Enlarged Aorta Risks, Symptoms and Treatment: What to Know

Each year in the United States, aortic aneurysms contribute to nearly 20,000 deaths. But with awareness, monitoring and proper care, aortic aneurysm treatment can be relatively simple — often with a minimally invasive procedure if surgery becomes necessary.

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To raise awareness of aortic aneurysms, also known as an enlarged aorta, Michigan Medicine vascular surgeon Jonathan Eliason, M.D., outlines the symptoms and risk factors.

What are enlarged aorta symptoms, and how is it diagnosed?

Eliason: An individual with an enlarged aorta typically experiences no symptoms until the aneurysm ruptures. In most cases, this means an aortic aneurysm wouldn’t be discovered unless some type of screening was performed that allowed aortic measurements. Aortic aneurysm screenings are recommended for certain individuals, depending on their age, gender, family history and other risk factors.

Screening is typically done via an ultrasound scan, a painless test that uses sound waves to create images of organs and structures inside the body. If an aneurysm is detected, its size can also be measured by ultrasound.

What are enlarged aorta risk factors?

Eliason: Because the condition can be hereditary, screening is recommended for men or women over age 65 who have a person in their immediate family with an abdominal aortic aneurysm (AAA). Men over 65 who have smoked more than 100 cigarettes in their lifetime should also be screened. According to the U.S. Preventive Services Task Force, this group stands to benefit the most from early detection and surgical treatment due to a higher prevalence of larger AAAs compared to other patient groups. Routine screening is not recommended for women, who are at lower risk for AAAs.

Individuals with connective tissue disorders, such as Marfan or Loeys-Dietz syndromes, are more likely to experience an aortic aneurysm at a younger age and should be closely monitored.

The vast majority of patients with an AAA do not have a family history and instead have other risk factors. Smoking is by far the strongest risk factor for aortic aneurysm, even a remote history of smoking cigarettes or breathing secondhand smoke. Uncontrolled high blood pressure is also a risk factor, though far less than cigarette smoking. Hardening of the carotid or coronary arteries contributes as well. We often order testing in these areas if a patient has an AAA.

How much can an aorta stretch before it could burst?

Eliason: The average aorta is approximately 2 cm, or slightly smaller than one inch. An aneurysm means that the diameter is 1.5 times larger than normal, or 3 cm, in the abdominal aorta.

SEE ALSO: Observe or Operate? When an Enlarged Aorta Requires Action

The rupture rate really increases at 5.5 cm in men and 5 cm in women. That doesn’t mean an aneurysm can’t rupture at a smaller diameter or at a larger diameter, but these tend to be the sizes where surgery is actively considered. If a person has a connective tissue disorder, aneurysm repair may be considered at a smaller size.

What happens if an aneurysm ruptures? Is there any warning?

Eliason: During an abdominal aortic aneurysm rupture, an individual typically experiences severe abdominal or back pain. Sudden death can also occur. In some cases, patients might experience symptoms without a rupture. These patients may get a warning of abdominal pain or escalating back pain. If the aneurysm is in the chest only, the individual may experience chest or upper back pain.

Is an individual with an aortic aneurysm more likely to experience another aneurysm?

Eliason: Yes. One study reported that just over a quarter of individuals with an abdominal aortic aneurysm had a simultaneous thoracic aortic aneurysm. This suggests that thoracic aortic aneurysm screening is appropriate for patients with abdominal aortic aneurysms.

Is there anything else individuals should know about risks associated with an enlarged aorta?

Eliason: Yes, anyone diagnosed with an abdominal aortic aneurysm is more likely to have atherosclerosis (hardening or blockages) in other arteries. This may put them at an increased risk for other cardiovascular conditions such as heart attack or stroke. Screening for these conditions may be indicated.

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Heart Health

Aortic Aneurysm

Cardiovascular: Diseases & Conditions

Aneurysm: Causes, symptoms, and treatments

An aneurysm is the enlargement of an artery caused by weakness in the arterial wall. Often there are no symptoms, but a ruptured aneurysm can lead to fatal complications.

An aneurysm refers to a weakening of an artery wall that creates a bulge, or distention, of the artery.

Most aneurysms do not show symptoms and are not dangerous. However, at their most severe stage, some can rupture, leading to life-threatening internal bleeding.

The Centers for Disease Control and Prevention (CDC) advise that aortic aneurysms contribute to over 25,000 deaths in the United States (U.S.) each year.

Around 30,000 brain aneurysms rupture in the U. S. each year. An estimated 40 percent of these cases cause death within 24 hours.

