Abdominal Aortic Aneurysm

ABDOMINAL AORTIC ANEURYSMS

Abdominal Aortic Aneurysm

ABDOMINAL AORTIC ANEURYSMSABDOMINAL AORTIC ANEURYSMS

Did you know one of the greatest minds in history succumbed to

AAA?

JK WICKS



Albert Einstein diedfrom an abdominal aortic aneurysm, a type of vascular disease that affects more than 700,000 people in Europe.



Abdominal Aortic Aneurysms:

An expanding problem?

Mr JK Wicks, FRACS (vasc)



What is an Abdominal Aortic Aneurysm (or AAA)?

Normal aortaAorta with an abdominal aneurysm

• An Abdominal Aortic Aneurysm (AAA) is a permanentlocalized dilatation of the abdominal aorta.

• The disorder is conventionally diagnosed if the aortic diameter is 30 mm or more.

• Or increase in size ofVessel 1 and half times normal diameter

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Why are AAAs a serious healthcare issue?

• An estimated 80 million people aged 60 years and older are at risk in Western Europe.

• AAA is the 12th leading cause of death in Western societies.

• It is a silent killer because there are often no symptoms that an aneurysm is developing in the abdominal aorta.

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Epidemiology

• Incidence of AAA is estimated between 4% and 8% of the male population aged 65 years or older.

• Comparatively, it is between 0.5% and 1% in females of the same age.

• Incidence of AAA has been estimated as a result of large screening programs.

• Incidence is growing as the population is aging.

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Pathophysiology of a AAA

• Pathological changes in the aortic wall:

– Inflammatory process

– Causing breakdown of elastic elements in media

– Decrease tensile strength

– Leading to expansion



Pathophysiology of a AAA – risk factors

• Main risk factors are

– Male

– Smoking history

– Hypertension

– Family history

– Increasing age

– Atherosclerosis

– COPD

– Infection/inflammation

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Pathophysiology of a AAA – aneurysm growth

• AAA growth:

– Expansion tends to be highly variable

– AAA growth accelerates with the diameter of the AAA

– Aneurysm growth is influenced by risk factors

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Types of AAA

• Morphological Classification• True aneurysm

• Fusiform aneurysms• Saccular aneurysms

• Pseudo-aneurysms

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Why is early diagnosis of AAA so important?

• The operative mortality of treating a ruptured aneurysm is 80%

• For elective AAA cases, the operative mortality rate is drastically reduced, approximately only 2-7% of cases result in death.

• AAA ruptures can be avoided by identifying the population at risk and conducting simple and inexpensive ultrasound examinations.

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If untreated, the AAA may rupture

When the aneurysm diameter reaches 5cm, the risk of rupture is generally considered to be higher than the operative risk.

0

Risk of rupture for untreated

aneurysm within 5 years (%)

10

70

60

40

50

30

20

80

25%35%

75%

Aneurysm Size5-5.9cm 6-7cm >7cm

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Why do you have a decisive role in preventing AAA ruptures?

• You are the first to see the patient.

• No national or international AAA screening program is in place today, except in the U.S.A.

• A simple ultrasound examination easily detects aneurysms.

Click here to see the press release

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How can you diagnose a AAA?

• Clinical features

– Majority are asymptomatic

– Symptomatic can present with spectrum

• Physical examination:

– With palpation, pulsating mass in the middle of a patient’s abdomen

– However, you may miss up to 80% of AAA if the diagnosis is limited to physical examination.

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• Ultrasound scan has proven to be a reliable and cost-effective way to diagnose a AAA.

– It is an extremely sensitive test for all AAA sizes.

– It is painless andnon-invasive.

– It is cost-effective.

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• An additional benefit of ultrasound examination is that you may help diagnose other vascular diseases:

– Carotid artery disease (CAD)

– Renal artery disease

– Peripheral artery disease (PAD)




Who are the patients at risk?

• AAA primarily affects people over 60 years old and are more common in men than in women.

