2. June ‘XX Presents to Beaumont A&E c/o Abdominal Pain B/G: Known AAA Radiating through to the back Constant for 24 hrs Vomit x 6 Fever, Malaise No Hx of Haemoptysis PR Bleed G.I Symptoms

3. O/E: Abd SNT Tender, Expansile, Pulsatile Mass No Signs of Rigidity or Guarding Peripheral Pulses: Present Bilaterally No Other Abnormal Findings Ix: FAST Scan Performed: No Increased Size of AAA Last AAA Scan Oct ’12 - 4.5 cm

4. Work up for Differential Dx General Surgical Consult OGD: Normal PFA: Normal Glasgow EMRIE Score: 0 Ultrasound Abd: Normal

5. Summary B/G Hx: Known AAA Tender Central Mass Haemodynamically Stable All other differentials have been out ruled Impression: Symptomatic AAA

6. What would you do next?

7. CT Aortic Angiogram

8. Plan 1. Admit Patient 2. Analgesia 3. DVT Prophylaxis 4. CT Aortic Angiogram: AAA- 4.5cm No Evidence of Leakage or Rupture No Evidence of Retroperitoneal Bleed 5. EVAR Patient Discharged 3/7 Post-Op

9. EVAR Completion Angiogram

10. Indications for AAA Repair

11. Standard Practise AAA Repair is performed when: Diameter >5.5cm Symptomatic Ruptured AAA The presence of other Large Vessel Aneurysms Rapid Rate of Expansion Treatment Options: EVAR Open Repair

12. Annual Risk of Rupture <4.0 cm = <0.5% 4.0 to 4.9 cm = 0.5 to 5% 5.0 to 5.9 cm = 3 to 15% 6.0 to 6.9 cm = 10 to 20% 7.0 to 7.9 cm = 20 to 40% >/=8.0 cm = 30 to 50%

13. UKSAT Trial First trial of its kind to compare Surveillance vs Open repair for small asymptomatic AAA 4.1-5.5 cm Large study done in the UK between 1994 and 1998 1090 participants 83% male Infra-renal Asymptomatic AAA

14. Results Non-Significant Survival Benefit for Intervention Group. 6 years Survival was 64% in Both Groups 30-day Post-Operative Mortality 5.6% Cost £1,064 more overall for EVAR group

15. Overall Survival

16. Recommendations Surveillance strategy based on minimized likelihood of growth >5.5cm to <1% probability: 3.5 - 3.8cm =36 months 4.0 - 4.4cm =24 months 4.5 – 4.9cm =12 months 5.0-5.4cm = 3 months Current UK/NI guidelines 3.0-4.4cm 12 months 4.4-5.4cm 3 months

17. Render unto C.A.E.S.A.R… Comparison of Surveillance Versus Aortic Endografting For Small Aneurysm Repair First large trial to compare Surveillance Vs Immediate EVAR Randomised Control Trial Trial involving 20 approved European/Western Asian hospitals 4.1-5.4cm Asymptomatic AAA Patients Enrolled between 2004- 2008 378 participants

18. CAESAR trial Inclusion criteria: Exclusion criteria: AAA 4.1-5.4cm diameter 50-79 years of age Suitable for EVAR by CT scan Minimum 5 year Life Expectancy Severe comorbidities Suprarenal/Thoracic aorta ≥4.0cm Needed Urgent Repair Unable or unwilling to give informed consent or follow the protocol

19. Method Surveillance Group: 6/12 U/S Scan 1 yr CT Indications for progression to Repair: Aneurysm grew to 5.5cm Rapid increase in Diameter Became Symptomatic EVAR Group: Graft Standardised: Zenith AAA Endovascular Graft Follow up: 6/12 U/S + Clinical Exam 1 yr Abdo X Ray + CT scan CT mandatory for Aneurysmal Diameter and suitability for EVAR before Randomisation as well as follow up

20. Estimates of All Cause Mortality in EVAR vs Surveillance Groups

21. Estimated Probability of Delayed Repair in Surveillance Group

22. months3652 41-44mm23.3%- 45-49mm57.6%76.1% 50-54mm90%95% Cumulative probability for Aneurysmal Repair in 3 Groups based on Size at Presentation

23. Results Rupture rate below Annual Rate of 1%: Surveillance: 2 Ruptures 5.6cm & 5.5cm Had been Scheduled for EVAR Aneurysm Related Mortality: EVAR: 1 Surveillance: 1 16.4% Surveillance Group Lose Eligibility for EVAR Positive Association with Delayed Repair: Absence of Diabetes Absence of Peripheral Vascular Disease Predictor for Delayed Repair: Large Aneurysm Diameter Absence of Hypertension under Medical Management All Cause Mortality Determined to be Insignificant EVAR 14.5% Vs Surveillance 10.1%

24. Discussion Surveillance provides a Safe Alternative Management for AAA 4.1-5.4cm Requires Accurate Imaging and Close Monitoring EVAR suitability before and after Randomisation left at Discretion of Participating Centres Need to Optimise Best Medical Management: Only 47% on statin Peri-Operative risk: 0.55% EVAR Vs 5.8% Open repair (UKSAT)

25. Cochrane Review for Surgery for Small Asymptomatic AAAs: Metanalysis of Long Survival for Asymptomatic AAA 4-5.5cm 3,314 Patients Randomised Controlled Trials: Open: UKSAT, ADAM EVAR: CAESAR, PIVOTAL Comparing Immediate AAA Repair Vs. Surveillance

26. Conclusion The studies Indicate no Long Term Benefit between the Control Groups and does not favour Immediate EVAR The Surveillance control group showed better Survival Rates in the Early Stages due to the 30 day Post-Operative Period. 31-75% Surveillance Group eventually require Repairs ~60% Require Repair within 1 year Review Illustrates need for more Information on Patient Demographics so Surveillance can be performed appropriately for Sub Groups based on Age, Gender, Aneurysm Morphology