june ‘xx presents to beaumont a&e c/o abdominal pain b/g: known aaa radiating through to the...
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AAABefore 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
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
Work up for Differential Dx
General Surgical ConsultOGD: NormalPFA: Normal Glasgow EMRIE Score: 0Ultrasound Abd: Normal
SummaryB/G Hx: Known AAATender Central MassHaemodynamically StableAll other differentials have been out ruled
Impression: Symptomatic AAA
What would you do next?
CT Aortic Angiogram
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
EVAR Completion Angiogram
Indications for AAA Repair
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
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%
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
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
Overall Survival
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
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
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
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
Estimates of All Cause Mortality in EVAR vs Surveillance Groups
Estimated Probability of Delayed Repair in Surveillance Group
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
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%
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)
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
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
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