Aortic aneurysm

Dr. Suvansh Raj NirulaMBBS

December 10, 2020

December 10, 2020

Aortic aneurysm
Aortic aneurysm

An aortic aneurysm is an unusual bulge in the wall of the aorta (a very important blood vessel that is responsible for carrying blood from the heart to the rest of the body).

What is the aorta?

The aorta is the largest artery of the body. It links to the left ventricle (bottom chamber of the heart) which is the main pumping segment of the heart. The blood has to pass through the aortic valve as it passes from the left ventricle to the aorta.

Sections of the aorta

The aorta has four different sections:

  • Ascending aorta: A two-inch segment from which coronary arteries that supply the heart branch off.
  • Aortic arch: The part that curves over the heart and supplies blood to the arms, head and neck.
  • Descending thoracic aorta: The section of aorta that travels downwards and supplies the ribs and chest structures.
  • Abdominal aorta: Starts at the diaphragm, divides to give rise to the iliac arteries in the lower quadrants of the abdomen. It supplies a majority of essential organs.

Layers of the aorta

  • There are three layers of the aorta which are as follows:
  • Adventitia: The outermost layer which maintains the structural integrity of the aorta
  • Tunica media: It is the middle layer and aids in the expansion and contraction of the aorta as the heart beats
  • Tunica intima: It is the innermost layer. 

Smoking, advancing age, illness can all increase one's risk of developing an aortic aneurysm. Often, patients do not show any symptoms. However, if your doctor suspects an aortic aneurysm during a routine check-up or while examining you for other causes, you should get all the test that your doctor recommends. Read on to know all about aortic aneurysm, its symptoms, risk factors, tests, treatment and prognosis or expected outcome.

Types of aortic aneurysm

There are two major types of aortic aneurysms. A patient may present with any of the following:

  • Thoracic aortic aneurysm: Present in that part of the aorta that traverses through the chest cavity.
  • Abdominal aortic aneurysm: Present in that part of the aorta that traverses through the abdomen.

Some individuals may have a combination of both thoracic and abdominal aortic aneurysm.

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Aortic aneurysm symptoms

Symptoms may vary, based on the type of aortic aneurysm

Thoracic aortic aneurysm 

Physical examination of the patient is extremely important to successfully diagnose aortic aneurysms.

Abdominal aortic aneurysm

  • Most patients with abdominal aortic aneurysms have no symptoms. They are usually discovered incidentally on clinical examinations or on radiological scans like ultrasound, computed tomography (CT) scans or magnetic resonance imaging (MRI) scans.
  • Pain: Back pain, abdomen pain or groin pain may occur due to the pressure exerted by the aneurysm on surrounding structures.
  • Abdominal swelling: A pulsatile (beating or throbbing) swelling may be observed on the patient’s abdomen.
  • Weight loss
  • In case of rupture of the aneurysm, the patient may present with low blood pressureloss of consciousness and severe abdominal pain
  • Sometimes, on examination a bruising on the abdominal flanks may be observed (Grey-Turners sign) 

Risk factors of aortic aneurysms

Aortic aneurysms may arise due to a single factor or may be caused by a combination of factors.

The risk factors are as follows:

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Diagnosis of aortic aneurysm

Depending on the type of aortic aneurysm, diagnosis may involve the following:

Thoracic aortic aneurysm

Thoracic aortic aneurysms are diagnosed based on clinical examination, radiological and routine biochemical investigations. 

The biochemical investigations to be performed are as follows: 

The radiological investigations to be performed are as follows: 

  • Chest X-ray: A thoracic aortic aneurysm can be detected on a plain Chest X-ray by identifying the widening of the mediastinum (Space between the two lungs in the chest cavity) with the deviation of the trachea (windpipe). Even if this feature is present, further investigations are needed to make a definite diagnosis. 
  • Computed tomography scan (CT scan) with contrast: It is the most appropriate investigation that is usually conducted for diagnosing a thoracic aortic aneurysm. Generates 3D images using an X-ray machine. It makes it possible to determine the level (Section of aorta) and the size of the aneurysm. 
  • Transoesophageal echocardiography (TOE): It is beneficial as it helps in identifying any complications associated with Thoracic aortic aneurysms such as aortic insufficiency and aortic dissection. Apart from people suspected of having thoracic aortic disease, it is routinely conducted in patients with genetic disorders like Marfan disease.
  • Magnetic resonance imaging (MRI) angiography: Performs the same function as the computed tomography (CT) scan as it shows the anatomical structures well. The only difference is that this modality uses magnetic waves instead of X-rays. 
  • Coronary angiography: May be performed in certain cases like assessment for fitness of surgery in patients with thoracic aortic disease.

Abdominal aortic aneurysm

Diagnosis of abdominal aortic aneurysm is usually made by a combination of patient profile, clinical examination, biochemical and radiological investigations. 