Fast facts on aneurysms

• Aneurysms affect a variety of arteries. The most significant aneurysms affect the arteries supplying the brain and the heart. An aortic aneurysm affects the body’s main artery.
• The rupture of an aneurysm causes internal bleeding.
• The risk of an aneurysm developing and rupturing varies between individuals. Smoking and high blood pressure are major risk factors for the development of an aneurysm.
• Some types of aneurysm may need surgical treatment to prevent rupture. Doctors will only operate on others if they are life-threatening.

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Aneurysms are classified by their location in the body. The arteries of the brain and heart are the two most common sites of a serious aneurysm.

The bulge can take two main shapes:

• Fusiform aneurysms bulge all sides of a blood vessel
• Saccular aneurysms bulge only on one side

The risk of rupture depends on the size of the bulge.

Aortic aneurysm

The aorta is the large artery that begins at the left ventricle of the heart and passes through the chest and abdominal cavities. The normal diameter of the aorta is between 2 and 3 centimeters (cm) but can bulge to beyond 5 cm with an aneurysm.

The most common aneurysm of the aorta is an abdominal aortic aneurysm (AAA). This occurs in the part of the aorta that runs through the abdomen. Without surgery, the annual survival rate for an AAA of over 6 cm is 20 percent.

AAA can rapidly become fatal, but those that survive the transfer to a hospital have a 50 percent chance of overall survival.

Less commonly, a thoracic aortic aneurysm (TAA) can affect the part of the aorta running through the chest. TAA has a survival rate of 56 percent without treatment and 85 percent following surgery. It is a rare condition, as only 25 percent of aortic aneurysms occur in the chest.

Cerebral aneurysm

Aneurysms of the arteries that supply the brain with blood are known as intracranial aneurysms. Due to their appearance, they are also known as “berry” aneurysms.

A ruptured aneurysm of the brain can be fatal within 24 hours. Forty percent of brain aneurysms are fatal, and around 66 percent of those who survive will experience a resulting neurological impairment or disability.

Ruptured cerebral aneurysms are the most common cause of a type of stroke known as subarachnoid hemorrhage (SAH).

Peripheral aneurysm

An aneurysm can also occur in a peripheral artery. Types of peripheral aneurysm include:

• Popliteal aneurysm: This happens behind the knee. It is the most common peripheral aneurysm.
• Splenic artery aneurysm: This type of aneurysm occurs near the spleen.
• Mesenteric artery aneurysm: This affects the artery that transports blood to the intestines.
• Femoral artery aneurysm: The femoral artery is in the groin.
• Carotid artery aneurysm: This occurs in the neck.
• Visceral aneurysm: This is a bulge of the arteries that supply blood to the bowel or kidneys.

Peripheral aneurysms are less likely to rupture than aortic aneurysms.

Not all cases of unruptured aneurysm need active treatment. When an aneurysm ruptures, however, emergency surgery is needed.

Aortic aneurysm treatment options

The doctor may monitor an unruptured aortic aneurysm, if no symptoms are evident. Medications and preventive measures may form part of conservative management, or they may accompany active surgical treatment.

A ruptured aneurysm needs emergency surgery. Without immediate repair, patients have a low chance of survival.

The decision to operate on an unruptured aneurysm in the aorta depends on a number of factors related to the individual patient and features of the aneurysm.

These include:

• the age, general health, coexisting conditions and personal choice of the patient
• the size of the aneurysm relative to its location in the thorax or abdomen, and the aneurysm’s rate of growth
• the presence of chronic abdominal pain or risk of thromboembolism, as these may also necessitate surgery

A large or rapidly growing aortic aneurysm is more likely to need surgery. There are two options for surgery:

• open surgery to fit a synthetic or stent graft
• endovascular stent-graft surgery.

In endovascular surgery, the surgeon accesses the blood vessels through a small incision near the hip. Stent-graft surgery inserts an endovascular graft through this incision using a catheter. The graft is then positioned in the aorta to seal off the aneurysm.

In an open AAA repair, a large incision is made in the abdomen to expose the aorta. A graft can then be applied to repair the aneurysm.

Endovascular surgery for the repair of aortic aneurysms carries the following risks:

• bleeding around the graft
• bleeding before or after the procedure
• blockage of the stent
• nerve damage, resulting in weakness, pain or numbness in the leg
• kidney failure
• reduced blood supply to the legs, kidneys or other organs
• erectile dysfunction
• unsuccessful surgery that then needs further open surgery
• slippage of the stent

Some of these complications, such as bleeding around the graft, will lead to further surgery.

Cerebral aneurysm treatment options

Share on PinterestA ruptured intracerebral aneurysm will usually need emergency surgery.

In the case of a brain aneurysm, the surgeon will normally operate only if there is a high risk of rupture. The potential risk of brain damage resulting from surgical complications is too great.

As for AAA, the likelihood of a rupture depends on the size and location of the aneurysm.

