Aortic Aneurysm

Aortic aneurysm is an enlargement of the aorta, the largest artery in the human body, starting at the heart and travels throughout the anterior spine.  It has the shape of a bag; usually, it has a size of a few centimeters at the beginning. However, over time, certain aneurysms can grow to become large, thus, increasing the risk of rupture. The risk of rupture of an aortic aneurysm becomes more life-threatening when the bulge reaches a diameter of 50 millimeters (1.95 inches). At this stage, surgery is vital; death occurs in 75 to 90% of cases.

Even an unruptured aneurysm can be life threatening. A small aneurysm of the aorta can cause abnormal electrical activity in the heart muscle, leading to irregular heartbeat or heart failure. Some small aneurysms tend to grown to become large. Without a medical intervention, a large aortic aneurysm will rupture, possibly causing irreparable damages or sudden death. In fact, ruptured brain aneurysm represents approximately 10% of cerebrovascular accidents (stroke).

Fortunately, all aortic aneurysm ruptures do not cause death. In fact, some people are completely recovered after the accident. It is estimated that 2/3 of patients survive, and about 1/3 will only have minor effects after a cardiac rehabilitation. However, to increase your chance of recovery, you must be treated urgently, a few hours, at most 3 days after the first bleeding; otherwise, your chance of recurrence and death are highly increased. 

Aortic Aneurysm Symptoms

You can live a long period of time with a slow-growing aortic aneurysm without experiencing any symptoms. In fact, even a fast growing aortic aneurysm can be completely asymptomatic at the beginning; that does not prevent the bulge from growing in your aorta. Yet, when it expands too much, the vessel wall may come to break and cause an effusion of blood. Its failure can cause major bleeding, and even rapid death. In addition, symptoms of the aneurysm differ slightly depending on the organ affected.

An aneurysm can locate on one of the following segments of the aorta:

Thoracic aortic aneurysm – in this case, the aneurysm affects your thoracic aorta, a weak area in the aorta in your chest. The thoracic aorta consists of three segments: the ascending aorta (ascending aortic aneurysms), horizontal and downward (horizontal / descending aortic aneurysms). Most common thoracic aortic aneurysm symptoms include:

• discomfort when swallowing (dysphagia)
• breathing discomfort (dyspnea)
• swelling of head, neck, and/or arms
• pain in the chest, neck, and/or back
• heart failure symptoms: shortness of breath, cough, fatigue…

Abdominal aorta aneurysm – An aneurysm of the abdominal aorta is an expansion of the portion of the aorta in your abdomen, specifically the extrarenal abdominal aorta or the abdominal aorta-renal. In most cases, abdominal aorta aneurysms are due to buildup of cholesterol plaque in the arteries, and are rare before the age of 60. Abdominal aorta aneurysms represent about 90% of aneurysms. It is the thirteenth leading cause of death in the United States, with a mortality rate of nearly 5% associated with surgery.

The most common abdominal aorta aneurysm symptoms include:

• Fever
• Black or blue painful toe
• Back pain or discomfort
• Tenderness or pain in the abdomen
• Pulsating sensation in the abdomen, near the navel
• Flank pain (kidney pain) that travels around the trunk to the abdomen then to the groin.

Aortic Aneurysm  Complications

The complications of aneurysms of the abdominal aorta may include heart attack (myocardial infarction), heart failure and hemorrhage, which may require blood transfusion. In severe cases, ischemic colitis (swelling or inflammation of a part of the large intestine) can occur, which often necessities a colectomy, surgical removal of all or part of the colon. In men, abdominal aorta aneurysms can lead to temporary or permanent retrograde ejaculation problems.

dissection and rupture are the most serious complications of abdominal aorta aneurysms, with a mortality rate of about 90% in the absence of treatment; less than 60% of patients that have a chance to arrive alive to the operating room survive.

Contact your doctor immediately if you experience any of the following signs and symptoms below; they can indicate a burst aortic aneurysm:

• Sweatiness
• Clamminess
• Dizziness
• Loss of consciousness
• Shortness of breath
• high pulse rate and a low blood pressure
• Sudden intense abdominal or chest pain
• A sudden pain that radiates to your back or legs.

