Beth Israel Deaconess Medical Center Harvard Medical School 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 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
AAA
AAA-related Mortality • • 13 th leading cause of death in US Documented 15 K but likely up to 30 k deaths per year • Mean F/U of 8 years
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
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
Physical Examination • • • 30% of asymptomatic AAA discovered during routine PE Pulsatile large Abd. mass Sensitivity of PR 22 -96%
Screening – Benefit? • In men age 50+ rupture in 5 years 49% decrease in AAA • In men age 50+ in 9 years 64% decrease in AAA rupture Wilminek et al. JVS 2003
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. 5 cm 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
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
Screening Guidelines Class I • Men age 60+ with FHx of AAA Class IIa • Men age 65 – 75 with h/o tobacco USx 1 PE and US PE and BUT: No screening for non-smokers and women! ACC/AHA Guidelines for PVD; JACC 2006
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
Imaging – CT/MRI • • Better definition of AAA shape Better image suprarenal AAA Detection of other Abd. pathology Other vascular structures visible (renal, iliac arteries)
Follow-up Surveillance n n 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
Follow-up Surveillance • • AAA <4. 0 cm AAA 4. 0 – 5. 4 cm annual US 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
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
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
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
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)
Therapy EVAR • • • Peri-operative mortality 1. 0 -2. 4% May have lower mortality for ruptured AAA surgery Recovery within 1 -3 days
Surgery vs. EVAR
Therapy - EVAR
Therapy - EVAR
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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