Aortic Aneurysms

The largest artery in your body is named aorta. It is a tough, durable blood vessel, but sometimes its walls may become weak, and bulge. Such an abnormal bulging is called an aortic aneurysm and it may occur at any part of the aorta. Aortic aneurysm symptoms depend on the location of the bulge and may be missing in some cases. Aortic aneurysm treatment always aims to prevent aneurysm rupturing and includes in most cases 2 main options: monitoring and surgery. Below we are going to review this condition together with the symptoms it may cause, diagnostics services and aortic aneurysm treatment options available in more detail.

The most important muscle in your body is your heart. It will pump enough blood to fill about 3 supertankers during your lifetime . The aorta is the largest blood vessel in the body that helps to push all that blood along.

Sometimes, the walls of your aorta can weaken and bulge in what is called an aortic aneurysm. When that occurs, it causes a leak that spills blood into your body.

Some aortic aneurysms burst while some don’t. Other aortic aneurysm force blood flow away from your organs and tissues causing problems like heart attacks, kidney damage, stroke and even death.

What causes an aortic aneurysm?

The wall of the aorta is usually very elastic. It can stretch and shrink back as needed to adapt to blood flow. However, some medical problems such as high blood pressure and atherosclerosis (hardening of the arteries) may weaken the artery walls. These problems along with aging can result in a weak aortic wall that bulges outward.

There are 2 types of aortic aneurysms:

• Thoracic aortic aneurysm: Located in the chest. This aneurysm is a weakened area in the upper part of the aorta. A thoracic aortic aneurysm may also be called thoracic aneurysm and aortic dissection (TAAD) as an aneurysm can lead to a tear in the artery wall that may cause life-threatening bleeding.

  Small and slow-growing thoracic aortic aneurysms may not ever rupture. However, large and fast-growing aneurysms may rupture. Based on the size and growth rate of the aneurysm, treatment may vary from watchful waiting to emergency surgery. Ideally, surgery can be planned if necessary.

• Abdominal aortic aneurysm: Located in the abdomen. It is an enlarged area in the lower part of the aorta. This is the major blood vessel that supplies blood to the body. A ruptured abdominal aortic aneurysm can cause life-threatening bleeding as the aorta is the body’s main supplier of blood.

  Depending on the size and the rate of the aneurysm, treatment may vary from watchful waiting to emergency surgery. Once the aneurysm is found, doctors will monitor it closely so that surgery can be planned if it’s necessary. Emergency surgery for a ruptured abdominal aortic aneurysm can be risky.

AORTIC ANEURYSM SYMPTOMS

Thoracic aortic aneurysms normally grow slowly and usually without symptoms. This makes them difficult to detect. Some aneurysms will never rupture. Many aneurysms start small and stay small. Even though many expand over time. How quickly it may grow is difficult to predict. As it grows, some people may notice:

• Tenderness or pain in the chest
• Back pain
• Hoarseness
• Cough
• Shortness of breath

On the other hand, abdominal aortic aneurysms normally grow slowly and usually without symptoms. This makes them difficult to detect as well and some aneurysms will never rupture. Like thoracic aortic aneurysms, many start small and stay small and many of them expand over time while others expand quickly. Predicting how fast an abdominal aortic aneurysm may enlarge is difficult. Some people may notice the following symptoms an abdominal aortic aneurysm enlarges.

• A pulsating feeling near the navel
• Deep, constant pain in your abdomen or on the side of your abdomen
• Back pain

AORTIC ANEURYSM TREATMENT OPTIONS

The treatment goal is to prevent your aneurysm from rupturing. Your treatment options will normally be medical monitoring or surgery. The decision depends on the size of the aortic aneurysm and how the speed of growth.

Surgery (open or endovascular) is the definite treatment. Medical therapy is usually conducted for smaller aneurysms or for elderly, frail patients where the risks of surgical repair exceed the risks of non-operative therapy (observation alone).

Medical monitoring

If the aneurysm is small, medical monitoring may be recommended. This includes regular appointments to make sure your aneurysm isn’t growing and management of other medical conditions that could potentially worsen your aneurysm. You will also be asked multiple questions on the signs or symptoms you may be experiencing that could be related to the aneurysm.