Aortic Aneurysm Causes and Risk Factors

Typically, an aneurysm is due to dilation or weakness of the artery wall. The main cause of this dilation is a fibrous degeneration of the aorta, most often, due to deposits of cholesterol on the inner wall of the arteries. Sometimes, syphilis can be responsible for developing aneurysms of the ascending aorta. In addition, other medical conditions can also lead to the development of an aortic aneurysm, principally:

• Chest trauma, a serious injury of the chest
• Infective endocarditis, an infection of the endocardial surface of the heart
• Sepsis, an overwhelming of the bloodstream by bacteria
• Polyarteritis nodosa, a serious blood vessel disease in which small and medium-sized arteries become swollen and damaged.

The causes of are not well known; some risk factors, however, are suspected:

Age – onset of aortic aneurysm increases after age 65

Sex – although the disease affects both men and women, men are more victims of aortic aneurisms than women are.

Vasculitis – infection in the aorta can lead to inflammatory destruction of blood vessels and formation of bulging in the aorta; however, this barely occurs and tends to run in families.

Injury to the aorta – your risk of suffering from thoracic aortic aneurysm is higher if you had an Injury of the thoracic aorta and/or its major branch.

Smoking – tabagism, chewing or smoking (including second hand smoke), fosters all forms of pulmonary and cardiovascular diseases including all form of aortic aneurysms.

Lifestyle – a diet high in fat, especially when it is associated with physical inactivity and excess weight is a major risk factor for occurrence of aneurysm of the aorta.

Marfan syndrome – Marfan syndrome, also known as Marfan’s disease is a genetic disorder of connective tissue. It affects mostly the eye, skeleton and cardiovascular system. It begins to manifest at birth and continues gradually until adulthood. People born with the syndrome are more likely to have thoracic aortic aneurysm.

Diagnosis

Most of times, a thoracic aortic aneurysm is discovered during a routine chest X-ray performed for other reasons of health. During a physical exam, your doctor may hear a diastolic murmur of an aortic insufficiency (also known as aortic regurgitation); he may also perceive an unequal pulse and blood pressure of the upper limbs, which often indicates an aortic aneurysm.

Abdominal aortic aneurysms can be discovered by palpitation of the abdomen during a physical exam. In cases of large aneurysms, the presence of the disease can be suspected by a pulsating bulge if you are not obese – detection of abdominal aorta aneurysm by a physical exam is difficult in obsesses and in young women with hyperpulsatiles arteries – Lumbar and/or abdominal pain is typical symptom of the aneurysm, experiencing it can make your doctor consider performing other exams that can help confirm you have an abdominal aortic aneurysm.

Depending on the results of these exams, other diagnostic procedures such as ultrasound, fluoroscopy, CT scan and MRI can be outperformed to confirm the disease. Aortography is sometimes practiced to confirm an aortic aneurysm.

Abdominal Ultrasound – This is a non-invasive and fast medical technique often used to diagnose abdominal aortic aneurysm; it helps detect and measure the extent of the aneurysm and the thickness of the blood clot (thrombus) in your artery. However, abdominal ultrasound can be disturbed by the presence of bloating or abdominal fat (in case of obesity). Ultrasound is insufficient to confirm an aortic aneurysm diagnosis; performing a CT scan is often necessary.

Computerized tomography (CT) scan – this is a medical imaging technique used to create a three-dimensional image of the inside of your body. CT scan is the standard exam of the aortic aneurysm; it helps your physician measure the outside diameter of the aneurysm, and locate the presence of an intra-or retroperitoneal bleeding in case of rupture.

Magnetic Resonance Imaging (MRI) – MRI is a painless medical imaging technique recently appeared in the 1980s. It allows your doctor to take detailed images of your internal organs and tissues that are not visible with other imaging techniques. Unlike many other imaging techniques, an MRI can detect an aortic aneurysm in its early stage.

Aortic Aneurysm Treatment

In cases of aneurysms less than 50 mms (less than 1.95 inches), surgery may not be necessary; in fact, it is rarely performed in such small aortic aneurysms. Your physician may prescribe you drugs (mostly beta blockers) associated with regular monitoring by ultrasound or CT to follow the disease closely.  The monitoring may be followed by a surgical procedure in case the aneurysm increases in size or pertinent symptoms occurs.

