Aortic Aneurysm

About Aortic Aneurysms

Definition

The aorta is the major blood vessel that takes the blood from the heart to the rest of the body. An ascending or aortic arch aneurysm refers to enlargement of the aorta which causes aortic wall weakening. Aneurysms can develop anywhere along the aorta, which runs from the heart to the abdomen. Depending on their location, they are called thoracic, thoracoabdominal or abdominal aneurysms.

Depending on its size and growth, an aortic aneurysm may not ever rupture. However, follow-up is necessary because as the aortic wall enlarges, there is risk of the wall tearing.  This is called dissection and can cause life-threatening bleeding, requiring emergency surgery. It’s therefore important to treat an aortic aneurysm before dissection occurs.

Cause

Factors that can contribute to development of an aortic aneurysm are:

  • Atherosclerosis (hardening of the arteries)
  • Genetic conditions. Genetic conditions that affects the connective tissue (lining and walls of the vessels and aorta) in the body, are at risk of a thoracic aortic aneurysm. Some of these conditions include Marfan syndrome, Ehlers-Danlos syndrome and Loeys-Dietz syndrome.
  • Hypertension (high blood pressure)
  • Bicuspid aortic valve. Approximately 2% of the population has a bicuspid aortic valve, meaning the aortic valve has only two leaflets (or cusps) instead of three. These people are born with this form of aortic valve. People with bicuspid aortic valve have an increased risk of thoracic aortic aneurysm.
  • Other causes. Inflammatory conditions, such as giant cell arteritis and Takayasu arteritis.

Symptoms

Many patients have no symptoms and their problem is diagnosed on routine testing.  Some present with high blood pressure, chest pain and/or shortness of breath.  Some patients have a family history of aneurysm.  An incidental murmur can also be found on routine examination by a GP or other health check.

Diagnosis and tests

  • CT is the most common test to evaluate the aortic aneurysm
  • MRI is another form of imaging to evaluate the aneurysm and sometimes the flow in the vessels
  • Echocardiography is an ultrasound scan which evaluates the aneurysm, heart valves and function of the ventricles (the pumping chambers of the heart).

Each test will take half to one hour and is performed as out-patient.

  • Coronary angiography is a test to evaluate the state of the coronary arteries (vessels running on the surface of the heart). It is performed by injecting a dye into the groin or an arm vessel and then imaging the coronary arteries.
  • Genetic screening consists of blood sampling and sometimes testing of saliva.

Treatment for aortic aneurysm

Depending on the size and growth rate of your thoracic aortic aneurysm, treatment may vary from watchful waiting (closely watching a patient’s condition but not giving treatment unless symptoms appear or change).to emergency surgery. Ideally, surgery for a thoracic aortic aneurysm can be planned electively. Aortic dissection (tear in the aorta) is a life-threatening emergency.

Aortic Surgery

The aim of surgery is to treat aneurysm, mainly by removing it and replacing it with artificial material.  This material does not wear and tear.  In some the actual aortic valve needs replacing as well.  Some of the aneurysms in the lower parts of the aorta are treated with different forms of stents, which means the patient will not have open surgery.

Surgery may include:

  • Aortic root replacement
  • Valve sparing root replacement
  • Aortic arch replacement
  • Surgery for aortic dissection
  • Hybrid arch surgery
  • Surgery for descending aortic aneurysm
  • Surgery of aorta in pregnant patients
  • Endovascular aortic repair

The surgery is performed through an incision in the middle of the chest.

The heart is connected to a heart-lung bypass machine which takes over the work of the heart and the lungs, circulating oxygenated blood throughout the body. During surgery, the diseased portion of the aorta is replaced with an artificial alternative.

If there is disease of the aortic valve or other valves in the heart or coronary artery disease is present, these conditions will be operated on during the same procedure.

The average hospital stay is between 5-10 days. It will take approximately 2-3 months to make a full recovery from aortic surgery. You will be given advice about your recovery and rehabilitation programme.

Endovascular aortic repair

Aneurysms (weakening of the wall or ballooning out of the aorta) of the thoracic and abdominal aorta can be repaired without surgically opening the chest or abdomen. This minimally invasive procedure is called Thoracic Endovascular Aortic Repair (TEVAR) and can be used to address:

  • Aneurysm of the aorta
  • Separation of one of the aorta’s three layers (dissection)
  • Narrowing of the inside of the aorta (stenosis)
  • Damage to the aorta from major trauma (transection)

TEVAR ProcedureTo fix or “re-line” the aorta, a device is placed through a small hole in the groin, known as a stent graft. This device is made of a fabric – covered metal mesh which is fully opened under x-ray. The device repairs the diseased aorta and helps to keep it open and allow blood to flow properly to the rest of the body.

Depending on the type of disease, the TEVAR procedure usually provides a cure. The procedure usually takes a few hours to complete. Current devices (stent grafts) have a lifespan of at least 10 years.