screening guidelines and treatment options for abdominal aortic aneurysms allen jeremias, md...
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Screening Guidelines and Treatment Options for Abdominal
Aortic Aneurysms
Allen Jeremias, MDDivision of Cardiology
Beth Israel DeaconessMedical Center
Harvard Medical School
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-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
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 cm0.35 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 cm0.5 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 cm20 to 40% for AAA 7.0 to 7.9 cm30 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+ 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
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
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 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
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
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 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
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 yearsLederle 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