Non surgical treatment

Beta blockers are prescribed in most cases of thoracic aortic aneurysm. Along with the medications, it is always better to change your diet and all habits fostering the development of growing of the aneurysm. A healthy lifestyle not only helps the beta blockers to work better but also reduce their side effects:

• Itching
• Easy bruising or bleeding
• Swollen hands or feet
• Confusion
• Depression
• Sore throat
• Dizziness
• Trouble breathing
• Drowsiness
• Blurred vision
• Decreased blood circulation to the extremities
• Coldness of your hands and feet.

Surgical Treatment

Surgical or endovascular intervention remains the best chance of survival if you have an aneurysm over 1.95 inches. your surgeon can perform an endovascular surgery, open-chest or abdominal surgery, depending on your condition and the localization of the aneurysm. Without surgery, risks of rupture and death are very high; in fact, nearly:

• 80% of patients who have an aneurysm rupture don’t survive
• 50% of patients die before their transfer to hospital
• 25% of patients who arrive at the hospital alive die before the surgery
• 42% of patients die during or in the aftermath of the intervention.

Aortic Aneurysm  Prevention

Some causes of aortic aneurysm such as age and sex cannot be prevented. However, the majority of causative factors can be reduced or prevented. In fact, all the preventive measures of cardiovascular problems are applicable in aneurysm prevention:

• Do not smoke; quit if you are already a smoker
• Monitor your blood pressure regularly
• Exercise regularly
• Avoid bad stress ; laugh and relax whenever it is possible
• Eat a healthy diet:

Avoid red meat in your diet; eat lean meat moderately, and hours before going to bed

Avoid all unsaturated fats in your diet – Cook with vegetable oils such as extra virgin olive oil and sunflower oil

Drink low fat milk: skimmed milk or milk containing 1% fat

Eat low fat yogurt and cheese – eat cottage cheese that contains about 1% fat

Limit your salt (and salted foods) intake – you can replace salt with herbs and spices or savory ingredients: tarragon, basil, curry, garlic, flavored vinegars, etc.

Eat foods rich in enzymes and fiber: fruits and cruciferous vegetables, peas, barley, brown rice, whole grain bread, beans and lentils are good for your cardiovascular health.

References:

1 – Chirurgie, Pierre A. Grace et Neil R. Borley, Ed. DeBoeck Université

2 – 3% pour les anévrismes de moins de 4 cm, 10% pour les anévrismes de 5.5 à 6.9 cm, 30% pour les anévrismes plus importants

3 –  Masson, Paris, FRANCE  (1976) (Revue): Journal des maladies vasculaires ISSN 0398-0499   CODEN JMVADL ; 2003, vol. 28, n^o3, pp. 145-150 [6 page(s) (article)] (11 ref.)

4 –  Bentall H, De Bono A, A technique for complete replacement of the ascending aorta [archive], Thorax, 1968;23:338–9.

5 – Halpern BL, Char F, Murdoch JL, Horton WB, McKusick VA, A prospectus on the prevention of aortic rupture in the Marfan syndrome with data on survivorship without treatment, Johns Hopkins Med J, 1971;129:123–129

6 – Dietz HC, Cutting GR, Pyeritz RE, et als. Marfan syndrome caused by a recurrent de novo missense mutation in the fibrillin gene [archive], Nature, 1991;352:337-339

7 – Infirmiers : Cours – Vasculaire – Anevrysme de l’aorte abdominale – AAA

8 –  Routine screening in the management of AAA, UK Department of Health study Report

9 – “Abdominal Aortic Aneurysm”. Bandolier 27 (3). May 1996.

10 – http://www.ahjonline.com/article/S0002-8703%2808%2900828-4/abstract?cc=y=

11 – http://www.sciencedaily.com/releases/2013/03/130306084157.htm

12 – “Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm Trial Participants”. Lancet 352 (9141): 1649–55. November 1998. doi:10.1016/S0140-6736(98)10137-X. PMID 9853436.