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AAA Before the Bubble Bursts

AAA Before the Bubble Bursts

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AAA Before the Bubble Bursts. 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. O/E: Abd SNT Tender, Expansile , Pulsatile Mass - PowerPoint PPT Presentation

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Page 1: AAA Before the Bubble Bursts

AAABefore the Bubble Bursts

Page 2: AAA Before the Bubble Bursts

June ‘XXPresents to Beaumont A&E c/o Abdominal Pain B/G: Known AAA

Radiating through to the backConstant for 24 hrsVomit x 6Fever, MalaiseNo Hx of

Haemoptysis PR Bleed G.I Symptoms

Page 3: AAA Before the Bubble Bursts

O/E:Abd SNTTender, Expansile , Pulsatile MassNo 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

Page 4: AAA Before the Bubble Bursts

Work up for Differential Dx

General Surgical ConsultOGD: NormalPFA: Normal Glasgow EMRIE Score: 0Ultrasound Abd: Normal

Page 5: AAA Before the Bubble Bursts

SummaryB/G Hx: Known AAATender Central MassHaemodynamically StableAll other differentials have been out ruled

Impression: Symptomatic AAA

Page 6: AAA Before the Bubble Bursts

What would you do next?

Page 7: AAA Before the Bubble Bursts

CT Aortic Angiogram

Page 8: AAA Before the Bubble Bursts

Plan1. Admit Patient2. Analgesia3. DVT Prophylaxis4. CT Aortic Angiogram:

AAA- 4.5cm No Evidence of Leakage or Rupture No Evidence of Retroperitoneal Bleed

5. EVARPatient Discharged 3/7 Post-Op

Page 9: AAA Before the Bubble Bursts

EVAR Completion Angiogram

Page 10: AAA Before the Bubble Bursts

Indications for AAA Repair

Page 11: AAA Before the Bubble Bursts

Standard Practise AAA Repair is performed when:

Diameter >5.5cmSymptomatic Ruptured AAAThe presence of other Large Vessel AneurysmsRapid Rate of Expansion

Treatment Options: EVAROpen Repair

Page 12: AAA Before the Bubble Bursts

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%

Page 13: AAA Before the Bubble Bursts

UKSAT TrialFirst 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

Page 14: AAA Before the Bubble Bursts

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

Page 15: AAA Before the Bubble Bursts

Overall Survival

Page 16: AAA Before the Bubble Bursts

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

Page 17: AAA Before the Bubble Bursts

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

Page 18: AAA Before the Bubble Bursts

CAESAR trialInclusion 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

Page 19: AAA Before the Bubble Bursts

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

Page 20: AAA Before the Bubble Bursts

Estimates of All Cause Mortality in EVAR vs Surveillance Groups

Page 21: AAA Before the Bubble Bursts

Estimated Probability of Delayed Repair in Surveillance Group

Page 22: AAA Before the Bubble Bursts

months 36 52

41-44mm

23.3% -

45-49mm

57.6% 76.1%

50-54mm

90% 95%

Cumulative probability for Aneurysmal Repair in 3 Groups based on Size at Presentation

Page 23: AAA Before the Bubble Bursts

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%

Page 24: AAA Before the Bubble Bursts

DiscussionSurveillance provides a Safe Alternative

Management for AAA 4.1-5.4cmRequires 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)

Page 25: AAA Before the Bubble Bursts

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, ADAMEVAR: CAESAR, PIVOTAL

Comparing Immediate AAA Repair Vs. Surveillance

Page 26: AAA Before the Bubble Bursts

ConclusionThe 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