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

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

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

Clinical findings Examination picks up only 40- 50% 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

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)

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

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

Treatments Open Surgical Repair EndoVascular Aneurysm Repair (EVAR)

Open aneurysm treatment

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

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

Endovascular Aneurysm Repair Technique

Cook Zenith Stentgraft

Aorto-uni-iliac Graft

EVAR I Trial 30-day mortality EVAR I 1.7%

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

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

UK Small Aneurysm Trial

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

Aneurysm Screening

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%

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

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)

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%

MASS Results

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