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

2. Aneurysm  A permanent and irreversible localized dilatation of a vessel A permanent and irreversible localized dilatation of a vessel

3. Aorta with an infrarenal diameter > 30mm 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 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 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 The Society for Vascular Surgery and the International Society for the Cardiovascular Surgery in 1991

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

5. Histopathology Fragmentation of elastic fibres Fragmentation of elastic fibres Decrease in concentration of elastin Decrease in concentration of elastin Reduction in the density of smooth muscle cells 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 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 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 Bimanual palpation Sensitivity increases with diameter Sensitivity increases with diameter 61% for 3.0 – 3.9 cm 61% for 3.0 – 3.9 cm 69% for 4.0 – 4.9 cm 69% for 4.0 – 4.9 cm 82% for >= 5.0 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 Fink HA. The accuracy of physical examination to detect abdominal aortic aneurysm. Arch Intern Med 2000;160;833-36

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

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

9. Angiogram Angiogram CT / MRA CT / MRA

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

11. Indications for treatment Indication for surgical treatment deduced Indication for surgical treatment deduced Estimated risk of rupture Estimated risk of rupture Estimated risk of surgical procedure Estimated risk of surgical procedure Estimated life expectancy Estimated life expectancy Rigorous surveillance of intrarenal aortic aneurysms < 5.5cm is safe 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 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 Varies among hospital and surgeons Mean 30-day mortality 1.1 – 7% Mean 30-day mortality 1.1 – 7% Risk factors Risk factors Renal failure Renal failure COAD COAD Myocardial ischaemia Myocardial ischaemia

13. coronary artery revascularisation before surgery? Benefit remains controversial Benefit remains controversial Simultaneous aneurysm repair and coronary revascularisation recommended in selected patient 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 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 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 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 5 preoperative risk factors predict mortality Age > 76 Age > 76 Creatinine > 190 umol/L Creatinine > 190 umol/L Haemoglobin < 9 g/dL Haemoglobin < 9 g/dL Loss of conscious Loss of conscious ECG evidence of ischaemia ECG evidence of ischaemia

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

16. Management surgery vs endovascular repair Endovascular repair Endovascular repair Introduced by Parodi in 1991 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 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 Lancet 2005;365;2179-86 Randomized controlled trial of 1082 patient aged >=60 with aneurysm >= 5.5cm Randomized controlled trial of 1082 patient aged >=60 with aneurysm >= 5.5cm Referred to one of 34 hospitals proficient to EVAR Referred to one of 34 hospitals proficient to EVAR EVAR (n=543) or open repair (n=539) EVAR (n=543) or open repair (n=539)

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

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

20. 30-day operative mortality in EVAR was 9% 30-day operative mortality in EVAR was 9% No significant difference No significant difference All-cause mortality All-cause mortality Aneurysm-related mortality Aneurysm-related mortality Conclusions Conclusions EVAR did not improve survival EVAR did not improve survival Need for continued surveillance and reinterventions > increased cost 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 First reported by Yusuf et al in 1994 Yusuf SW et al. Emergency endovascular repair of leaking aortic aneursym. Lancet 1999;344;1645 Yusuf SW et al. Emergency endovascular repair of leaking aortic aneursym. Lancet 1999;344;1645

23. Retrospective reviews Retrospective reviews Improve early outcomes Improve early outcomes Shorter ICU stay 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 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 Patients associated with heavy comorbidities > no difference in mid-term motality

24. Non-invasive prevention of growth and rupture Stop smoking reduces the growth of aneurysm 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 Brady AR. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. Circulation 2004;110;16-21 Tetracycline prevents aneurysm growth 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 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

25. β - blockers β - blockers reduce the growth rate of large (>5cm) aneurysm and even to lessen the size 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 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 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 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 Propranol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms; results of a randomized trial. J Vasc Surg 2002;35;72-79 Statins Statins Reduce expansion of various inflammatory molecules Reduce expansion of various inflammatory molecules Long term use reduced mortality after surgery 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 Kertai MD. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med 2004;116;96-103

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

27. The End Thank you