Why A National AAA Screening Programme Is Essential?Posted on: 06 June 2008 by Gareth Hargreaves
Vascular surgeon, Matthew Waltham, explains why an Abdominal Aortic Aneurysms (AAA) screening programme is essential.
As the Government’s plans to implement health checks for the over 40s come under scrutiny, vascular surgeon Mr. Matthew Waltham, who is implementing an AAA screening programme in Southwark and Lambeth, explains why a national AAA screening programme is important.
What Is AAA?
The Government’s plans for health screening the over 40s received a mixed reception. Detractors argued that the plans have not been fully evaluated, far less approved by the National Screening Committee, and that the practicalities of implementing a programme have not been thought through. They may be right on many counts, however, there is one element of screening which has been widely researched and proven to be worthwhile - screening for Abdominal Aortic Aneurysms or AAA.
Seven percent of British men over 65 have an aortic abdominal aneurysm and, for men, it is the 12th most common cause of death, although the true figures are somewhat hidden since most home deaths of men over 65 are attributed to heart attacks when many could be from AAA ruptures.
At present, screening is not generally offered to patients, even those at high risk. If an aneurysm is picked up, usually if a patient is treated or screened for other conditions, then depending on its size, the patient will either be operated on immediately or monitored. Elective surgery to repair an aneurysm carries good odds, with chances of survival at around 95%.
Many aneurysms are undetected until they rupture. In this instance the overall chances of survival are slim: between 6% - 22% survive, with 50% dying before they even make it to hospital.
Screening is relatively simple; all that is involved is a straightforward ultrasound scan, which can detect an aneurysm. A number of local centres across the UK have already begun to screen patients. This has resulted in an increase in the number of people diagnosed with aneurysms and a reduction in the number of people dying from rupture.
The most recent study, the Multicentre Aneurysm Screening Study (MASS) published in the Lancet, evaluated the screening process in over 67,000 men aged 65 - 74 in a randomised controlled trial. According to Prof. Martin Buxton, a leading UK health economist at Brunel University and one of the trialists, “the result provided clear evidence to support the cost effectiveness of this particular form of screening for elderly men.” Put simply, the screening saved enough lives and was simple enough a process to make it worthwhile.
Moving It Forward
I approached Guy’s and St. Thomas’ Charity for a grant to start a local screening programme in the London boroughs of Southwark and Lambeth, covering the population served by Guy’s and St Thomas’ NHS Foundation Trust.
The charity has provided funding for a 3-year screening programme, which will be implemented across Southwark and Lambeth. All 65-year old men in the area will be invited to be screened. This will be done either at GP practices or at Guy’s and St. Thomas’.
From the GP’s point of view, all they have to do is agree for patients to partake in the programme and where possible make a room available where the simple ultrasound can take place. All equipment and staff are provided as part of the charity’s grant. If the ultrasound shows that an aneurysm over 5cm is present, the patient will be referred to the vascular team at Guy’s and St. Thomas’ for further assessment and to plan repair if appropriate.
Aneurysms under 5cm are not deemed to be an immediate risk and are put on a surveillance programme of repeat ultrasound scanning. 65 is the optimum age to perform screening - there are few occurrences of rupture before that age and if anyone is to have an aneurysm at risk of rupture in the future, the aneurysm will most likely already be present at 65.
Benefits To Both Patients & GPs
The benefits for patients are clear. A national screening programme will ensure that patients benefit from reduced mortality from aneurysm rupture. It will also be cost-effective as screening will afford consultants and patients the luxury of time, so they can decide when is best to have a repair operation.
The alternative is often to be rushed to hospital following a rupture, which requires a 24-hour emergency operating suite and is thus very expensive. A patient who has undergone a rupture will also need more intensive care levels and their recovery can take days, if not weeks or longer.
The most common treatment for AAA is to undertake an open repair, however, a growing number of consultants now offer endovascular repair (EVAR), which is less invasive.
It is carried out via two cuts to the groin, and is possible with a new range of smaller, more flexible stent grafts, such as those offered by device companies like Cook Medical. Since it requires only regional anaesthetic, it incurs less risk and a shorter recovery time – both a big plus point for the patient and the hospital.
EVAR also offers the possibility of treatment to some patients whose circumstances mean that they would not otherwise be candidates for repair. There are also four hospitals which offer emergency 24-hour EVAR for ruptured aneurysms – Belfast, Liverpool, Newcastle and Guys and St Thomas’.
The role for GPs is vital, not simply to provide a screening venue, but also to help raise awareness of this silent killer and to support those at risk. GPs should also be able to advise patients – most of whom will be men as it’s five times more likely to hit males than females – on what treatment options are available.
The London screening programme has just started in Southwark and Lambeth – we’ve already detected our first aneurysm. The first targets to receive invitations to be screened will be men aged 65, but the programme is also open to both men and women over 65, as it aims to provide a comprehensive screening scheme to the affected population.
For further infomation on the Circulation Foundation visit www.circulationfoundation.org.uk.
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