A regular imaging tests is likely to be ordered to check on the size of your aneurysm. Expect to have an echocardiogram, CT scan or magnetic resonance angiography (MRA) at least 6 months after your aneurysm is diagnosed and then at regular follow-up exams and imaging tests after the first imaging test. The frequency of your imaging tests depends on whether the aneurysm is growing and the speed of growth.

Medications

Patients with thoracic aorta aneurysms may be offered this treatment option. It’s likely that your doctor will prescribe medications if you have high blood pressure or blockages in your arteries to lower your blood pressure and reduce your cholesterol levels to reduce the risk of complications from your aneurysm. They include:

• Beta blockers: It lowers your blood pressure by slowing down your heart rate. Beta blockers may reduce how fast the aorta is dilating in people with Marfan syndrome. Some examples of beta blockers include metoprolol (Lopressor, Toprol-XL), atenolol (Tenormin) and bisoprolol (Zebeta).
• Angiotensin II receptor blockers: These may be prescribed if beta blockers aren’t enough to control your blood pressure or if you can’t consume beta blockers. People with Marfan syndrome are recommended these medications even if they don’t have high blood pressure. Some examples of angiotensin II receptor blockers include losartan (Cozaar, Hyzaar), valsartan (Diovan) and olmesartan (Benicar).
• Statins: Help to lower your cholesterol which can help reduce blockages in your arteries and reduce your risk of aneurysm complications. Some examples of statins include atorvastatin (Lipitor), lovastatin (Altoprev), simvastatin (Zocor) and others.

Blood pressure goal is to lower it to less than 140/90 millimeters of mercury. It’s important that you quit if you smoke or chew tobacco as tobacco can worsen your aneurysm.

Surgery

Surgery is generally recommended if your aneurysm is about 1.9 to 2.4 inches (about 5 to 6 centimeters) and larger. Your doctor may recommend surgery for smaller aneurysms because you have a higher risk of having an aortic dissection if you have Marfan syndrome, a bicuspid aortic valve or a family history of aortic dissection.

Open chest surgery is the most common procedure done to fix this condition but in some cases, your doctor may determine if you’re a candidate for endovascular surgery depending on your condition and the location of your thoracic aortic aneurysm, you may be recommended to undergo:

• Open chest surgery: Repair a thoracic aortic aneurysm that involves removing the damaged section and replacing it with a synthetic tube (graft) that’s sewn into place. This surgery requires open abdominal or open chest surgery and will take a month or more to fully recover. You may have surgery to treat a section of the aorta that lies close to the junction of the aorta and the heart (aortic root) if you have Marfan syndrome or other related conditions. Your surgeon removes a section of your aorta and your aortic valve and replaces the section of the aorta with a graft in an aortic root replacement. A mechanical or biological valve replaces the aortic valve. Alternately, you may have valve-sparing aortic root repair. The enlarged section of the aorta is replaced with a graft and the aortic valve remains in place.
• Endovascular surgery: A synthetic graft is attached to the end of a catheter. It’s then inserted through an artery in your leg and threaded up into your aorta. The graft is placed at the site of the aneurysm and positioned with small hooks or pins. The graft reinforces the weakened section of the aorta to prevent the aneurysm from rupturing. This procedure generally has a faster recovery time compared to open chest surgery but endovascular surgery can’t be performed on everyone. Talk to your doctor to determine whether you’re a candidate for this procedure. After the surgery, regular follow-up imaging scans are required to ensure that the graft isn’t leaking.



• Other heart surgeries: If you have another condition and it’s contributing to your aneurysm development (such as a problem with your heart’s valves), additional surgeries will be recommended to repair or replace the damaged valves. Your doctor may recommend regular monitoring of your condition after receiving surgery.

Abdominal aneurysms treatment option may include:

• Open abdominal surgery: Open abdominal surgery to repair involves removing the damaged section of the aorta and replacing it with a graft that is sewn into place. The recovery time will generally take a month or more.



