Updates on Abdominal Updates on Abdominal aortic aneurysmaortic aneurysm

Yvonne TsangYvonne Tsang

North District HospitalNorth District Hospital

AneurysmAneurysm

ανευρυσμαA permanent and irreveA permanent and irreve

rsible localized dilatatirsible localized dilatation of a vesselon of a vessel

Aorta with an infrarenal diameter > 30mAorta with an infrarenal diameter > 30mmm

McGregor JC. The value of ultrasonography in the diagnosis of abdominal aorMcGregor JC. The value of ultrasonography in the diagnosis of abdominal aortic aneurysm. tic aneurysm. Scott Med J 1975;20:133—37Scott Med J 1975;20:133—37

Infrarenal diameter should be 1.5 times tInfrarenal diameter should be 1.5 times the expected normal diameterhe expected normal diameter

The Society for Vascular Surgery and the International The Society for Vascular Surgery and the International Society for the Cardiovascular Surgery in 1991Society for the Cardiovascular Surgery in 1991

EpidemiologyEpidemiology

PrevalencePrevalence1.3 - 8.9% in men 1.3 - 8.9% in men 1.0 - 2.2% in women1.0 - 2.2% in women

Rupture of abdominal aortic Rupture of abdominal aortic aneurysmsaneurysms8000 death per year in UK8000 death per year in UK15 000 death per year in US15 000 death per year in US

Overall mortality rate of ruptured AAAOverall mortality rate of ruptured AAA65 – 85%65 – 85%

HistopathologyHistopathology

Fragmentation of elastic fibresFragmentation of elastic fibresDecrease in concentration of elastin Decrease in concentration of elastin Reduction in the density of smooth musReduction in the density of smooth mus

cle cellscle cells Baxter BT et al. Elastin content, crosslinks, and mRNA in normal and aneBaxter BT et al. Elastin content, crosslinks, and mRNA in normal and ane

urysmal human aorta. urysmal human aorta. J Vasc Surg 1992;16;192-200J Vasc Surg 1992;16;192-200 Sakalihasan N et al. Modifications of the extracellular matrix of aneurysSakalihasan N et al. Modifications of the extracellular matrix of aneurys

mal abdominal aortas as a function of their size. mal abdominal aortas as a function of their size. Eur J Vasc Surg 1993;7;Eur J Vasc Surg 1993;7;633-37633-37

DiagnosisDiagnosis

Bimanual palpationBimanual palpation Sensitivity increases with diameterSensitivity increases with diameter

61% for 3.0 – 3.9 cm61% for 3.0 – 3.9 cm69% for 4.0 – 4.9 cm69% for 4.0 – 4.9 cm82% for >= 5.0 cm82% for >= 5.0 cm

Fink HA. The accuracy of physical examination to detect abdominal aortic Fink HA. The accuracy of physical examination to detect abdominal aortic aneurysm. aneurysm. Arch Intern Med 2000;160;833-36Arch Intern Med 2000;160;833-36

UltrasonographyUltrasonographyAccuracy of 3 mmAccuracy of 3 mmFor initial assessment,For initial assessment,surveillance and screesurveillance and scree

ningning Quill DS. Ultrasonic screening fQuill DS. Ultrasonic screening f

or the detection of abdominal or the detection of abdominal aortic aneurysms. aortic aneurysms. Surg Clin NoSurg Clin North Am 1989;69;713-29rth Am 1989;69;713-29

Computed TomographComputed TomographyyVisualise the proximal nVisualise the proximal n

eck, the extension to the eck, the extension to the iliac arteries and the patiliac arteries and the patency of the visceral arterency of the visceral arteries.ies.

Measure the thickness of Measure the thickness of the mural thrombusthe mural thrombus

AngiogramAngiogramCT / MRACT / MRA

Clinical presentationClinical presentation

UnrupturedUnrupturedGenerally asymptomaticGenerally asymptomaticAfter complicationsAfter complications

RupturedRupturedTriadTriadRetroperitoneal spaceRetroperitoneal space

Indications for treatmentIndications for treatment

Indication for surgical treatment deduceIndication for surgical treatment deduceddEstimated risk of ruptureEstimated risk of ruptureEstimated risk of surgical procedureEstimated risk of surgical procedureEstimated life expectancyEstimated life expectancy

Rigorous surveillance of intrarenal aortiRigorous surveillance of intrarenal aortic aneurysms < 5.5cm is safec aneurysms < 5.5cm is safe

