Screening Guidelines and Treatment Options for Abdominal Aortic Aneurysms Allen Jeremias, MD Division of Cardiology B eth I srael D eaconess M edical C enter Harvard Medical School

AAA Normal size: 2 cm AAA: 3 cm Prevalence: 1.3% in men aged BUT 12.5% in age 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 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 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 A bd. 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 % decrease in AAA rupture in 5 years In men age % decrease in AAA rupture in 9 years Wilminek et al. JVS 2003

Screening – Benefit? Population based study of 67,800 men aged 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 years Lederle et al., NEJM 2002

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

Therapy EVAR Peri-operative mortality % May have lower mortality for ruptured AAA surgery Recovery within 1-3 days

Surgery vs. 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