Instead of surgery, patients receive guidance on how to monitor and manage the risk factors for a ruptured brain aneurysm, for example, monitoring blood pressure.

If a ruptured cranial aneurysm results in a subarachnoid hemorrhage, surgery is likely. This is considered a medical emergency.

This procedure would aim to close off the ruptured artery in the hope of preventing another bleed.

Most aneurysms are clinically silent. Symptoms do not usually occur unless an aneurysm ruptures.

However, an unruptured aneurysm may still obstruct circulation to other tissues. They can also form blood clots that may go on to obstruct smaller blood vessels. This is a condition known as thromboembolism. It can lead to ischemic stroke or other serious complications.

Share on PinterestAneurysms are generally symptomless, but their complications can cause severe chest pain.

Rapidly growing abdominal aneurysms are sometimes associated with symptoms. Some people with abdominal aneurysms report abdominal pain, lower back pain, or a pulsating sensation in the abdomen.

Similarly, thoracic aneurysms can affect nearby nerves and other blood vessels, potentially causing swallowing and breathing difficulties, and pain in the jaw, chest, and upper back.

Symptoms can also relate to the cause of an aneurysm rather than the aneurysm itself. For example, in the case of an aneurysm caused by vasculitis, or blood vessel inflammation, a person may experience fever, malaise, or weight loss.

Complications

The first signs of a previously undetected aneurysm could be complications upon rupture. Symptoms tend to result from a rupture rather than the aneurysm alone.

Most people living with an aneurysm do not experience any complications. However, in addition to thromboembolism and rupture of the aorta, complications can include:

• Severe chest or back pain: Severe chest or back pain may arise following the rupture of an aortic aneurysm in the chest.
• Angina: Certain types of aneurysm can lead to angina, another type of chest pain. Angina can lead to myocardial ischemia and heart attack.
• A sudden extreme headache: If a brain aneurysm leads to SAH, the main symptom is a sudden, severe headache.

Any rupture of an aneurysm may cause pain, low blood pressure, a rapid heart rate, and lightheadedness. Most people with an aneurysm will not experience any complications.

An aneurysm can happen in any part of the body. Blood pressure can more easily distend a weakened arterial wall.

Further research is necessary to confirm why an artery wall weakens to cause an aneurysm. Some aneurysms, though less common, are present from birth as an arterial defect.

Aortic dissection

Aortic dissection is one identifiable cause of an aortic aneurysm. The arterial wall has three layers. Blood can burst through a tear in the weakened wall of the artery, splitting these layers. It can then fill the cavity surrounding the heart.

If the tear occurs on the innermost layer of the arterial wall, blood channels into and weakens the wall, increasing the risk of rupture.

People with aortic dissection often describe abrupt and excruciating chest pain. This pain can travel as the dissection progresses along the aorta. It may, for example, radiate to the back.

Dissection leads to compression. Compression prevents blood from returning to the heart. This is also known as a pericardial tamponade.

Risk factors

There are some lifestyle choices and physical characteristics that can increase the chance of an aneurysm.

• smoking tobacco
• hypertension, or high blood pressure
• poor diet
• inactive lifestyle
• obesity

Smoking is by far the most common risk factor, especially in cases of AAA. Tobacco use has been shown not only to increase cardiovascular disease and the risk of an aneurysm but also increase the risk of rupture once an aneurysm has taken effect.

Aneurysms often remain undetected. Screening aims to identify people who need monitoring or treatment.

The US Preventive Services Task Force (USPSTF) recommends ultrasound screening for signs of AAA for all men aged 65 to 75 years who have smoked 100 cigarettes or more in their lives.

The taskforce does not recommend routine screening for women, whether they have smoked or not, as women have a lower risk of AAA.

If symptoms appear, an MRI scan can identify an aneurysm that has not yet ruptured. CT scans are usually preferred for ruptured aneurysms, especially if there is a risk of bleeding on the brain.

In cases of a severe or ruptured aneurysm in the brain or heart that needs emergency surgery, an angiogram can identify the exact area in need of repair. A catheter is inserted into a blood vessel in the thigh, under local anesthetic, and the catheter is then threaded through to the relevant part of the body.

The doctor applies a dye, helping to identify the area of the heart or brain that needs treatment.

A person can live with an unruptured aneurysm and not notice it. However, if it bursts, it can be life-threatening.

It can lead to:

• hemorrhagic stroke
• hydrocephalus
• coma
• vasospasm
• long- or short-term brain damage

Vasospasm is the main cause of disability or death following a burst aneurysm.

Factors affecting the chance of making a full recovery include the type and extent of the aneurysm, the overall health of the person before it ruptured, and how quickly they receive treatment.

