Aortic Aneurysms Optimum Re Underwriting Seminar Dallas 2015

Aortic Aneurysms Optimum Re Underwriting Seminar Dallas 2015 Jean-Marc Fix, FSA, MAAA VP R&D

Thanks • • Dr. M. Nguyen Dr. Z. Sasson Dr. F. Sestier and Dr. A. Khoury

Agenda • • • Anatomy of the aorta Aneurysm definition Thoracic aortic aneurysm Abdominal aortic aneurysm Case studies

Anatomy of the Aorta Source : clevelandclinic. org

Definition of Aneurysm • Local dilatation of the aorta o by over 50% over the normal diameter and o involving all three layers of the vessel (intima, media and adventitia) • Abdominal aneurysm more common than thoracic

Morphology of Aneurysm • Fusiform: symmetrical • Saccular: pouch

Cause • A weakening of the aortic wall o Trauma or infection o Defect in aortic walls proteins o Age

Consequences • Expansion • Rupture • Death

Distribution by Age ORIC all aneurysms 30 Number of cases 25 20 15 10 5 0 25 -34 35 -44 45 -54 55 -64 Issue Age 65 -74 75 -85

Mortality by Age From Pharmaceuticalintelligence. com but specifics of chart not clear

Thoracic Aortic Aneurysm • • Epidemiology Etiology Treatment Mortality and rating

TAA Epidemiology • Incidence 6 -10/100, 000 • Prevalence 0. 16 -0. 34% for 5 cm+ undetected • Most common your 60 s and 70 s • Males 2 -4 times more than female • 13% have multiple aneurysm • 20 -25% of large TAA also have AAA Source : GA Kuzmik et al Natural history of thoracic and aortic aneurysm, J Vasc Surg 2012 56: 565 -571, EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Anatomy • Ascending (between aortic valve and innominate artery) 60% • Aortic arch 10% • Descending (distal to left subclavian artery) 40% • Thoracoabdominal 10% • (more than I segment possible) Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Causes • Most often cystic medial degeneration (increases with age) • Marfan syndrome • Familial TAA Syndrome • Bicuspid aortic valve (have a fibrillin defect) • Atherosclerosis (mostly for descending TA, maybe secondary) [ZS 5 a] Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Causes • • Syphilis Turner syndrome Aortic arteritis (Takaysu’s and giant cell) Aortic dissection Trauma (often deceleration injuries) Ehlers-Danlos syndrome Rheumatoid and psoriatic arthritis Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Clinical Manifestation • 95%+ asymptomatic • Sometimes mass may create compression of trachea or main bronchus, esophagus or laryngeal nerve • Rarely back or chest pain • Rupture: abrupt onset of severe pain Source : GA Kuzmik et al Natural history of thoracic and aortic aneurysm, J Vasc Surg 2012 56: 565 -571, EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Diagnosis • CT scan or MRI • In Marfan’s especially, transthoracic echo (good only for the root) Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

Dimensions of the Thoracic Aorta Evangelista A et al. Eur J Echocardiogr 2010; 11: 645 -658

TAA Imaging CT Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Imaging CT -2 Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Imaging MRI Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

TAA Natural History • Aorta loses flexibility when reaching 6 cm and can’t absorb extra blood pressure • Ascending aorta grows by 0. 10 cm a year • Descending aorta grows by 0. 29 cm a year • Familial TAA grows faster

TAA Natural History • Rupture is key danger o 41% reach hospital alive o Perioperative mortality 23 -29% • Non emergency surgical mortality 35%

TAA Management • Surveillance • Surgery

Treatment • Surgical repair o Open o Endovascular

TAA Repair NO Size 3. 5 -4. 4 cm Size 5. 5 cm or + Growth 0. 5 cm/yr Symptomatic Size 4. 5 -5. 4 cm YES Surgical candidate CAD/Valve issue YES Annual CT/MRI NO NO Semi-annual CT/MRI Valve/ CABG + aneurysm repair Aneurysm repair

Types of Surgery • Open surgery • Endovascular aneurysm repair

Pros and Cons • Open repair (from the 1950 s) o Pros: stable, handle any aortic geometry o Cons: invasive, circulation stopped, higher perioperative mortality and complications (x 2 EVAR) • EVAR (from the 1990 s) o Pros: less invasive, faster recuperation o Cons: less stable in time, need conducive aortic geometry, follow-up and reintervention may be needed

EVAR Follow-Up • Need CT scan 30 days after operation • Done in about 1/3 cases! • Then annual imaging Source : T Garg Adherence to postoperation surveillance guidelines after endovascular aortic repair among Medicare beneficiary, Stanford School of Medicine 2012(? ) 111: 816 -828

TAA Rating Factors • Pre surgery o Growth rate o Size o Age • Post surgery o Age o Type of surgery o Time since surgery

Abdominal Aortic Aneurysm • • Epidemiology Etiology Treatment Mortality and rating

AAA Epidemiology • Much more common • Aneurysm 4 cm+ in 1% of men ages 55 -64 and increase by 2 -4% per decade • Incidence rise rapidly after age 50 for men and 70 for women • Less common in women Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828 JT Powell Small abdominal aortic aneurysm < NEJM 2003 348: 1895 -1901

AAA Causes and Risk Factors • • • Smoking Hypertension Hyperlipidemia Atherosclerosis Family history (could increase risk by 30%, younger age, more likely to rupture) • Males 10 times more likely to have aneurysm>4 cm than females Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828 W Tang et al Association between middle age risk factors and risk of asymptomatic AAA (ARIC study )Circulation 2014 129: AP 341

AAA Clinical Manifestation • Mostly asymptomatic • Found incidentally • If pain , it is usually below the stomach or in the lower back • If abrupt violent back pain and tender or painful abdomen -> ER Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

AAA Diagnosis • May be detected by palpation • Ultrasound prefer detection modality • CT scan and CT angio better for sizing and therefore for follow-up • Size by CT is 3 -9 mm greater than by ultrasound (depending on the aneurysm size) Source : EM Isselbacher Thoracic and aortic aneurysm, Circulation 2005 111: 816 -828

AAA Natural History • Rupture is also key danger o 25% die before reaching the hospital o 51% die prior to surgery o 46% of those having surgery die! • Elective is best and combine with aortic valve surgery if needed

AAA Natural History • Rupture is more frequent o In smokers o In hypertensive o In fast growing aneurysm

AAA Management • Surveillance frequency depends on size o 4. 0 -4. 4 cm every 2 years o 4. 5 -4. 9 cm every year • Surgery o When 5. 5 cm+ o When growth of 10 mm+/year Source : 2014 European Society of Cardiology guidelines on the diagnosis and treatment of artic diseases

Pros and Cons for AAA Trial 30 days mort. Long term mort. EVAR/Open EVAR 1 1. 8%/4. 3% 23. 1%/22. 3% (4 y) DREAM 1. 2%/4. 6% 31. 1%/30. 1% (6 y) OVER 0. 5%/3. 0% 7. 0%/9. 8% (2 y) Medicare 1. 2%/4. 8% 34. 0/34. 3% (5 y) • EVAR has short term advantage but does not seem to sustain that advantage over open surgery longer term. Why is still unclear! Source : Table 1 A Schanzer & L Messina Two decades of endovascular aortic aneurysm repair: enormous progress with serious lessons learned, J Am Heart Assoc 2012 1: e 000075

AAA Screening • Medicare covers one abdominal ultrasound for adults age 65+

AAA Rating Factors • Pre surgery o Growth rate o Size o Age • Post surgery o Age o Type of surgery o Time since surgery