1. 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

2. 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

3. AAA

4. 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

5. 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

6. 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

7. Physical Examination 30% of asymptomatic AAA discovered during routine PE Pulsatile large Abd. mass Sensitivity of PR 22-96%

8. 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

9. 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

10. 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

11. 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

12. 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

13. Imaging – CT/MRI Better definition of AAA shape Better image suprarenal AAA Detection of other Abd. pathology Other vascular structures visible (renal, iliac arteries)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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)

20. Therapy EVAR Peri-operative mortality 1.0-2.4% May have lower mortality for ruptured AAA surgery Recovery within 1-3 days

21. Surgery vs. EVAR

22. Therapy - EVAR

24. 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