The UK Small ameurysm trial Participants. Mortality results for randomiThe UK Small ameurysm trial Participants. Mortality results for randomized controlled trial of early elective surgery or ultrasonographic surveillzed controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. ance for small abdominal aortic aneurysms. Lancet 1998;352;1649-55Lancet 1998;352;1649-55

Risk of elective aneurysm Risk of elective aneurysm repairrepair

Varies among hospital and surgeonsVaries among hospital and surgeonsMean 30-day mortality 1.1 – 7%Mean 30-day mortality 1.1 – 7%Risk factorsRisk factors

Renal failureRenal failureCOADCOADMyocardial ischaemiaMyocardial ischaemia

coronary artery revascularisation bcoronary artery revascularisation before surgery?efore surgery?

Benefit remains controversialBenefit remains controversial Simultaneous aneurysm repair and coronary rSimultaneous aneurysm repair and coronary r

evascularisation recommended in selected paevascularisation recommended in selected patienttient

El-Sabrout RA. Outcome after simltaneous abdominal arotic aneurysm repair and coronary El-Sabrout RA. Outcome after simltaneous abdominal arotic aneurysm repair and coronary bypass. bypass. Ann Vasc Surg 2002;16;321-30Ann Vasc Surg 2002;16;321-30

RCT > no significant difference in long-term ouRCT > no significant difference in long-term outcome when coronary artery revascularisation tcome when coronary artery revascularisation undertaken before elective surgeryundertaken before elective surgery

McFalls EO. Coronary-artery revascularisation before elective major vascular sMcFalls EO. Coronary-artery revascularisation before elective major vascular surgery. urgery. N Eng J Med 2004;351;2795-804N Eng J Med 2004;351;2795-804

Risk of emergency repair for Risk of emergency repair for ruptured aneurysmruptured aneurysm

5 preoperative risk factors predict mort5 preoperative risk factors predict mortalityality

Age > 76Age > 76Creatinine > 190 umol/LCreatinine > 190 umol/LHaemoglobin < 9 g/dLHaemoglobin < 9 g/dLLoss of consciousLoss of consciousECG evidence of ischaemiaECG evidence of ischaemia

Risk factorsRisk factors mortality mortality33 100 10022 48 4811 28 2800 18 18

Prance SE. Ruptured abdominal aortic aneurysms: selected Prance SE. Ruptured abdominal aortic aneurysms: selected patients for surgery. patients for surgery. Eur J Vasc Endovasc Surg 1999;17;129-3Eur J Vasc Endovasc Surg 1999;17;129-322

ManagementManagementsurgery vs endovascular repairsurgery vs endovascular repair

Endovascular repairEndovascular repairIntroduced by Parodi in 1Introduced by Parodi in 1

991991Placement of a graft acroPlacement of a graft acro

ss the aneurysm and the fss the aneurysm and the fixation to the normal arotixation to the normal arotic and iliac wall with stentic and iliac wall with stents at both endss at both ends

EVAR trial 1EVAR trial 1

Lancet 2005;365;2179-86Lancet 2005;365;2179-86Randomized controlled trial of 1082 Randomized controlled trial of 1082

patient aged >=60 with aneurysm patient aged >=60 with aneurysm >= 5.5cm>= 5.5cm

Referred to one of 34 hospitals Referred to one of 34 hospitals proficient to EVARproficient to EVAR

EVAR (n=543) or open repair EVAR (n=543) or open repair (n=539)(n=539)

Higher number of complications and reiHigher number of complications and reinterventions in EVARnterventions in EVAR

Significance difference the aneurysm-relSignificance difference the aneurysm-related mortality at 4 yearsated mortality at 4 years

4% in EVAR vs 7% in open repair4% in EVAR vs 7% in open repairEVAR higher cost and longer follow upEVAR higher cost and longer follow upAfter 4 years, all-cause mortality did not After 4 years, all-cause mortality did not

differdiffer

EVAR trial 2EVAR trial 2

Lancet 2005;365;2187-92Lancet 2005;365;2187-92Patients unfit for open repairPatients unfit for open repairRandomized controlled of 338 Randomized controlled of 338

patients aged >= 60 years with patients aged >= 60 years with aneurysms >= 5.5 cmaneurysms >= 5.5 cm

Referred to one of 31 hospitals in UKReferred to one of 31 hospitals in UKEVAR (n=166) or no intervention EVAR (n=166) or no intervention

