1. Aneurysms & Aneurysm Screening
Mr Marcus Cleanthis
Consultant Vascular Surgeon
Frimley Park Hospital

2. Aortic Aneurysms
Most common in men over 65 who smoke and are hypertensive
Are treated when above 5.5 cm
Can be treated by open surgery or stenting

3. Abdominal Aortic Aneurysms
Aorta larger than 1.5 times its normal diameter Or aorta exceeds 3 cm in

4. Clinical findings
Examination picks up only % of AAA False positive diagnosis in thin individuals Low accuracy for size estimation 60% found on radiological imaging a fifth of them not palpable on examination

5. Clinical Presentation
Most are asymptomatic, found on scanning or examination Back pain Abdominal pain ( suspect inflammatory aneurysm) Distal embolisation Aneurysm thrombosis ( rare) Primary aorto-duodenal fistula ( rare)

6. Mis-Diagnosis Initial Diagnosis Misdiagnosed Cases, % Average Delay, h
Renal colic 24 15
Diverticulitis 13 79
GI hemorrhage 17
Acute MI
8.7
Back pain 18
Motor vehicle accident
6.5
1.5
Sepsis 26
Other GI problem 4
Other/no diagnosis

7. Rupture risk
<40mm <1% per yr 40-55mm 1% per yr 55-79mm 10% per yr >70mm 25% per yr Risk factors for rupture Larger size >55mm Rapid expansion >10mm/yr Hypertension Smoking COPD Female sex

8. Treatments
Open Surgical Repair EndoVascular Aneurysm Repair (EVAR)

10. Open aneurysm treatment

11. ENDOVASCULAR ANEURYSM REPAIR (EVAR)
Minimal invasive aortic aneurysm repair through an endoluminal approach via a remote artery.

12. Endovascular Aneurysm Repair
Minimally invasive
Reduced morbidity
Reduced mortality
Less post-op pain
No/minimal ITU/HDU
Reduced hospital stay

13. Endovascular Aneurysm Repair Technique

14. Cook Zenith Stentgraft

15. Aorto-uni-iliac Graft

17. EVAR I Trial
30-day mortality EVAR I 1.7%

18. TREATMENT THRESHOLD AAA diameter
5.0cm? 5.5cm? 6.0cm?
UK Small Aneurysm Trial

20. UK Small Aneurysm Trial
1090 patients, Aged 60-76years, Fit
Asymptomatic 4.0 – 5.5cm AAA
Randomised: Early Surgery/Surveillance
Mean FU 4.6years
Statistical analysis: Intention to Treat
Primary endpoint: death

21. UK Small Aneurysm Trial

22. UK Small Aneurysm Trial
No difference in mortality in two groups
Cost analysis: surveillance cheaper
Conclusion: AAA <5.5cm should be managed conservatively

23. Aneurysm Screening

24. UK AAA Screening Men aged 65 and over are eligible for AAA screening
The NHS invites men for AAA screening during the year
they turn 65
Men over 65 who have not been screened previously can arrange a screening appointment by contacting their local programme directly
Screening involves an ultrasound scan that takes around 10 minutes
The NHS AAA Screening Programme aims to reduce deaths from ruptured AAA amongst men aged 65 and over by up to 50%

25. Gloucestershire Aneurysm Screening
25,000 ultrasound invitations
85% attendance
Costs approx. £10 per scan
99% imaging success
1% of aortas >4cm diameter

26. Gloucestershire Aneurysm Screening
Most rupture occurred in the 15% of patients who DNA’d
Incidence of aneurysm rupture in the screened group reduced by 85%
(Scott et al Br J Surg 1995)

28. MASS Results 80% of screened group accepted invitations
1333 aneurysms detected
65 aneurysm-related deaths invited group
113 aneurysm related deaths control group
42% risk reduction in invited group
53% risk reduction in those screened
Elective mortality 6%
Emergency surgery mortality 37%

29. MASS Results

30. Summary Treatment for AAA : greater than 5.5cm growth 1.0cm /12months
Tender AAA (inflammatory….)
Rupture AAA