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Aortic Aneurysm by Rosalyn Carson-DeWitt, MD

Definition

An aortic aneurysm is a weak, bulging area in the wall of the aorta. The bulging develops from a weakness or defect in the aortic wall and tends to get bigger with time. The aorta is the body's largest artery. It carries blood from the heart for delivery to the rest of the body. The aorta travels through the chest (thoracic aorta) and the abdomen (abdominal aorta). Abdominal aortic aneurysms are more common than thoracic aortic aneurysms.

The greatest danger is that an aneurysm will rupture. This will cause heavy, uncontrollable bleeding (hemorrhage). Aortic aneurysms can also occur with aortic dissection. Dissection is defined as a small tear in the aortic wall. Blood from the aneurysm can leak through this tear and spread between the layers of the aortic wall, eventually leading to rupture of the vessel.

Aneurysms can develop anywhere, but are most common in the aorta, iliac artery, and femoral artery.

Abdominal Aortic Aneurysm

Causes

Atherosclerosis is frequently associated with aneurysm. However, it is not thought that this disease alone causes the growth of an aneurysm. It is believed that other factors, such as high blood pressure or connective tissue disorders, must be present for an aneurysm to form.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition. Risk factors for an aortic aneurysm include the following:

High blood pressure
Smoking
Arteriosclerosis, atherosclerosis
Inherited connective tissue defects ( Marfan syndrome , Ehlers-Danlos syndrome )
Polyarteritis nodosa
Bacterial endocarditis
Syphilis
Age: 60 or older
History of heart attack
Obesity
Family members with aneurysms, particularly male children of an effected mother
Infectious aortitis
Great vessel arteritis (Takayasu’s disease)
Injury to the aorta, from either a motor vehicle accident or a stab wound

Symptoms

Many aneurysms do not have symptoms and are detected during a routine physical exam or during x-ray evaluation for another disorder.

Symptoms may occur when the aneurysm grows or disrupts the wall of the aorta. Symptoms depend on the size and location of the aneurysm and may include:

Pain in the abdomen or in the lower back
Boring, gnawing, constant pain occurring over hours or days
Sudden onset of severe stabbing pain
Unusual sensation of pulsing in the abdomen
Cough, shortness of breath (thoracic aortic aneurysm)
Sudden blood pressure drop, fainting (upon rupture of aneurysm)
Hoarseness
Difficulty swallowing
Coughing up blood
Weight loss
Bowel obstruction
Chest pain

Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. Pain is the symptom that will most likely cause you to go to the doctor. Most aortic aneurysms are discovered during a routine physical exam.

Tests may include:

Abdominal or chest x-ray
Abdominal or chest ultrasound
CT scan of the abdomen or chest—a type of x-ray that uses a computer to make images of the inside of the body
MRI scan of the abdomen or chest—a test that uses magnetic waves to make images of the inside of the body
Transesophageal echocardiography —the use of ultrasound to study the heart and its vessels; a transducer, which records the information, is swallowed by the patient
Aortography —the use of x-rays and injection of a contrast dye to make images of the heart and the aorta
Cardiac catheterization —a tube-like instrument is inserted into the heart through a vein or artery (usually in the arm or leg) to detect problems with the heart and its blood supply

Treatment

Treatment includes surgery or stenting.

Surgery

Surgery to repair an aortic aneurysm is called aneurysmectomy . It involves removing the portion of the aorta that contains the aneurysm and replacing it with a mesh graft.

With aneurysms of the thoracic aorta, the aortic valve may also be affected and need to be replaced or repaired. If the aneurysm involves important branches of the aorta, these vessels may either be repaired or bypassed.

When deciding whether to operate, the doctor will consider:

Your age
Your general health
Your symptoms
The size of your aneurysm
Associated disease (eg, kidney failure , stroke )
If the aneurysm has ruptured or not
If you've had a recent heart attack

Stenting

Depending on where the aneurysm is located and how complex it is, stenting may be done. A stent-graft is a polyester tube covered by a tubular metal web. The stent-graft is inserted through a small incision in the upper thigh into the aorta. Using x-ray, it is guided through the aorta to the site of the aneurysm. With the stent-graft in place, blood flows through the stent-graft instead of into the aneurysm, eliminating the chance of rupture.

Prevention

There are no guidelines for preventing an aneurysm because the cause is not known. However, you can reduce some of your risk factors by following these recommendations:

Eat a healthful diet , one that is low in saturated fat and rich in whole grains, fruits, and vegetables.
Don't smoke. If you smoke, quit .
- The US Preventive Services Task Force recommends that men aged 65-75 who have ever smoked be screened once for abdominal aortic aneurysm with ultrasound . This is a painless procedure that gives a picture of the abdomen using sound waves. Early detection of abdominal aortic aneurysm in this group has been shown to reduce mortality from this condition.
Maintain a healthy weight .
Begin a safe exercise program with the advice of your doctor.
Seek treatment for high blood pressure, syphilis, and other infections.
If you have Marfan syndrome, see your doctor regularly for monitoring and CT scans.

RESOURCES:

American Heart Association http://www.americanheart.org/
The National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov/health/

CANADIAN RESOURCES:

Canadian Cardiovascular Society http://www.ccs.ca/home/index_e.aspx/
Heart and Stroke Foundation of Canada http://ww2.heartandstroke.ca/splash/

References:

Aneurysm, aortic. American Heart Association website. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4455 . Accessed July 8, 2009.
Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine . 6th ed. Philadelphia, PA: WB Saunders Company; 2001.
Cecil RL, Goldman L, Bennett, JC. Cecil Textbook of Medicine . 21st ed. Philadelphia, PA: WB Saunders Company; 2000.
Sabiston DC, Townsend CM. Sabiston Textbook of Surgery . 16th ed. Philadelphia, PA: WB Saunders Company; 2001.
US Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/clinic/uspstf05/aaascr/aaars.htm . Accessed July 8, 2009.
¹7/21/2009 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Thompson SG, Ashton HA, Gao L, Scott RA, Multicentre Aneurysm Screening Study Group. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ. 2009;338:b2307.

Last reviewed September 2009 by David N. Smith, MD

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