Aortic Diseases
Elliot L. Chaikof, MD, PhD
Roberta and Stephen R. Weiner Department of Surgery
Beth Israel Deaconess Medical Center
Harvard Medical School
Clinical Practice
Council of the SVS
AAA Practice Guidelines
Writing Committee
Elliot L. Chaikof, MD, PhD
David C. Brewster, MD
Ronald L. Dalman, MD
Michel S. Makaroun, MD
Karl A. Illig, MD
Gregorio A. Sicard, MD
Carlos H. Timaran, MD
Gilbert R. Upchurch, Jr., MD
Frank J. Veith, MD
Prevalence of Aortic Aneurysm
• Prevalence of AAA among women is
slowly increasing, with women now
representing 1/3 of patients presenting
with rupture.
Circulation 2011; 124:1118-1123
AAA (> 3 cm)
in 1.7% of
26,000 65 y/o
men screened
Annual Open AAA and EVAR in US:
1993 - 2005
45000
40000
35000
30000
TOTAL
OPEN
25000
20000
15000
EVAR
10000
5000
0
1993
1995
1997
1999
2001
Schermerhorn M et al. JVS 2009; 49(3):543-50
2003
2005
Lancet 2002; 360: 1531–39
Community-based screening reduces
mortality from an AAA in men aged 65–79
years, but are not cost effective in women
in whom the prevalence of AAAs is lower
Jonk YC, Kane RL, Lederle FA, MacDonald R, Cutting AH, Wilt TJ.
Int J Technol Assess Health Care 2007;23:205-15.
All Markov modeling studies published to
date have predicted higher lifetime costs
associated with EVAR
SVS Clinical Decisions for
Patients with Aortic Disease
1. Comparative effectiveness of OR vs EVAR
•
•
•
Ascending and arch aortic aneurysms
Thoracoabdominal aneurysms
Acute or Chronic Type B aortic dissections
2. Optimal treatment of AAA between 5 – 6 cm
3. Optimal surveillance regimens after EVAR
Bending the cost curve
$7,300 per capita in US in 2008
• Selective screening and surveillance
• Selective repair
• Reducing costs for EVAR or
OSR
Reduce
Reduce Per
Capita Costs
Unnecessary
Interventions
Screening Abdominal Aortic Aneurysms Very
Efficiently (SAAAVE) Act 2006
•Who
A one-time
qualifiesAAA
for the
US Medicare
screening screening?
as part of a
InWelcome
2009, 20,000
Medicare
patients
were
to
Medicare
physical
exam.
•screened
Men who out
haveof
smoked
sometime
during
their
life
200,000 in the US at risk
•• The
must
be aconducted
duringofthe
first
Menphysical
and women
with
family history
AAA
12 months of enrollment.
Risk Factors for Aortic Aneurysms
• Smoking is the single strongest risk
factor for the development of AAA
• AAA risk increases by 40% every 5
years after the age of 65 years
• Men are at much higher risk of AAA
than women
• Central obesity increases risk
• A family history of AAA doubles the risk
of AAA
Risk factors for aortic aneurysms
do not correlate with many risk
factors for atherosclerosis • Hypertension is weakly associated with
AAA
• The relationship between hyperlipidemia
and AAA is complex
• Diabetes is protective of AAA formation
Nat. Genet. 40, 217–224 (2008)
Nat. Genet. 42, 692–697 (2010)
Who do we screen?
Ann Intern Med. 2005;142:203-211
British Medical J 2004; 329: 1259-1262
• Selective screening of high risk
groups
• Risk factor scores
J Vasc Surg 2005;41:741-51
Who should be enrolled in
continued AAA Surveillance
Should we follow aneurysms less
than 4 cm in diameter given their
low risk of rupture?
Br J Surg 90: 821-6, 2003
• 12 yr analysis of 1121 AAA in 65 yr-old men
• 2.6 cm < AAA < 2.9 cm
• 14% > 5.4 cm at 10 years
• 3.5 cm < AAA < 3.9 cm
• 10.5% > 5.4 cm and 1.4% had
ruptured at 2 years
Biomarkers for AAA Disease
Management of the Small AAA
Immediate EVAR vs. Surveillance
4.0 cm < AAA < 5.4 cm
Has the balance of risk
and benefit changed
with EVAR?
