Screening Guidelines and Treatment

Options for Abdominal Aortic Aneurysms

Dr. Mohd Mazri Yahya

Consultant General, Vascular and Endovascular Surgeon
Johor Specialist Hospital
 HISTORY

 Early 1800- first operations on the aorta due to syphilis

 1817 – sir Astley Cooper ligated the aortic bifurcation in a 38y.o man
with ruptured iliac artery aneurysm. The patient died soon after
operation.
 Keen, Tillaux, Morris and Halstead reported similar attempt without
patient survival in the 100 years following Cooper’s initial report
 1923 – Matas, chief surgeon at Tulane University successfully ligate
the abdominal aorta with survival of his patient. In all operated >600
aorta with low morbidity and mortality
 The eventual development of synthetic grafts propelled aortic surgery
to its current maturity
 DeBakey’s introduction of knitted Dacron in 1957 allowed widespread
application of the prosthetic graft
 Definition

 Abdominal aortic aneurysm (AAA) is defined as

an aortic diameter of greater than 3 cm and its
incidence increases with age.
 Clinical Presentation

• Most AAA quiescent until rupture

• Rarely Abd. pain or back pain
• New pain and tenderness indicate recent
expansion
• Thromboembolism to lower extremities
• Ruptured AAA: Triad of Abd. or back pain,
hypotension, and pulsatile Abd. mass
 Physical Examination

• 30% of asymptomatic AAA discovered during

routine PE
• Pulsatile large Abd. mass
• Sensitivity of PE 22-96%
Risk Factors for AAA (OR)
 Smoking (odds ratio 5.57)
 Male sex (4.56)
 Positive family history (1.95)
 White versus black race (2)
 Atherosclerosis (1.5)
 Hypertension (1.2)
 (Diabetes) (0.54)
 Age, height, hyperlipidemia also associated but smoking-related
risk explained 78% of all AAA found in this study of 73,451
patients.

(Odds Ratios From Aneurysm Detection and Management (ADAM) Veterans Affairs
Cooperative Study Group, Ann Inter Med 3/97)
 Prevalence

Figure 1. Prevalence of abdominal aortic aneurysm 4.0 cm or

larger in men by age and smoking history. Data adapted from
Lederle et al. (28).
Prevalence of Abdominal Aortic Aneurysms 3.0
cm or Larger in Veterans 50 to 79 Years of Age

Lederle, F. A. Ann Intern Med 2003;139:516-522

 Natural History: Rate of Increase

 0.19 cm per year for aneurysms 2.8 to 3.9 cm in

baseline diameter.

 0.27 cm per year for those 4.0 to 4.5 cm in

baseline diameter.

 0.35 cm per year for those 4.6 to 8.5 cm in

baseline diameter
.
 Rate of increase is more rapid in smokers.
(Estimates of 20-25% increase in rate).
 Natural History: Risk of Rupture

 Very low in aneurysms less than 4.0 cm in

diameter.

 5 percent for those 4.0 to 4.9 cm in diameter.

 25 percent for those 5.0 to 5.9 cm in diameter.

 35 percent for those 6.0 to 6.9 cm in diameter.

 75 percent for those 7.0 cm in diameter.

 AAA-related Mortality

• 13th leading cause of death

in US

• Documented 15K but

likely up to 30k deaths per
year

• Mean F/U of 8 years

 Natural History: Surgical Intervention

 Elective repair is considered for aneurysms

that are:
 Bigger than 5.5cm
 Increasing by >0.5cm in 6months
 Symptomatic
 Mortality With AAA Repair

 Elective repair of AAA is performed with

mortality rates averaging less than 5%.

 In the presence of a ruptured AAA the surgical

mortality is 50-80%.
 Intermediate Size AAA (4-5.5 cm)

UK Small Aneurysm trial

• Randomized 1090 Pt. to

surgery vs. US
surveillance every 6
months
• Operative mortality 5.4%

• Mean F/U of 8 years

Lancet 1998
 Intermediate Size AAA (4-5.5 cm)

US ADAM Study

• Randomized 1136 Pt. to

surgery vs. US
surveillance every 6
months
• Operative mortality 2.7%

• Mean F/U of 5 years

Lederle et al., NEJM 2002

 Why Screen for AAA at All?

 It’s estimated that only 18% of patients with ruptured

AAA reach a hospital and survive surgery.

 An AAA usually enlarges over time and once 5 cm in

diameter the risk of rupture is 25-41% over 5 years.