• Endovascular surgery: A less invasive procedure that’s used more frequently to repair an aneurysm. A synthetic graft to the end of a catheter and it’s inserted through an artery in your leg and threaded up into your aorta.

The graft is placed at the site of the aneurysm and is expanded. The graft is positioned in place with the metal mesh that usually has small hooks or pins. The graft reinforces the weakened section of the aorta to prevent rupture of the aneurysm.

Recovery time is normally a lot shorter compared to an open abdominal surgery. This procedure however, can’t be performed on about 30% of people with an aneurysm. Talk to your doctor to determine if you’re a candidate for this procedure. You’ll need to have regular follow-up imaging tests after surgery to ensure that the graft isn’t leaking. Survival rates (long-term) are similar for both endovascular surgery and open surgery.

The type of treatment will depend on a variety of factors including location and size of the aneurysm, your age, and other existing conditions that may potentially increase your risk of surgery or endovascular repair. The most appropriate treatment will be discussed with you.

DIAGNOSING AORTIC ANEURYSMS

Thoracic aortic aneurysms often discovered during routine medical tests like a chest X-ray or ultrasound of the heart or abdomen that may have been sometimes ordered for a different reason. The tests include:

• Chest X-ray: A thoracic aortic aneurysm may be first suspected by your doctor when looking at chest X-ray images. X-ray images ordered to check for another condition may sometime reveal a thoracic aortic aneurysm.
• Echocardiogram: This technique may sometimes reveal a thoracic aortic aneurysm. It’s often used to screen family members of those who have thoracic aortic aneurysm. Sound waves are used to capture real-time images of your heart and the ascending aorta.

  The procedure can show how well your heart chambers and valves are working. Sometimes, to better view your aorta, your doctor may recommend a transesophageal echocardiogram. Sound waves are generated from within your body by a device threaded down your esophagus in this procedure.

• Computerized tomography (CT) scan: Clear images of your aorta can be seen on CT scans and it can determine the size and shape of an aneurysm. You will be required to lie on a table inside a doughnut-shaped machine. X-rays are generated to produce cross-sectional images of your body. A dye may be injected into your blood vessels to help your arteries show up more on the images.

  A con of this scan is that when detecting and following aortic aneurysms is the exposure to radiation. Especially for people who require frequent monitoring such as those with Marfan syndrome. Thankfully, newer CT scan techniques may be recommended to reduce radiation exposure at some medical centers.

• Magnetic resonance angiography (MRA): This painless imaging test can diagnose an aneurysm and determine its size and location. You will be required to lie on a movable table that slides into the tunnel. It uses magnetic field and pulses of radio wave energy to create pictures of the body. A dye may be injected into your blood vessels to make your blood vessels show up more on images (magnetic resonance angiography). This could be an alternative to CT scans for people who require frequent monitoring.

An abdominal aortic aneurysm can be diagnosed through medical reviews and family history and physical examinations. Specialized tests can confirm your diagnosis if your doctor suspects that you may have an abdominal aortic aneurysm. These tests might include:

• Abdominal ultrasound: Most commonly used to diagnose abdominal aortic aneurysms. Your are required lie on an examination table and a small amount of warm gel is applied to your abdomen to eliminate the formation of air pockets between your body and the instrument used to view your aorta (transducer). The transducer is pressed against your skin over your abdomen moving from one area to another. Images are sent to a computer screen to check for a potential aneurysm.
• Computerized tomography (CT) scan: Clear images of your aorta can be provided by CT scans and it can determine the size and shape of an aneurysm. You will be required lie on a table inside a doughnut-shaped machine where X-rays are used to produce cross-sectional images of your body. A dye may be injected into your blood vessels to help your arteries show up more on the CT pictures.
• Magnetic resonance imaging (MRI): This scan may be used to diagnose an aneurysm and determine the size and location. You will be required to lie on a movable table that slides into a tunnel. Magnetic field and pulses of radio wave energy will be used to create images of your body. A dye is injected into your blood vessels to help your blood vessels show up more on images (magnetic resonance angiography).