Abdominal Aortic Aneurysm

Sean Tierney,

Consultant Vascular Surgeon

Adelaide & Meath National Children’s Hospital,

Tallaght

http://www.perfuse.netVascular surgery @ Tallaght

The problemThe problem

• Population survey (n=7887)

• Chichester, UK• Aneurysm >3cmScott et al. Br J Surg 1995

Age Men Women65 5.9 0

66-70 5.9 171-75 9 1.876-80 9.2 1.6

Total (>65y) 7.6 1.3

% prevalence

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PrevalencePrevalence

Prevalence • all 65-80 yo = 4%1

• elderly males = 5-9%2

• only 40% reach criteria for surgery

Mortality• Males = 1.4% of all death >55 years• Females = 0.5% >55 yearsNetherlands 19903

1 Scott BJS 1991

2 Hak EJVES 1996

3 Pleumeekers EJVS 1994

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PrognosisPrognosis

Szilagyi 1966

0

10

20

30

40

50

60

70

<6cm >6cm

Aneurysm size

Surgery

Observation

% 5 year survival

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Law of Laplace (sphere) P =2T/R

0

20

40

60

80

<5cm 5.0-5.9cm >6.0-6.0cm >7.0cm

5 year risk of rupture

Aneurysm size

RisksRisks

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Presentation - rupturePresentation - rupture

Blood loss

Blood Pressure

Minutes…

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Presentation - rupturePresentation - rupture

Blood loss

Blood Pressure

Hours

Retroperitoneal irritation Collapse

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Rupture - outcomeRupture - outcome

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Other presentationsOther presentations

incidental

symptomatic

embolisation

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Conventional repairConventional repair

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Conventional repairConventional repair

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Conventional repairConventional repair

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Aortic Aneurysm repairAortic Aneurysm repair

• DuBost – first homograft repair 1951

• Modern graft materials 1953

Postoperative• 5 year survival = 63-84% disease matched control

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Problem solved?Problem solved?

%Mortality 4.9Cardiac 0.0

MI 5.3LVF 6.2

Renal 5.7Respiratory 6.9Others 4.0

Rutherford Vascular Surgery 1995

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New technologyNew technology

Parodi et al Ann Vasc 1991

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EVAREVAR

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ProblemsProblems

• Implantation– microembolism– blood loss– endoleak

• Device related– kinking– migration– stent fracture– graft failure/porosity

• Endoleak

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EVAR - 1 EVAR - 1 OutcomesOutcomes

****

Lancet 2004; 364: 843–48

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EVAR - 1 EVAR - 1 OutcomesOutcomes

Lancet 2004; 364: 843–48

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DurabilityDurability

0

20

40

60

80

100

0 1 2 3 4 5

Years

Fre

edo

m f

rom

rei

nte

rven

tio

n

Eurostar BJS 2000

Cumulative reintervention rate > 10% per year

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EVAR - 2 EVAR - 2 OutcomesOutcomes

Lancet 2005; 365: 2187–92

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Technical limitations (EVAR)Technical limitations (EVAR)

• Neck– length– diameter– thrombus– angulation

• Iliac artery– size– tortuosity– aneurysms (esp bilateral)

At least 1/3 (33%) anatomically unsuitable

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Place for EVARPlace for EVAR

IndicationsIndications• still unresolved issues• anatomical suitability• older vs younger• ? high risk patient• significant costs

• Complement rather than replaces open surgery

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ScreeningScreening

Screened ControlTotalUptake 80%AAA 5%>5.5cm 0.60%

AAA mortality 3.3/1000 1.9/1000OR

33400

0.58 (0.42-0.78)* *p<0.001

Screened ControlTotalUptake 80%AAA 5%>5.5cm 0.60%

AAA mortality 3.3/1000 1.9/1000OR

33400

0.58 (0.42-0.78)* *p<0.001

Lancet 2002; 360: 1531–39

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Cost effectiveCost effective

• Cost of screening £63 per patient

• Cost-effectiveness ratio:– £28,400 per life year gained (4

years)– c£8,000 (10 years).

Lancet 2002; 360: 1531–39