 It is the tenth most common cause of death for an

individual over 55. (About 9000 deaths/yr in the US).
 BACKGROUND AND RATIONALE

 Screening first reported in 1966 by Schilling et al

 Using PE and lateral abdominal radiography
 26 AAA of 3.6cm in 873men 55-64y.o (3.1%)

 Cabellon et al in 1983
 Using PE and abdominal ultrasound
 7 AAA of 73 asymptomatic patients with
vascular disease (5.3%)

 Since then being accepted practice in some

country
 BACKGROUND AND RATIONALE

 The idea is appealing

 Must be undertaken with caution

 The risks and costs apply to many but the
benefits affect few
 Criteria for an acceptable screening program

1. The disease must have a significant effect on the quality and

quantity of life
2. Acceptable methods of treatment must be available
3. The disease must have an asymptomatic period during which
detection and treatment significantly reduce morbidity,
mortality or both
4. Treatment in the asymptomatic phase must yield a therapeutic
result superior to that obtained by delaying treatment until
symptoms appear
5. Test must be available at reasonable cost to detect the
condition in the asymptomatic period
6. The incidence of the condition must be sufficient to justify the
screening
 Screening Modalities

 Palpation
 Abdominal ultrasound
 CT
 MRI
 Palpation

 Varying results but one study (Annals March 01) showed:

 Sensitivity of 68%
 Specificity of 75%

 Sensitivity increases with size of aneurysm (82% for 5

cm or more)

 Sensitivity decreases with obesity. (in 12 out of 99

patients with AAA who had waist of less than 40 inches
and AAA > 5cm the sensitivity was 100%)
 ABDOMINAL AORTIC
ANEURYSM THE EXAM

METHOD
THE PATIENT’S ABDOMEN SHOULD BE
RELAXED WITH THE KNEES FLEXED.
THE EXAMINER FEELS CEPHALAD OF
THE UMBILICUS FOR THE AORTIC
PULSATION.
PLACE BOTH HANDS ON THE ABDOMEN
WITH THE INDEX FINGER ON EITHER
SIDE OF THE PULSATING AORTA.
ESTIMATE THE WIDTH ( NL <2.5CM IN
WIDTH).

JAMA 1999;281:77-81
BATES 8TH ED, 2003
 Ultrasound Screening

 Simple and Safe

 No radiation
exposure
 Sensitivity and
specificity are nearly
100%
 Cost-Effective
 Effectiveness of Screening

 Four randomized trials of AAA screening done since the

last USPSTF recommendation, including more than
125,000 men, have now reported results of up to 5 years
of follow-up.

 Deaths related to AAA were reduced by 28 to 68%.

 Largest of the four was the Multicentre aneurysm

screening study (MASS).

 These trials are reviewed in depth in Annals Sept 2003

article.
 MultiCentre Aneurysm Screening Study
(MASS) (Nov. 02)

• Population based study of 67,800 men aged 65-74 with

random allocation to Abd. US
• Objective: to assess the cost effectiveness of ultrasound
screening for AAA.
• Yearly US for AAA> 3 cm and surgery for AAA> 5.5cm or 1
cm progression within 1 year
 Death due to AAA was reduced 42% in the screening group.
(elective repair if > 5.5cm)
 Total of 47 fewer deaths in screening group
 Over 4 years the cost was about 45,000$ /year gained.
This is expected to go down with time.

MASS: BMJ 2002

 Patient Selection

 For screening to be
efficient, it must
target the population
 Most important
factors
 Gender – Men:
women 4:1
 Age
 Smoking
 Repeated Screening

 Several screening programs have addressed

this. (Annals Sept. 2003).

 The yield is very low (0.1% in one study of 2622

veterans).

 Repeat screening is not recommended based on

the results of these studies.
 Screening in Women
 A randomized trial of 9342 women (Br J Surg 2002)
has shown the incidence of rupture at 5 and 10
years was the same for the screened and
control groups of women.

 There has been no evidence that screening in

women is effective.
 Current Recommendations by USPSTF

 One-time AAA screening with ultrasound for

men 65 – 75 y.o who have ever smoked

 Made no recommendation for men who had

never smoke

 Recommended against routine screening for

AAA in women
 Future Directions

 Primary care specialists could start using

personal ultrasound imagers to screen during
the preventative exam.
 AAA Screening by Internists

 If we should be screening for AAA then we

should be proactive about getting that
screening for our patients.
 We can afford an ultrasound imager for limited
exams in our clinics.
 We can learn to use it easily.
 We can be ahead of the curve, when screening
is recommended.
 AAA Screening by Internists

 A study in J Gen intern med (Dec 2001) showed

that primary care residents were able to
achieve an abdominal aortic ultrasound-
independent competence level after an average
of 3.4 proctored exams.
 Follow-up Surveillance

 Aortic diameter <3 cm — no further testing

 Aneurysm 3 to 4 cm — annual ultrasound

 Aneurysm 4 to 4.5 cm — ultrasound every six months

 Aneurysm >4.5 cm — referral to a vascular specialist

Society for Vascular Surgery

 Conclusions

 Many large AAA remain undetected until

rupture and many small AAA that will never
rupture are detected incidentally.

 Recent evidence have demonstrated a

substantial reduction in AAA related mortality
from ultrasound screening.
Thank you