Blood tests that are performed are as follows: 

  • Complete blood count (CBC)
  • Coagulation screening to identify any bleeding disorders
  • Liver function test
  • Blood matching and arranging blood for transfusion if surgery is planned
  • If inflammatory cause is suspected, an Erythrocyte sedimentation rate (ESR) and C - reactive protein (CRP) tests are to be performed. 
  • ECG (Electrocardiogram) is also to be performed to rule out any cardiac complication.

Radiological investigations are required to make a definite diagnosis of abdominal aortic aneurysm. The following investigations are to be ordered: 

  • Ultrasound scan: It is the initial/first radiological investigation that is performed in patients with suspected abdominal aortic disease. It is convenient, easy to perform and cheap. It can assess the aorta in great detail. 
  • Computed tomography scan (CT scan): It is considered superior to an ultrasound and is the most appropriate investigation that is performed in patients suspected of suffering from abdominal aortic aneurysm. It has the advantage of providing more anatomical details. A thin-slice contrast-based CT angiography (Using a dye to identify the disease more accurately) is preferred over a plain CT scan as per universal guidelines. 
  • Abdominal X-ray: May be performed to rule out any other causes of severe abdominal pain such as perforation of an ulcer. It rarely shows an abdominal aortic aneurysm.

Aortic aneurysm के बचाव के उपाय - Prevention of Aortic aneurysm in Hindi

There are surgical and non-surgical treatment options for both types of aortic aneurysms:

Patients with thoracic aortic aneurysms

Which patients require surgery? 

  • Immediate surgery is needed if the patient has a complicated disease like ruptured TAA or aortic dissection
  • Surgery to be considered for patients with a symptomatic TAA (Patients who present with clinical features) 
  • Also to be considered in certain asymptomatic cases. For example, if aneurysm diameter is >5.5cm or patients with a genetic disorder like Marfan syndrome. 

The surgical technique that is commonly used is called an Endovascular repair. It is also known as endovascular stenting. It is a minimally invasive procedure that involves placing a stent via a blood vessel. Possible complications of this method are stroke (reduction in blood supply to the brain) and acute kidney failure. 

Medical management

For those patients who do not meet the criteria for undergoing surgery, medical treatment is initiated.  This involves the following: 

  • Controlling the blood pressure with the help of drugs like beta blockers. 
  • Patients to stop smoking
  • Treatment of the underlying cause for example, infection
  • Treatment of other risk factors like high cholesterol or high lipid levels with the help of lipid lowering drugs (statins).
  • Regular monitoring of the thoracic aortic aneurysm with the help of CT or MRI every six months 

Patients with abdominal aortic aneurysm

Which patients require surgery? 

  • Patients with abdominal aortic aneurysm of size >5.5cm in diameter 
  • Patients with abdominal aortic aneurysm that is expanding at the rate of >1cm/year
  • Patients with symptomatic abdominal aortic aneurysms 
  • Complicated abdominal aortic aneurysm such as aortic rupture

Types of surgeries that are routinely performed are: 

  • Surgical (open) repair: It is common traditional surgery that involves clamping of the abdominal aorta and placing a graft to replace the aneurysmal portion of the blood vessel. The graft is considered to be highly effective for a long duration of time. 
  • Endovascular repair: A stent with a graft is inserted through the femoral artery (an artery in the thigh), which realigns the aneurysm and diverts the flow of blood through the graft. 

Endovascular repair has better short term results as it reduces the hospital stay and 30 day perioperative and postoperative mortality. But, studies suggest that it has a higher rate of rupture of the aneurysm. In terms of long term outcomes, both procedures are equally effective. Hence, it is recommended that in young patients a Surgical (Open) repair is to be performed. 

Medical management

Medical treatment is provided to those patients who do not meet the specific criteria for surgical repair. 

  • Blood pressure control to be encouraged using drugs like beta-blockers
  • Cessation of smoking 
  • Drugs that reduce the occurrence of various cardiovascular diseases like Aspirin (Anti-platelet drug) and Statins (lipid-lowering drugs)
  • Weight loss
  • Exercise

Patients with abdominal aortic aneurysm of size less than 5.5cm are supposed to undergo routine monitoring using Ultrasound scans. The frequency of these scans is as follows: 

  • 3-4.4cm: Annual ultrasound
  • 4.5-5.4 cm: Ultrasound scan every three months
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Prognosis or outcome for aortic aneurysm

The outcome, too, depends on the type of aneurysm:

Thoracic aortic aneurysm

The most common cause of death in these patients is rupture of the aneurysm. In case of a rupture, the patient usually dies within six hours. 

In patients undergoing surgery, 30 day perioperative (occurring during or around the time of surgery) mortality is around 5%.

Abdominal aortic aneurysm

Patients who suffer a rupture of the abdominal aortic aneurysm have a mortality of 80%. The risk of rupture depends on the diameter of the aneurysm. Most patients usually die before reaching the hospital. Even after surgical repair of a ruptured abdominal aortic aneurysm, mortality rate stands at 50%. 

70% of patients undergoing open or endovascular repair usually will survive for the next five years after the surgery. 

Patients who don’t undergo surgery and have an abdominal aortic aneurysm of more than 5 cm have an annual survival rate of only 20%.