CAESAR Small AAA Trial:
Immediate EVAR vs. Surveillance
360 patients
180 pts Surveillance
180 pts EVAR
Mean f/u 26 mos.
236 pts EVAR
15 pts OSR
102 pts Surv.
• Aneurysm-related mortality
(0.6% vs 0.6%; p=1)
• 30-day mortality
(1% vs 0%; p=1)
• Aneurysm rupture
(0% vs 0.2%; p=0.2)
CAESAR Trial at 3 Years:
Immediate EVAR vs. Surveillance
• 76/180 (42%) patients in the
surveillance group underwent repair
• The probability of receiving AAA
repair over a 3-yr study interval was
• > 50%
> 4.5 cm
• 32/180 (18%) underwent open surgery
because of loss of EVAR suitability
Crossover Effect in Trials of
AAA Treatment vs Observation
• UK SAT: 62% (327/527) crossed
over during a 5-year follow-up period.
• ADAM: 62% (351/567) crossed over
during a 5-year follow-up period.
• Crossovers related to subjective
‘symptoms’ or patient preference.
Patient Perspective with a
Small AAA
The question is not…
“if” EVAR should be performed
but “when”…
Pharmacological Strategies to
Prevent AAA Expansion or Rupture
• b-blockers
and ACE
inhibitors
The
Non-Invasive
Treatment
of Abdominal
Aortic
• Tetracycline
Aneurysmand
Clinical
macrolide
Trial antibiotics
(N-TA3CT)
• Anti-platelet
agents 248 patients
NIH
Funded Trial - Randomize
• Statins
Determine if doxycycline (100 mg bid) will inhibit
by 40% the increase in diameter of small AAA
Surg 2002;
36: 1-12
(3.5-5.0 cm in men, 3.5-4.5 cmJ Vasc
in women)
over
a
24-month period.
Clinical Trials to Assess Risk and the
Benefit of Medical Intervention
• Inflammation and Risk Prediction in Patients
With AAA (Vanderbilt, PI: U. Sampson )
– predicting risk using FDG-PET with CT
• Study on Anti-inflammatory Effect of Antihypertensive Treatment in Patients With
Small AAA's and Mild Hypertension (VU
University, PI: Jan D. Blankensteijn)
– Aliskiren and Amlodipine
Clinical Trials to Assess Risk and the
Benefit of Medical Intervention
• Evaluation of Effect of ACE Inhibitors
(perindopril) on Small Aneurysm Growth
Rate
– (Imperial College, PI: Neil R Poulter)
• Feasibility Study of Exercise Training
for AAA Disease
– (Sheffield Teaching Hospitals/University
of Hull)
Morbidity of Open and EVAR AAA
Repairs: 1995 - 2008
Schermerhorn M et al. NEJM 2008; 358:464-474.
Risk Models for Elective EVAR or
Open AAA Repair
• Risk models that incorporate physiological
and anatomical data (APACHE II, GAS,
POSSUM).
• Improved tools to assess likelihood of
aneurysm expansion and rupture risk among
high risk patients.
• Interventions to reduce postoperative
morbidity (e.g. cardiac, pulmonary, renal)
N Engl J Med 2007;357:2277-84
Doubling
in less
than a
decade
Number of CT scans/yr in US
Lifetime Cancer Risk/Abdominal CT
J Vasc Surg 2009;49:60-5
• 406 paired CT/US examinations
• Sensitivity for Duplex ultrasound was 86%
• All clinically significant endoleaks demonstrated on
CTA were also detected on Duplex ultrasound
US vs CTA for Surveillance
After EVAR
• Contrast Ultrasound in the Surveillance
of EVAR (n = 160)
– Ottawa Hospital Research Institute, PI:
Sudhir Nagpal
• CT Versus Color Duplex US for
Surveillance of EVAR. A Prospective
Multicenter Study (n = 1000)
– Centre Hospitalier Universitaire de Nice, PI:
Hassen-Khofja Reda