1. Aortic Aneurysm Screening
Willy Pillay
Endovascular Surgeon

2. 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

3. 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)

4. 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 ( ), 3/12 ( )
Follow-up 4.6 year (mean)
Doncaster Vascular Centre

5. 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

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

7. 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

8. MASS Multicentre Aortic Aneurysm Screening Study
2002, Lancet
67800 males (65-74yr)
Invited for US screening or control
annual/ mthly
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

9. 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

10. 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 cm
?women
?2nd scan at 75yr if US<3.0cm
Doncaster Vascular Centre

11. Doncaster Vascular Centre
Mass (2)
Doncaster Vascular Centre

12. 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 , 3 OCT 2012 DOI: /bjs

13. 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 , 3 OCT 2012 DOI: /bjs

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

15. 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/ , but screening planned only for men=65!)
Over 20 years ( 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

16. 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

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

18. 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

19. 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

20. 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%