WHEN TO REFER
1. Refer all patients to vascular at initial detection of asymptomatic abdominal aortic aneurysm (AAA – aortic diameter 3cm or greater) unless they meet the exclusion criteria
The vascular team will arrange further surveillance scanning and follow-up as appropriate.
2. Refer acute symptomatic AAA or suspected rupture (any size AAA) as a surgical emergency to on-call surgical or vascular registrar; admit via 999.
Symptoms of AAA rupture/leakage include unexplained abdominal and/or back pain, pulsating pain/sensation in abdomen, or distal embolization.
Note: Symptoms of expanding/leaking AAA may be mistaken for renal colic – have a high index suspicion with first ever presentation of renal colic in male over 50.
If your male patient has a first degree male relative with AAA, refer for an abdominal USS (not to vascular) when he is 50y, and then every 5 years until he enters the screening programme at 65y, unless he meets the referral to vascular criteria sooner.
WHEN NOT TO REFER
- If the aorta is 2.5-2.9cm at the initial USS there is no need for follow up (except in first degree male relatives)
- Do not refer if the patient is under palliative/end of life care.
- Do not refer to vascular for follow up if the patient’s AAA has been detected by the link National AAA Screening Programme . They will follow up the patient and refer to vascular when the AAA reaches 5.5cm. However if GP has concerns AAA is becoming symptomatic then refer to vascular.
MANAGEMENT IN PRIMARY CARE
- Refer acutely symptomatic AAA or suspected rupture as emergency to on-call vascular team via 999
- When referring asymptomatic patient with AAA to vascular, please include in referral letter:
- mode of presentation, age of patient, BMI
- examination findings eg pulsatile mass, femoral and popliteal pulses
- past medical history eg. CKD, IHD, hypertension, NIDDM etc
- medications eg anti-coagulants etc
- copy of USS report
- up-to-date UE (within 6 weeks)
- ABPI is helpful but not essential
3. Initiate secondary prevention (antiplatelet (aspirin or clopidogrel) and atorvastatin 20mg), manage hypertension and strongly encourage smoking cessation
NATIONAL SCREENING PROGRAMME
The NHS invites men for AAA screening during the year they turn 65. Once he has entered the screening programme, the patient have all further follow up and/or referral to vascular arranged by the screening service.
Please note, if a man has already been diagnosed with an AAA, he will be excluded from this screening programme. He will have been referred to vascular for surveillance as above.
Men over 65y who have not been screened can arrange a screening appointment by contacting their local programme directly:
The Peninsula AAA Screening Service covers Cornwall, Isles of Scilly, Plymouth and parts of Devon (Tavistock, Lifton, Ivybridge,
Yelverton, Modbury and Wembury).
Screening takes place in the community in a mixture of Community Hospital and GP Practices.
0800 970 8700 (patients)
or 01752 764859
Tamar View Industrial Estate
Saltash PL12 6LE
The USS takes about 10 minutes.
If the aorta diameter is 3-4.4cm, the patient will be called for annual surveillance.
If the aorta is 4.5-5.4cm, the patient will be called for 3 monthly scans.
When the AAA reaches 5.5cm, the patient will be referred to the local vascular team by the screening programme.
Link for patient information leaflets re screening programme
-approximately 75% of infra-renal AAA are suitable for repair by EVAR (keyhole)
-average mortality with EVAR is 1%
-average mortality for open conservative repair or for complex fenestrated EVAR in suprarenal is 5-8%
- the risk of rupture increases with size, untreated hypertension and smoking
- 50% will die of AAA rupture if left untreated (but 50% won’t!)
-if someone ruptures their AAA out of hospital, mortality rate before they reach hospital is 50%
-if they reach hospital alive with a rupture, 50% will die in surgery or in the post-op period
-surgery for AAA may not always be appropriate or possible. This is one of the reasons why the vascular team like to make the initial assessment and counselling of the patient.
-suprarenal AAA repairs go to Bristol, Birmingham or St George’s (London)