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AAA Before the Bubble Bursts

AAA Before the Bubble Bursts. June ‘XX. Presents to Beaumont A&E c/o Abdominal Pain B/G: Known AAA Radiating through to the back Constant for 24 hrs Vomit x 6 Fever, Malaise No Hx of Haemoptysis PR Bleed G.I Symptoms. O/E: Abd SNT Tender, Expansile , Pulsatile Mass

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AAA Before the Bubble Bursts

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  1. AAABefore the Bubble Bursts

  2. June ‘XX • Presents to Beaumont A&E c/o Abdominal Pain • B/G: Known AAA • Radiating through to the back • Constant for 24 hrs • Vomit x 6 • Fever, Malaise • No Hx of • Haemoptysis • PR Bleed • G.I Symptoms

  3. O/E: • Abd SNT • Tender, Expansile , Pulsatile Mass • No Signs of Rigidity or Guarding • Peripheral Pulses: Present Bilaterally • No Other Abnormal Findings • Ix: • FAST Scan Performed: • No Increased Size of AAA • Last AAA Scan Oct ’12 - 4.5 cm

  4. Work up for Differential Dx • General Surgical Consult • OGD: Normal • PFA: Normal • Glasgow EMRIE Score: 0 • Ultrasound Abd: Normal

  5. Summary • B/G Hx: Known AAA • Tender Central Mass • Haemodynamically Stable • All other differentials have been out ruled • Impression: Symptomatic AAA

  6. What would you do next?

  7. CT Aortic Angiogram

  8. Plan • 1. Admit Patient • 2. Analgesia • 3. DVT Prophylaxis • 4. CT Aortic Angiogram: • AAA- 4.5cm • No Evidence of Leakage or Rupture • No Evidence of Retroperitoneal Bleed • 5. EVAR • Patient Discharged 3/7 Post-Op

  9. EVAR Completion Angiogram

  10. Indications for AAA Repair

  11. Standard Practise • AAA Repair is performed when: • Diameter >5.5cm • Symptomatic • Ruptured AAA • The presence of other Large Vessel Aneurysms • Rapid Rate of Expansion • Treatment Options: • EVAR • Open Repair

  12. Annual Risk of Rupture • <4.0 cm = <0.5% • 4.0 to 4.9 cm = 0.5 to 5% • 5.0 to 5.9 cm = 3 to 15% • 6.0 to 6.9 cm = 10 to 20% • 7.0 to 7.9 cm = 20 to 40% • >/=8.0 cm = 30 to 50%

  13. UKSAT Trial • First trial of its kind to compare Surveillance vs Open repair for small asymptomatic AAA 4.1-5.5 cm • Large study done in the UK between 1994 and 1998 • 1090 participants • 83% male • Infra-renal Asymptomatic AAA

  14. Results • Non-Significant Survival Benefit for Intervention Group. • 6 years Survival was 64% in Both Groups • 30-day Post-Operative Mortality 5.6% • Cost £1,064 more overall for EVAR group

  15. Overall Survival

  16. Recommendations • Surveillance strategy based on minimized likelihood of growth >5.5cm to <1% probability: • 3.5 - 3.8cm = 36 months • 4.0 - 4.4cm = 24 months • 4.5 – 4.9cm = 12 months • 5.0-5.4cm = 3 months Current UK/NI guidelines 3.0-4.4cm 12 months 4.4-5.4cm 3 months

  17. Render unto C.A.E.S.A.R…Comparison of Surveillance Versus Aortic Endografting For Small Aneurysm Repair • First large trial to compare Surveillance Vs Immediate EVAR • Randomised Control Trial • Trial involving 20 approved European/Western Asian hospitals • 4.1-5.4cm Asymptomatic AAA • Patients Enrolled between 2004- 2008 • 378 participants

  18. CAESAR trial Inclusion criteria: Exclusion criteria: • AAA 4.1-5.4cm diameter • 50-79 years of age • Suitable for EVAR by CT scan • Minimum 5 year Life Expectancy • Severe comorbidities • Suprarenal/Thoracic aorta ≥4.0cm • Needed Urgent Repair • Unable or unwilling to give informed consent or follow the protocol

  19. Method • Surveillance Group: • 6/12 U/S Scan • 1 yr CT • Indications for progression to Repair: • Aneurysm grew to 5.5cm • Rapid increase in Diameter • Became Symptomatic • CT mandatory for Aneurysmal Diameter and suitability for EVAR before Randomisation as well as follow up • EVAR Group: • Graft Standardised: Zenith AAA Endovascular Graft • Follow up: • 6/12 U/S + Clinical Exam • 1 yr Abdo X Ray + CT scan

  20. Estimates of All Cause Mortality in EVAR vs Surveillance Groups

  21. Estimated Probability of Delayed Repair in Surveillance Group

  22. Cumulative probability for Aneurysmal Repair in 3 Groups based on Size at Presentation

  23. Results • All Cause Mortality • Determined to be Insignificant • EVAR 14.5% Vs Surveillance 10.1% • Rupture rate below Annual Rate of 1%: • Surveillance: 2 Ruptures • 5.6cm & 5.5cm • Had been Scheduled for EVAR • Aneurysm Related Mortality: • EVAR: 1 • Surveillance: 1 • 16.4% Surveillance Group Lose Eligibility for EVAR • Positive Association with Delayed Repair: • Absence of Diabetes • Absence of Peripheral Vascular Disease • Predictor for Delayed Repair: • Large Aneurysm Diameter • Absence of Hypertension under Medical Management

  24. Discussion • Surveillance provides a Safe Alternative Management for AAA 4.1-5.4cm • Requires Accurate Imaging and Close Monitoring • EVAR suitability before and after Randomisation left at Discretion of Participating Centres • Need to Optimise Best Medical Management: • Only 47% on statin • Peri-Operative risk: • 0.55% EVAR Vs 5.8% Open repair (UKSAT)

  25. Cochrane Review for Surgery for Small Asymptomatic AAAs: • Metanalysis of Long Survival for Asymptomatic AAA 4-5.5cm • 3,314 Patients • Randomised Controlled Trials: • Open: UKSAT, ADAM • EVAR: CAESAR, PIVOTAL • Comparing Immediate AAA Repair Vs. Surveillance

  26. Conclusion • The studies Indicate no Long Term Benefit between the Control Groups and does not favour Immediate EVAR • The Surveillance control group showed better Survival Rates in the Early Stages due to the 30 day Post-Operative Period. • 31-75% Surveillance Group eventually require Repairs • ~60% Require Repair within 1 year • Review Illustrates need for more Information on Patient Demographics so Surveillance can be performed appropriately for Sub Groups based on Age, Gender, Aneurysm Morphology

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