1. Aortic Aneurysms Optimum Re Underwriting Seminar Dallas 2015 Jean-Marc Fix, FSA, MAAA VP R&D

2. Thanks Dr. M. Nguyen Dr. Z. Sasson Dr. F. Sestier and Dr. A. Khoury

3. Agenda Anatomy of the aorta Aneurysm definition Thoracic aortic aneurysm Abdominal aortic aneurysm Case studies

4. Anatomy of the Aorta Source : clevelandclinic.org

5. Definition of Aneurysm Local dilatation of the aorta o by over 50% over the normal diameter and o involving all three layers of the vessel (intima, media and adventitia) Abdominal aneurysm more common than thoracic

6. Morphology of Aneurysm Fusiform: symmetrical Saccular: pouch

7. Cause A weakening of the aortic wall o Trauma or infection o Defect in aortic walls proteins o Age

8. Consequences Expansion Rupture Death

9. Distribution by Age ORIC all aneurysms Number of cases Issue Age

10. Mortality by Age From Pharmaceuticalintelligence.com but specifics of chart not clear

11. Thoracic Aortic Aneurysm Epidemiology Etiology Treatment Mortality and rating

12. TAA Epidemiology Incidence 6-10/100,000 Prevalence 0.16-0.34% for 5cm+ undetected Most common your 60s and 70s Males 2-4 times more than female 13% have multiple aneurysm 20-25% of large TAA also have AAA Source : GA Kuzmik et al Natural history of thoracic and aortic aneurysm, J Vasc Surg 2012 56:565-571, EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

13. TAA Anatomy Ascending (between aortic valve and innominate artery) 60% Aortic arch 10% Descending (distal to left subclavian artery) 40% Thoracoabdominal 10% (more than I segment possible) Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

14. TAA Causes Most often cystic medial degeneration (increases with age) Marfan syndrome Familial TAA Syndrome Bicuspid aortic valve (have a fibrillin defect) Atherosclerosis (mostly for descending TA, maybe secondary) [ZS 5a] Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

15. TAA Causes Syphilis Turner syndrome Aortic arteritis (Takaysu’s and giant cell) Aortic dissection Trauma (often deceleration injuries) Ehlers-Danlos syndrome Rheumatoid and psoriatic arthritis Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

16. TAA Clinical Manifestation 95%+ asymptomatic Sometimes mass may create compression of trachea or main bronchus, esophagus or laryngeal nerve Rarely back or chest pain Rupture: abrupt onset of severe pain Source : GA Kuzmik et al Natural history of thoracic and aortic aneurysm, J Vasc Surg 2012 56:565-571, EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

17. TAA Diagnosis CT scan or MRI In Marfan’s especially, transthoracic echo (good only for the root) Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

18. Dimensions of the Thoracic Aorta Evangelista A et al. Eur J Echocardiogr 2010;11:645-658

19. TAA Imaging CT Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

20. TAA Imaging CT -2 Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

21. TAA Imaging MRI Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

22. TAA Natural History Aorta loses flexibility when reaching 6cm and can’t absorb extra blood pressure Ascending aorta grows by 0.10 cm a year Descending aorta grows by 0.29 cm a year Familial TAA grows faster

23. TAA Natural History Rupture is key danger o 41% reach hospital alive o Perioperative mortality 23-29% Non emergency surgical mortality 3-5%

24. TAA Management Surveillance Surgery

25. Treatment Surgical repair o Open o Endovascular

26. TAA Repair Size 5.5cm or + Growth 0.5cm/yr Symptomatic Surgical candidate CAD/Valve issue Size 3.5-4.4 cmSize 4.5-5.4 cm Valve/ CABG + aneurysm repair Aneurysm repairAnnual CT/MRI Semi-annual CT/MRI YES NO YES

27. Types of Surgery Open surgery Endovascular aneurysm repair

28. Pros and Cons Open repair (from the 1950s) o Pros: stable, handle any aortic geometry o Cons: invasive, circulation stopped, higher perioperative mortality and complications (x2 EVAR) EVAR (from the 1990s) o Pros: less invasive, faster recuperation o Cons: less stable in time, need conducive aortic geometry, follow-up and reintervention may be needed

29. EVAR Follow-Up Need CT scan 30 days after operation Done in about 1/3 cases! Then annual imaging Source : T Garg Adherence to postoperation surveillance guidelines after endovascular aortic repair among Medicare beneficiary, Stanford School of Medicine 2012(?) 111:816-828

30. TAA Rating Factors Pre surgery o Growth rate o Size o Age Post surgery o Age o Type of surgery o Time since surgery

31. Abdominal Aortic Aneurysm Epidemiology Etiology Treatment Mortality and rating

32. AAA Epidemiology Much more common Aneurysm 4cm+ in 1% of men ages 55-64 and increase by2-4% per decade Incidence rise rapidly after age 50 for men and 70 for women Less common in women Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828 JT Powell Small abdominal aortic aneurysm < NEJM 2003 348:1895-1901

33. AAA Causes and Risk Factors Smoking Hypertension Hyperlipidemia Atherosclerosis Family history (could increase risk by 30%, younger age, more likely to rupture) Males 10 times more likely to have aneurysm>4cm than females Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828 W Tang et al Association between middle age risk factors and risk of asymptomatic AAA (ARIC study )Circulation 2014 129:AP341

34. AAA Clinical Manifestation Mostly asymptomatic Found incidentally If pain, it is usually below the stomach or in the lower back If abrupt violent back pain and tender or painful abdomen -> ER Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

35. AAA Diagnosis May be detected by palpation Ultrasound prefer detection modality CT scan and CT angio better for sizing and therefore for follow-up Size by CT is 3-9mm greater than by ultrasound (depending on the aneurysm size) Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111:816-828

36. AAA Natural History Rupture is also key danger o 25% die before reaching the hospital o 51% die prior to surgery o 46% of those having surgery die! Elective is best and combine with aortic valve surgery if needed

37. AAA Natural History Rupture is more frequent o In smokers o In hypertensive o In fast growing aneurysm

38. AAA Management Surveillance frequency depends on size o 4.0-4.4cm every 2 years o 4.5-4.9cm every year Surgery o When 5.5 cm+ o When growth of 10 mm+/year Source : 2014 European Society of Cardiology guidelines on the diagnosis and treatment of artic diseases

39. Pros and Cons for AAA EVAR has short term advantage but does not seem to sustain that advantage over open surgery longer term. Why is still unclear! Source : Table 1 A Schanzer & L Messina Two decades of endovascular aortic aneurysm repair: enormous progress with serious lessons learned, J Am Heart Assoc 2012 1:e000075 Trial30 days mort.Long term mort. EVAR/Open EVAR 11.8%/4.3%23.1%/22.3% (4y) DREAM1.2%/4.6%31.1%/30.1% (6y) OVER0.5%/3.0%7.0%/9.8% (2y) Medicare1.2%/4.8%34.0/34.3% (5y)

40. AAA Screening Medicare covers one abdominal ultrasound for adults age 65+

41. AAA Rating Factors Pre surgery o Growth rate o Size o Age Post surgery o Age o Type of surgery o Time since surgery