Aortic Aneurysm Screening Willy Pillay Endovascular Surgeon

Doncaster Vascular Centre Background AAA in 7.5% of Males > 65yr 2% of all deaths in males > 65 6800 AAA-related deaths/yr (Eng&Wales) 7% risk of family member having AAA 12% risk if index is female 3.1% have peripheral aneurysms 70% of peripheral aneurysms have AAA Doncaster Vascular Centre

Background on AAA Treatment when reaches 5.5cm size Prevent rupture Elective open surgery mortality 7.5% in UK (Vascunet Data 2008) AAA QIP to reduce mortality to 2.5% 2012: 2.4% (DVC: 3.9%, Now 2.6%) Emergency open surgery mortality 40-50% Elective EVAR mortality 2% Emergency EVAR mortality ??? (IMPROVE trial)

UK Small Aneurysm Trial 1998, Lancet 1090 patients (age 60 – 76) Asymptomatic AAA 4.0 – 5.5cm Early surgery vs. ultrasound surveillance Surgery if >5.5, increase> 1cm/yr, symptoms US 6/12 (4.0-4.9), 3/12 (5.0-5.5) Follow-up 4.6 year (mean) Doncaster Vascular Centre

UK Small Aneurysm Trial Operative mortality was 5.8% Hazard ratio 0.94 for early surgery (all-cause mortality) Mean survival 6.5 and 6.7 years No increase mortality with delayed surgery ¾ of surveillance group underwent surgery ‘early surgery gives no significant survival advantage over surveillance’ (…delayed surgery) Doncaster Vascular Centre

UK Small Aneurysm Trial 2002, NEJM Follow-up 8 yrs 7.2% survival advantage in early surgery Smoking cessation Doncaster Vascular Centre

Screening Pro-active: Invite a target population Opportunistic: e.g. HIV test at Antenatal Clinic The condition An important health problem Well understood epidemiology, disease progression, Latent period, risk factors Implemented cost-effective primary prevention strategy The Test Simple, safe, precise, and validated Repeatable, reliable Suitable cut-off levels defined and agreed A further diagnostic test for positive results The Treatment Effective, acceptable and available treatment for early detected disease Early treatments lead to better outcomes Clinical management should be optimised The Screening Programme RCT shows that screening reduces mortality & morbidity Clinically, ethically and socially acceptable to all Benefit should outweigh physical or psychological harm

MASS Multicentre Aortic Aneurysm Screening Study 2002, Lancet 67800 males (65-74yr) Invited for US screening or control 3.0-4.4 annual/ 4.4-5.4 3mthly Surgery >=5.5, symptoms, increase .1cm/yr 4.9% incidence AAA (12% >=5.5cm) Mortality elective 6%, emergency 37% Follow-up 4.1 yrs (mean) Doncaster Vascular Centre

Doncaster Vascular Centre MASS No difference in all-cause mortality (<3% of deaths) 42% RRR of mortality due to AAA (hazard ratio 0.58) (0.33 to 0.19) NNT = 710 screenings 41% RRR of rupture of AAA (hazard ratio 0.59) (0.41to 0.24) £28 400/ life year gained Doncaster Vascular Centre

Doncaster Vascular Centre MASS 2007, Annals Int Med Follow-up 7 yrs (mean) £12 000/life year gained Hazard ratio 0.53 2012, BMJ US<3.0cm rupture risk low But AAA rupture in those with initial size 2.5-2.9cm ?women ?2nd scan at 75yr if US<3.0cm Doncaster Vascular Centre

Doncaster Vascular Centre Mass (2) Doncaster Vascular Centre

Final follow‐up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening Abdominal aortic aneurysm (AAA)‐related mortality over 13 years in the Multicentre Aneurysm Screening Study © This slide is made available for non-commercial use only. Please note that permission may be required for re-use of images in which the copyright is owned by a third party. British Journal of Surgery Volume 99, Issue 12, pages 1649-1656, 3 OCT 2012 DOI: 10.1002/bjs.8897 http://onlinelibrary.wiley.com/doi/10.1002/bjs.8897/full#fig1

Final follow‐up of the Multicentre Aneurysm Screening Study (MASS) randomized trial of abdominal aortic aneurysm screening Rate of ruptured abdominal aortic aneurysm in men who originally screened normal and in the control group over time © This slide is made available for non-commercial use only. Please note that permission may be required for re-use of images in which the copyright is owned by a third party. British Journal of Surgery Volume 99, Issue 12, pages 1649-1656, 3 OCT 2012 DOI: 10.1002/bjs.8897 http://onlinelibrary.wiley.com/doi/10.1002/bjs.8897/full#fig2

Screening Men on 65th birthday Midline ultrasound AP measurement >3.0cm Surveillance >5.5cm Referred for treatment

Doncaster Vascular Centre Workload impact Men age 65 = +/- 0.4% of population Screening men > 65 yr 4% have slight enlargement 1% AAA > 4.0 0.5 % > 5.5cm (i.e. 8 newly detected men with AAA/ 400 000, but screening planned only for men=65!) Over 20 years (400 000 pop) Elective ops increase from 61% to 94% of all AAA surgery Increase 2.1 elective ops/month Decrease 0.5 emergency ops/month Increase 1.6 ops/month (after 20 yrs) Doncaster Vascular Centre

Doncaster Vascular Centre A note on screening Screening is not fool-proof Not every detected case will have a successful outcome Minimum number of false + Minimum number of false – Quality assurance (Reproducibility) Screening = risk reduction NOT diagnosis & cure Possible harm: High M&M of subsequent treatment Over detection of disease Psychological effects Genetic issues Doncaster Vascular Centre

Doncaster Vascular Centre Men > 65Yr Self-referral will be incorporated into screening program Aorta <3.0cm = 0.54 rupture/ 10 000 person years Doncaster Vascular Centre

Doncaster Vascular Centre Relatives < 65 yr Index case Known AAA Rupture Screened case Referred to Vascular Surgeon for US/ counselling (outside of screening) Doncaster Vascular Centre

Doncaster Vascular Centre Women 1.3% of women vs 7.6% men Cochrane review AAA screening (2007) No significant decrease in AAA-related mortality (OR 2 vs 0.5 for men) No significant decrease in in rupture (OR 1.5 vs 0.5 for men) Surgery equally likely if screened or not Possibly screen those with family history? Doncaster Vascular Centre

To date NHSAAASP: guidance to measure aorta AP and Longitudinal in Midline Inner wall to inner wall Prevalence in NHSAAASP is 1.5% (2012) Statins, Smoking Elective mortality has decreased to 2.4%