• Other main risk factors include:

– Smoking history

– Hypertension

– Family history of AAA



What if a AAA is diagnosed?

• Clinical practice suggests that:

Table based on protocols used in various AAA patient screening programs.Follow-up recommendations may vary. Please contact your vascular specialist for more information.

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Aneurysm diameter Follow-up action

Less than 4cm Recall annually

More than 4cm and less than 5cm Recall every 6 months

More than 5cm or symptomatic

or growing by more than 1cm per yearEndovascular or surgical management



2 Treatment options

Endovascular Stent GraftingOpen Surgery



Open surgical repair: advantages

• Aneurysm opened, graft sewn in, aorta wrapped and closed around graft

• Established procedure (with more than 40 years of clinical experience)

• Excludes aneurysm and prevents sac growth

• Proven, long-term results



Open surgical repair: drawbacks

• Significant incision in the abdomen

• 30–90 minute cross-clamp

• Up to 4-hour procedure

• Contraindicated in some patients

• 1–2 days intensive care5-7 days hospitalization4–6 weeks recovery time

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Open surgical repair: drawbacks

• Many patients considered “unfit” :

– High anesthesia risk

– Significant co-morbidities

– Previous abdominal surgery/hostile abdomen

• Difficult recovery for patient:

– Risks losing independence

– High perioperative morbidity

– 5% risk of mortality

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Endovascular stent grafting: advantages

• Benefits

• Minimally invasive

• Reduced risk of death

• Faster recovery

• Improved functional outcomes

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Endovascular stent grafting: drawbacks

• Drawbacks

– Complications and re-interventions:

• Endoleaks

• Stent graft migration

• Modular dislocation

– Most complications are benign and treatable by endovascular techniques.

– New stent graft generations are associated with fewer complications.45

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Endovascular stent grafting

• Morphology suitable for endovascular repair

• Adequate vascular access

• Appropriate landing zones

• Tortuosity, calcification, thrombus

– Precise sizing

• 3mm CT scan slices

– Good imaging equipment in the lab or in the operating room



Typical patient follow-up

• Following open surgery:

– Ultrasound every year for patients treated via open surgery

• Following endovascular stent grafting:

– Plain X-ray and CT scan at 6 months and then annually for patients treated with an endovascular stent graft

his is only indicative information. Follow up protocols and procedures may differ according to physician’s practice.




Which treatment for which patients?

• Case by case basis

• Endovascular stent grafting should be proposed to all AAA patients who:

• Are 70 yrs or older,

• And have an anatomy compatible with stent graft repair.

• Open surgery should be proposed to all patients fit for open repair or those who refuse EVAR and are fit for open repair.

• In patients with comorbidities who are unsuitable for open surgery, endovascular stent graft repair may be but balanced against life expectancy.

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Learning points

Who are the patients at risk of AAA?

• Predominantly males

• 60 years old or older

• Smoking history

• Hypertension

• Family history of AAA



Learning points

• The risk of rupture

– Only 18% of patients with a ruptured AAA survive.

– Operative mortality in elective cases is less than 5% with open surgery and less than 2% with endovascular repair.

– It is important to diagnose AAA as early as possible.

What is the main risk associated with an Abdominal Aortic Aneurysm?



Learning points

What should I do with a patient at risk?

• An ultrasound examination may be performed or prescribed to check the presence of a AAA. Palpation is not effective with all patients.



Learning points

What if an aneurysm is found by the ultrasound exam?

• Clinical practice suggests that:

If the AAA diameter <4cm

If the AAA diameter >4cm and <5cm

If the AAA diameter >5cmor if the AAA is symptomatic

or growing by more than 1cm per year

recall annually

recall every 6 months

Surgical or endovascular treatment

Table based on protocols used in various AAA patient screening programs.Follow-up recommendations may vary. Please contact your vascular specialist for more information.

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Health & Medicine

Abdominal Aortic Aneurysm