1 / 27

Updates on Abdominal aortic aneurysm

Updates on Abdominal aortic aneurysm. Yvonne Tsang North District Hospital. Aneurysm. ανευρυσμα A permanent and irreversible localized dilatation of a vessel. Aorta with an infrarenal diameter > 30mm

norah
Download Presentation

Updates on Abdominal aortic aneurysm

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Updates on Abdominal aortic aneurysm Yvonne Tsang North District Hospital

  2. Aneurysm • ανευρυσμα • A permanent and irreversible localized dilatation of a vessel

  3. Aorta with an infrarenal diameter > 30mm • McGregor JC. The value of ultrasonography in the diagnosis of abdominal aortic aneurysm. Scott Med J 1975;20:133—37 • Infrarenal diameter should be 1.5 times the expected normal diameter • The Society for Vascular Surgery and the International Society for the Cardiovascular Surgery in 1991

  4. Epidemiology • Prevalence • 1.3 - 8.9% in men • 1.0 - 2.2% in women • Rupture of abdominal aortic aneurysms • 8000 death per year in UK • 15 000 death per year in US • Overall mortality rate of ruptured AAA • 65 – 85%

  5. Histopathology • Fragmentation of elastic fibres • Decrease in concentration of elastin • Reduction in the density of smooth muscle cells • Baxter BT et al. Elastin content, crosslinks, and mRNA in normal and aneurysmal human aorta. J Vasc Surg 1992;16;192-200 • Sakalihasan N et al. Modifications of the extracellular matrix of aneurysmal abdominal aortas as a function of their size. Eur J Vasc Surg 1993;7;633-37

  6. Diagnosis • Bimanual palpation • Sensitivity increases with diameter • 61% for 3.0 – 3.9 cm • 69% for 4.0 – 4.9 cm • 82% for >= 5.0 cm • Fink HA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med 2000;160;833-36

  7. Ultrasonography • Accuracy of 3 mm • For initial assessment, • surveillance and screening • Quill DS. Ultrasonic screening for the detection of abdominal aortic aneurysms. Surg Clin North Am 1989;69;713-29

  8. Computed Tomography • Visualise the proximal neck, the extension to the iliac arteries and the patency of the visceral arteries. • Measure the thickness of the mural thrombus

  9. Angiogram • CT / MRA

  10. Clinical presentation • Unruptured • Generally asymptomatic • After complications • Ruptured • Triad • Retroperitoneal space

  11. Indications for treatment • Indication for surgical treatment deduced • Estimated risk of rupture • Estimated risk of surgical procedure • Estimated life expectancy • Rigorous surveillance of intrarenal aortic aneurysms < 5.5cm is safe • The UK Small ameurysm trial Participants. Mortality results for randomized controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998;352;1649-55

  12. Risk of elective aneurysm repair • Varies among hospital and surgeons • Mean 30-day mortality 1.1 – 7% • Risk factors • Renal failure • COAD • Myocardial ischaemia

  13. coronary artery revascularisation before surgery? • Benefit remains controversial • Simultaneous aneurysm repair and coronary revascularisation recommended in selected patient • El-Sabrout RA. Outcome after simltaneous abdominal arotic aneurysm repair and coronary bypass. Ann Vasc Surg 2002;16;321-30 • RCT > no significant difference in long-term outcome when coronary artery revascularisation undertaken before elective surgery • McFalls EO. Coronary-artery revascularisation before elective major vascular surgery. N Eng J Med 2004;351;2795-804

  14. Risk of emergency repair for ruptured aneurysm • 5 preoperative risk factors predict mortality • Age > 76 • Creatinine > 190 umol/L • Haemoglobin < 9 g/dL • Loss of conscious • ECG evidence of ischaemia

  15. Risk factors mortality • 3 100 • 2 48 • 1 28 • 0 18 • Prance SE. Ruptured abdominal aortic aneurysms: selected patients for surgery. Eur J Vasc Endovasc Surg 1999;17;129-32

  16. Managementsurgery vs endovascular repair • Endovascular repair • Introduced by Parodi in 1991 • Placement of a graft across the aneurysm and the fixation to the normal arotic and iliac wall with stents at both ends

  17. EVAR trial 1 • Lancet 2005;365;2179-86 • Randomized controlled trial of 1082 patient aged >=60 with aneurysm >= 5.5cm • Referred to one of 34 hospitals proficient to EVAR • EVAR (n=543) or open repair (n=539)

  18. Higher number of complications and reinterventions in EVAR • Significance difference the aneurysm-related mortality at 4 years • 4% in EVAR vs 7% in open repair • EVAR higher cost and longer follow up • After 4 years, all-cause mortality did not differ

  19. EVAR trial 2 • Lancet 2005;365;2187-92 • Patients unfit for open repair • Randomized controlled of 338 patients aged >= 60 years with aneurysms >= 5.5 cm • Referred to one of 31 hospitals in UK • EVAR (n=166) or no intervention (n=172)

  20. 30-day operative mortality in EVAR was 9% • No significant difference • All-cause mortality • Aneurysm-related mortality • Conclusions • EVAR did not improve survival • Need for continued surveillance and reinterventions > increased cost

  21. Emergency endovascular repair for ruptured abdominal aortic aneurysms • First reported by Yusuf et al in 1994 • Yusuf SW et al. Emergency endovascular repair of leaking aortic aneursym. Lancet 1999;344;1645

  22. Retrospective reviews • Improve early outcomes • Shorter ICU stay • Brandt M. Endovascular Repair of Ruptured Abdominal Aortic Aneurysm: Feasibility and Impacy on Early Outcome. J Vasc Interv Radiol 2005;16;1309-12 • Patients associated with heavy comorbidities > no difference in mid-term motality

  23. Non-invasive prevention of growth and rupture • Stop smoking reduces the growth of aneurysm • Brady AR. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation 2004;110;16-21 • Tetracycline prevents aneurysm growth • Baxter BT. Prolonged administration of doxycycline in patient with small asymptomatic abdominal aortic aneurysms: report of a prospective multicenter study. J Vasc Surg 2002;36;1-12

  24. β-blockers • reduce the growth rate of large (>5cm) aneurysm and even to lessen the size • Gadowski GR. Abdominal aortic aneurysm expansion rate: effect of size and beta-adrenergic blockade. J Vasc Surg 1994;19;727-31 • Slaiby JM. Expansion of arotic aneurysms is reduced by propranolol in a hypertensive rat model. J Vasc Surg 1994;20;178-83 • no effect on growth rate of small aneurysms • Propranol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms; results of a randomized trial. J Vasc Surg 2002;35;72-79 • Statins • Reduce expansion of various inflammatory molecules • Long term use reduced mortality after surgery • Kertai MD. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med 2004;116;96-103

  25. conclusions • Marked progress in past few decades • Diagnosis • Management • Timing of interventional treatments • Assessment of endovascular repair vs conventional surgery • What comes next?

  26. The End Thank you

More Related