(n=172)(n=172)

30-day operative mortality in EVAR was 30-day operative mortality in EVAR was 9%9%

No significant differenceNo significant differenceAll-cause mortalityAll-cause mortalityAneurysm-related mortalityAneurysm-related mortality

ConclusionsConclusionsEVAR did not improve survivalEVAR did not improve survivalNeed for continued surveillance and reinterNeed for continued surveillance and reinter

ventions > increased costventions > increased cost

Emergency endovascular repair for Emergency endovascular repair for ruptured abdominal aortic ruptured abdominal aortic

aneurysmsaneurysms

First reported by YusuFirst reported by Yusuf et al in 1994f et al in 1994

Yusuf SW et al. EmergencYusuf SW et al. Emergency endovascular repair of ly endovascular repair of leaking aortic aneursym. eaking aortic aneursym. Lancet 1999;344;1645 Lancet 1999;344;1645

Retrospective reviewsRetrospective reviewsImprove early outcomesImprove early outcomesShorter ICU stayShorter ICU stay

Brandt M. Endovascular Repair of Ruptured Abdominal Aortic Aneurysm:Brandt M. Endovascular Repair of Ruptured Abdominal Aortic Aneurysm: Feasibility and Impacy on Early Outcome. Feasibility and Impacy on Early Outcome. J Vasc Interv Radiol 2005;16;1J Vasc Interv Radiol 2005;16;1309-12309-12

Patients associated with heavy comorbiPatients associated with heavy comorbidities > no difference in mid-term motalidities > no difference in mid-term motalityty

Non-invasive prevention of Non-invasive prevention of growth and rupturegrowth and rupture

Stop smoking reduces the growth of aneStop smoking reduces the growth of aneurysmurysm

Brady AR. Abdominal aortic aneurysm expansion: risk factors and time intervaBrady AR. Abdominal aortic aneurysm expansion: risk factors and time intervals for surveillance. ls for surveillance. Circulation 2004;110;16-21Circulation 2004;110;16-21

Tetracycline prevents aneurysm growthTetracycline prevents aneurysm growth Baxter BT. Prolonged administration of doxycycline in patient with small asyBaxter BT. Prolonged administration of doxycycline in patient with small asy

mptomatic abdominal aortic aneurysms: report of a prospective multicenter mptomatic abdominal aortic aneurysms: report of a prospective multicenter study.study. J Vasc Surg 2002;36;1-12 J Vasc Surg 2002;36;1-12

ββ--blockers blockers reduce the growth rate of large (>5cm) aneurysm reduce the growth rate of large (>5cm) aneurysm

and even to lessen the sizeand even to lessen the size Gadowski GR. Abdominal aortic aneurysm expansion rate: effect of size aGadowski GR. Abdominal aortic aneurysm expansion rate: effect of size a

nd beta-adrenergic blockade. nd beta-adrenergic blockade. J Vasc Surg 1994;19;727-31J Vasc Surg 1994;19;727-31 Slaiby JM. Expansion of arotic aneurysms is reduced by propranolol in a Slaiby JM. Expansion of arotic aneurysms is reduced by propranolol in a

hypertensive rat model. hypertensive rat model. J Vasc Surg 1994;20;178-83J Vasc Surg 1994;20;178-83

no effect on growth rate of small aneurysmsno effect on growth rate of small aneurysms Propranol Aneurysm Trial Investigators. Propranolol for small abdominal Propranol Aneurysm Trial Investigators. Propranolol for small abdominal

aortic aneurysms; results of a randomized trial. aortic aneurysms; results of a randomized trial. J Vasc Surg 2002;35;72-79J Vasc Surg 2002;35;72-79

StatinsStatinsReduce expansion of various inflammatory moleReduce expansion of various inflammatory mole

culesculesLong term use reduced mortality after surgeryLong term use reduced mortality after surgery

Kertai MD. Association between long-term statin use and mortality after sKertai MD. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. uccessful abdominal aortic aneurysm surgery. Am J Med 2004;116;96-103Am J Med 2004;116;96-103

conclusionsconclusions

Marked progress in past few decadesMarked progress in past few decadesDiagnosisDiagnosisManagementManagementTiming of interventional treatmentsTiming of interventional treatmentsAssessment of endovascular repair vs conventioAssessment of endovascular repair vs conventio

nal surgerynal surgeryWhat comes next?What comes next?

The EndThe End

Thank youThank you