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Management Strategies for Symptomatic Abdominal Aortic Aneurysm: Insights from Recent Trials

This document presents a detailed case study of a patient with a known abdominal aortic aneurysm (AAA), highlighting symptoms, diagnostic workups, and management strategies, including surgical options like EVAR and traditional open repair. The discussion draws upon the latest clinical trials comparing surveillance versus immediate intervention for small asymptomatic AAAs, and the indications for surgical repair based on aneurysm diameter and symptoms. It aims to provide a comprehensive understanding of contemporary practices in managing AAA, emphasizing the importance of individualized patient care.

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Management Strategies for Symptomatic Abdominal Aortic Aneurysm: Insights from Recent Trials

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  1. AAABefore the Bubble Bursts

  2. June ‘XX • Presents to Beaumont A&E c/o Abdominal Pain • B/G: Known AAA • Radiating through to the back • Constant for 24 hrs • Vomit x 6 • Fever, Malaise • No Hx of • Haemoptysis • PR Bleed • G.I Symptoms

  3. O/E: • Abd SNT • Tender, Expansile , Pulsatile Mass • No 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

  4. Work up for Differential Dx • General Surgical Consult • OGD: Normal • PFA: Normal • Glasgow EMRIE Score: 0 • Ultrasound Abd: Normal

  5. Summary • B/G Hx: Known AAA • Tender Central Mass • Haemodynamically Stable • All other differentials have been out ruled • Impression: Symptomatic AAA

  6. What would you do next?

  7. CT Aortic Angiogram

  8. Plan • 1. Admit Patient • 2. Analgesia • 3. DVT Prophylaxis • 4. CT Aortic Angiogram: • AAA- 4.5cm • No Evidence of Leakage or Rupture • No Evidence of Retroperitoneal Bleed • 5. EVAR • Patient Discharged 3/7 Post-Op

  9. EVAR Completion Angiogram

  10. Indications for AAA Repair

  11. Standard Practise • AAA Repair is performed when: • Diameter >5.5cm • Symptomatic • Ruptured AAA • The presence of other Large Vessel Aneurysms • Rapid Rate of Expansion • Treatment Options: • EVAR • Open Repair

  12. 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%

  13. UKSAT Trial • First 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

  14. 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

  15. Overall Survival

  16. 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

  17. 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

  18. CAESAR trial Inclusion 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

  19. 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 • CT mandatory for Aneurysmal Diameter and suitability for EVAR before Randomisation as well as follow up • EVAR Group: • Graft Standardised: Zenith AAA Endovascular Graft • Follow up: • 6/12 U/S + Clinical Exam • 1 yr Abdo X Ray + CT scan

  20. Estimates of All Cause Mortality in EVAR vs Surveillance Groups

  21. Estimated Probability of Delayed Repair in Surveillance Group

  22. Cumulative probability for Aneurysmal Repair in 3 Groups based on Size at Presentation

  23. Results • All Cause Mortality • Determined to be Insignificant • EVAR 14.5% Vs Surveillance 10.1% • 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

  24. Discussion • Surveillance provides a Safe Alternative Management for AAA 4.1-5.4cm • Requires 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)

  25. 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, ADAM • EVAR: CAESAR, PIVOTAL • Comparing Immediate AAA Repair Vs. Surveillance

  26. Conclusion • The 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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