Transcript Endovascular Stenting for Aortic Aneurysms

Aneurysms & Aneurysm
Screening
Mr Marcus Cleanthis
Consultant Vascular Surgeon
Frimley Park Hospital
Aortic Aneurysms
• Most common in men over 65 who smoke and
are hypertensive
• Are treated when above 5.5 cm
• Can be treated by open surgery or stenting
Abdominal Aortic Aneurysms
Aorta larger than 1.5
times its normal
diameter
Or
aorta
exceeds 3 cm in
diameter
Clinical findings
Examination picks up only 40- 50% of AAA
False positive diagnosis in thin individuals
Low accuracy for size estimation
60% found on radiological imaging
a fifth of them not palpable on examination
Clinical Presentation
Most are asymptomatic, found on scanning or examination
Back pain
Abdominal pain ( suspect inflammatory aneurysm)
Distal embolisation
Aneurysm thrombosis ( rare)
Primary aorto-duodenal fistula ( rare)
Mis-Diagnosis
Initial Diagnosis
Misdiagnosed Cases, %
Average Delay, h
Renal colic
24
15
Diverticulitis
13
79
GI hemorrhage
13
17
Acute MI
8.7
13
Back pain
8.7
18
Motor vehicle accident
6.5
1.5
Sepsis
6.5
26
Other GI problem
6.5
4
Other/no diagnosis
13
18
Rupture risk
<40mm <1% per yr
40-55mm 1% per yr
55-79mm 10% per yr
>70mm 25% per yr
Risk factors for rupture
Larger size
>55mm
Rapid expansion >10mm/yr
Hypertension
Smoking
COPD
Female sex
Treatments
Open Surgical Repair
EndoVascular Aneurysm Repair (EVAR)
Open aneurysm treatment
• ENDOVASCULAR ANEURYSM REPAIR
(EVAR)
Minimal invasive aortic aneurysm repair
through an endoluminal approach via a
remote artery.
Endovascular Aneurysm Repair
•Minimally invasive
•Reduced morbidity
•Reduced mortality
•Less post-op pain
•No/minimal ITU/HDU
•Reduced hospital stay
Endovascular
Aneurysm
Repair
Technique
Cook Zenith Stentgraft
Aorto-uni-iliac Graft
EVAR I Trial
30-day mortality EVAR I 1.7%
TREATMENT THRESHOLD
AAA diameter
• 5.0cm? 5.5cm? 6.0cm?
• UK Small Aneurysm Trial
UK Small Aneurysm Trial
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1090 patients, Aged 60-76years, Fit
Asymptomatic 4.0 – 5.5cm AAA
Randomised: Early Surgery/Surveillance
Mean FU 4.6years
Statistical analysis: Intention to Treat
Primary endpoint: death
UK Small Aneurysm Trial
UK Small Aneurysm Trial
• No difference in mortality in two groups
• Cost analysis: surveillance cheaper
• Conclusion: AAA <5.5cm should be managed
conservatively
Aneurysm Screening
UK AAA Screening
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Men aged 65 and over are eligible for AAA screening
The NHS invites men for AAA screening during the year
they turn 65
Men over 65 who have not been screened previously
can arrange a screening appointment by contacting
their local programme directly
• Screening involves an ultrasound scan that takes
around 10 minutes
• The NHS AAA Screening Programme aims to reduce
deaths from ruptured AAA amongst men aged 65 and
over by up to 50%
Gloucestershire Aneurysm Screening
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25,000 ultrasound invitations
85% attendance
Costs approx. £10 per scan
99% imaging success
1% of aortas >4cm diameter
Gloucestershire Aneurysm Screening
• Most rupture occurred in the 15% of patients
who DNA’d
• Incidence of aneurysm rupture in the
screened group reduced by 85%
(Scott et al Br J Surg 1995)
MASS Results
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80% of screened group accepted invitations
1333 aneurysms detected
65 aneurysm-related deaths invited group
113 aneurysm related deaths control group
42% risk reduction in invited group
53% risk reduction in those screened
Elective mortality 6%
Emergency surgery mortality 37%
MASS Results
Summary
• Treatment for AAA :
– greater than 5.5cm
– growth 1.0cm /12months
– Tender AAA (inflammatory….)
– Rupture AAA