Abdominal Aortic Aneurysm

Background

Aneurysm rupture must be suspected in patients >50 years old presenting with sudden onset back pain/ or collapse. If in any doubt then 999 should be called for transfer to nearest emergency department.

Red Flags

Patients with an asymptomatic but rapidly expanding AAA (>5mm over 6 months) should he referred urgently via Vascular Surgery RAS (see below).

All patients with suspected symptomatic AAA should be discussed  immediately via the on call vascular team at NBT.

If a ruptured AAA is suspected (classic triade of hypotension, abdominal pain or back pain and a pulsatile abdominal mass) then call 999 and liaise with on call vascular team at NBT.

Connective tissue disease (i.e Marfan's syndrome) is associated with increased risk of thoracic or abdominal aortic aneurysm. Patients should be regularly screened but if any symptoms (e.g. chest pain or abdominal pain or collapse) then call 999 for transfer to local emergency department.

Asymptomatic AAA

Patients who are diagnosed with asymptomatic AAA incidentally (outside of screening program) or via a GP led investigation should be referred to the local vascular clinic (see referral section below). These patients cannot be referred into the screening program.

Local vascular surgeons advise the following management depending on size of the aneurysm:

Patients with asymptomatic AAA between 3.0 and 5.4cm should be referred for a routine appointment with the Vascular Clinical Nurse Specialist (CNS) clinics that run across the network (refer via eRS - see referral section below for details). This means that these patients receive a similar standard of care to patients with screen detected aneurysms. The CNS will talk to them about the diagnosis, look for other arterial disease and provide advice on exercise, lifestyle and cardiovascular risk reduction. The patient will be entered into surveillance under a named vascular surgeon. If their AAA grows to 5.5 cm they will be seen by the surgeon within 2 weeks to discuss repair. Some patients will have a second CNS review at 5.0 cm when surveillance moves to 3 monthly.

Patients with asymptomatic AAA 5.5 - 8.9cm should be referred urgently to the Vascular Surgery team (see referral section below for details).

Patients with asymptomatic AAA >9.0cm should be referred immediately to on call vascular team via NBT switchboard (0117 9505050).

Referral

Many patients with vascular disease require emergency or urgent specialist care (see page 4 of the Directory below). Such patients should be referred as per these pathways by telephone, referapatient® or NHS e-RS RAS. The specialist service during periods of ‘surge’ will be consultant led and referrals for advice are welcomed. Patients are at risk of life or limb loss or stroke when urgent vascular intervention is deferred.***

Referrals for asymptomatic AAA < 3.0 - 5.4cm diameter

Refer for a routine appointment with the Vascular Clinical Nurse Specialist (CNS) clinics  via eRS

Referrals for asymptomatic AAA 5.5 - 8.9cm diameter

Refer urgently to Vascular Surgery Triage service at NBT via eRS. Referrals are reviewed on a daily basis by the vascular team and booked into the Vascular HOT Clinic if appropriate (do not send via Referral Service to avoid any potential delays). Patients with AAA between 5.5 to 7cm will be triaged to clinic slots within 2 weeks. Patients with AAA greater than 7cm will be seen on the next working day.

Clinics are held in Southmead, BRI, WGH & Bath RUH. Referrals will be triaged on  a daily basis by the vascular team and booked into appropriate clinics.

Referrals for asymptomatic AAA >9.0 cm

Refer immediately to the on call vascular team via NBT switchboard (0117 9505050).

Screening Program

 An abdominal aortic aneurysm (AAA) is defined as an enlargement of the aorta of 3cm or greater in diameter ( NICE (February 2009). Endovascular stent-grafts for the treatment of abdominal aortic aneurysms. )

The national AAA screening program for England invites men to have screening in the year that they turn 65.  Men older than 65 who have not been screened can also self-refer into the screening program.  Please refer to the AAA screening website for information leaflets.

Tel: 0117 414 8610 or email: aaascreening@nbt.nhs.uk

Men who have an AAA identified via the screening program will be monitored within the program or referred directly to a vascular clinic if appropriate.

Resources

Please see the local Vascular Directory of Services

Also, the Vascular services - For clinicians page on the NBT website for further information or contact vascularnurses@nbt.nhs.uk

These resources may support the uptake of AAA screening in people with learning disabilities:

• Reducing inequalities in AAA screening
• Easy Read leaflet
• Easy Read initiation letter
• Somali easy read guide for Abdominal Aortic Aneurysm

If you need support or advice and guidance about supporting a patient with a learning disability, contact the Adult Learning Disability Health Service on 0300 124 5888 or sirona.bcldtadviceline@nhs.net

You can also view the population screening timeline poster with contact details for Bristol, North Somerset and South Gloucestershire.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.