israel Deaconess Medical Center Screening Guidelines and Treatment Options for Abdominal Aortic Aneurysms Allen Jeremias, MD Division of Cardiology

  2. AAA • Normal size: 2 cm • AAA: 3 cm • Prevalence: 1.3% in men aged 45-54 BUT 12.5% in age 75-84 • Risk factors: Same as CAD but mainly hereditary and tobacco • Natural history: Gradual expansion; mural thrombus • Complications: Rupture; thromboembolism; compression or erosion of adjacent structures

  3. AAA

  4. AAA-related Mortality • 13th leading cause of death in US • Documented 15K but likely up to 30k deaths per year • Mean F/U of 8 years

  5. Natural History • Yearly Growth Rates: 0.19 cm for AAA 2.8 to 3.9 cm 0.27 cm for AAA 4.0 to 4.5 cm 0.35 cm for AAA 4.6 to 8.5 cm • Rupture Rate at 5 years: AAA >6 cm – 43% vs. 20% for smaller AAA • Estimated Risk of Rupture: 0 in AAA less than 4.0 cm 0.5 to 5% for AAA 4.0 to 4.9 cm 3 to 15% for AAA 5.0 to 5.9 cm 10 to 20% for AAA 6.0 to 6.9 cm 20 to 40% for AAA 7.0 to 7.9 cm 30 to 50% for AAA 8.0 cm

  6. Clinical Presentation • Most AAA quiescent until rupture • Rarely Abd. pain or back pain • New pain and tenderness indicate recent expansion • Thromboembolism to lower extremities • Ruptured AAA: Triad of Abd. or back pain, hypotension, and pulsatile Abd. mass

  7. Physical Examination • 30% of asymptomatic AAA discovered during routine PE • Pulsatile large Abd. mass • Sensitivity of PR 22-96%

  8. Screening – Benefit? • In men age 50+ 49% decrease in AAA rupture in 5 years • In men age 50+ 64% decrease in AAA rupture in 9 years Wilminek et al. JVS 2003

  9. Screening – Benefit? • Population based study of 67,800 men aged 65-74 with random allocation to Abd. US • Yearly US for AAA> 3 cm and surgery for AAA> 5.5cm or 1 cm progression within 1 year • 4-year aneurysm-related mortality in control group: 0.33% vs. 0.19% (RR reduction 42%) • Total of 47 fewer deaths in screening group MASS: BMJ 2002

  10. Screening – Cost • Additional cost in screening group: $3.5 million • Incremental cost-effectiveness ratio: $45,000 per life-year gained • 10-year estimate: $12,500 per life-year gained • Recommendation: Screening for ‘high-risk’ groups MASS: BMJ 2002

  11. Screening Guidelines Class I • Men age 60+ with FHx of AAA PE and US Class IIa • Men age 65 – 75 with h/o tobacco PE and USx1 BUT: No screening for non-smokers and women! ACC/AHA Guidelines for PVD; JACC 2006

  12. Imaging - US • Optimal for screening – cheap, easy and no radiation exposure • Sensitivity almost 100% • No visualization of iliac arteries • Dependence on sonographer • 2-3% of patients cannot be imaged

  13. Imaging – CT/MRI • Better definition of AAA shape • Better image suprarenal AAA • Detection of other Abd. pathology • Other vascular structures visible (renal, iliac arteries)

  14. Follow-up Surveillance • Aortic diameter <3 cm — no further testing • Aneurysm 3 to 4 cm — annual ultrasound • Aneurysm 4 to 4.5 cm — ultrasound every six months • Aneurysm >4.5 cm — referral to a vascular specialist Society for Vascular Surgery

  15. Follow-up Surveillance • AAA <4.0 cm annual US • AAA 4.0 – 5.4 cm bi-annual US • Consider intervention when AAA >5.5 cm or >0.5 cm expansion within 6 months • Also, intervention with Abd./back pain or tenderness and embolism ACC/AHA Guidelines for PVD; JACC 2006

  16. Observational Management Class I • Peri-operative BB therapy for Pt. with CAD Class IIb • BB therapy to reduce rate of AAA expansion ACC/AHA Guidelines for PVD; JACC 2006

  17. Intermediate Size AAA (4-5.5 cm) UK Small Aneurysm trial • Randomized 1090 Pt. to surgery vs. US surveillance every 6 months • Operative mortality 5.4% • Mean F/U of 8 years Lancet 1998

  18. Intermediate Size AAA (4-5.5 cm) US ADAM Study • Randomized 1136 Pt. to surgery vs. US surveillance every 6 months • Operative mortality 2.7% • Mean F/U of 5 years Lederle et al., NEJM 2002

  19. Therapy Surgery • Peri-operative mortality 2.7-5.6% • 40-70% mortality for ruptured AAA surgery • Significant morbidity (5-12 weeks before returning to normal life style)

  20. Therapy EVAR • Peri-operative mortality 1.0-2.4% • May have lower mortality for ruptured AAA surgery • Recovery within 1-3 days

  21. Surgery vs. EVAR

  22. Therapy - EVAR

  23. Therapy - EVAR

  24. Surgery vs. EVAR Dream Trial • Randomized 351 Pt. to surgery vs. EVAR • Peri-operative survival advantage with EVAR lost beyond 1 year Blankensteijn et al., NEJM 2005

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