Around 40 percent of cases of ruptured aneurysm will be fatal within the first 24 hours. In up to 25 percent of people, complications will be fatal within 6 months.

Preventing an aneurysm is not always possible, as some are congenital, meaning they are present from birth.

However, some lifestyle choices can affect the risk:

Smoking is a risk factor for both aortic aneurysms and the rupture of an aneurysm anywhere in the body. Quitting smoking can reduce the risk of a severe aneurysm.

Managing blood pressure can also minimize the risk of an aneurysm. Healthful blood pressure can be achieved through dietary measures, regular exercise, and medications.

Obesity can put extra pressure on the heart, so taking these steps is important for reducing stress on the artery walls.

A healthful diet can also reduce cholesterol and decrease the risk of atherosclerosis. Fusiform aneurysms are often linked to atherosclerosis.

Anyone diagnosed with an aneurysm and prescribed a conservative treatment plan can work with a healthcare practitioner to address any risk factors.

Ascending aortic aneurysm, aortic enlargement

The aorta is the main blood vessel of the body, through which blood is distributed from the heart to tissues and organs.

It branches like a tree, first into large branches (trunks), then into smaller branches and twigs, and is conditionally divided into several parts or departments:

1. 1. The ascending aorta is the section from the aortic valve to the brachiocephalic trunk.
2. 2. The aortic arch is a short section from which all the vessels supplying the arms and head depart (brachiocephalic arteries). They anatomically form an arc connecting the ascending and descending aorta.
3. 3. The descending (thoracic) aorta starts from the mouth of the left subclavian artery and continues to the diaphragm.
4. 4. Below the diaphragm and before the bifurcation of the aorta (bifurcation) is the abdominal aorta.

The division of the aorta into sections is very important for assessing the risk and choosing the optimal treatment tactics in patients with aortic aneurysms.

Aortic aneurysm is the area of ​​its local expansion.

Causes of aortic enlargement

Congenital systemic connective tissue diseases: Marfan, Ehlers-Danlos syndrome, caused by genetic changes in which the aortic wall has an irregular structure, can cause the development of an aneurysm.

Acquired diseases that cause aneurysmal changes in the aortic wall: most often it is atherosclerosis. About 80% of all complicated aortic aneurysms are aneurysms caused by an atherosclerotic process, which leads to a weakening of the vessel wall, and the inability to withstand normal blood pressure, and as a result, to its expansion.

Less often, an aortic aneurysm develops in inflammatory diseases caused by external agents (syphilis, fungal infection, tuberculosis) or in autoimmune diseases (nonspecific aortoarteritis).

Aortic aneurysm symptoms

Unfortunately, the diagnosis of an aortic aneurysm cannot always be established during the “cold period” (before the development of complications), since this disease is usually asymptomatic. Most often, it is discovered by accident when performing fluorography, ultrasound or tomography studies performed in connection with other diseases. Treatment of an aneurysm of the ascending aorta before the development of complications is much safer for the patient, therefore, in the early diagnosis of an aneurysm of the aorta, planned medical examination is of great importance.

It is worth noting that every hundredth patient who died suddenly – dies from aortic dissection.

Complaints usually appear when the aneurysm begins to exfoliate or, as it grows, compresses the surrounding organs and tissues. There is pain or dysfunction of those organs that are located in the area of ​​the aneurysm. At first, this is not bright and, therefore, does not alarm either the patient or the doctor.

However, the pain increases with the development of these deadly complications of an aortic aneurysm – this is one of the most severe pain a person can experience. It is localized in the chest if the aneurysm is located in the ascending, descending sections or in its arc, or in the abdomen if it was formed in the abdominal section. Characterized by a sharp weakness, pallor, often a person loses consciousness.

Impaired blood supply to organs located in the area of ​​aneurysm rupture or aortic dissection (brain or spinal cord, kidneys, intestines, upper or lower limbs) leads to loss of function of these organs, and a large amount of blood loss during aortic rupture is the most serious danger. To save a life, minutes count. If early surgical treatment is not available, the mortality rate for aortic dissection on the first day is 1% per hour (one in a hundred people die every hour). During the first day, 33% of patients die from aortic dissection, 50% of patients within 48 hours and 75% within two weeks. Only early surgical intervention makes it possible to save a significant part of patients.

Diagnosis of aortic aneurysm

In the diagnosis of aortic aneurysms, the so-called imaging techniques (ultrasound, MRI, CT, AG) are of the greatest importance. In the ascending aorta, its arch and in the abdominal section, an aneurysm can be detected by ultrasound methods (ultrasound). To diagnose an aneurysm of the descending (thoracic) aorta, x-ray methods (radiography, computed tomography) are necessary. To establish the final diagnosis and choose the method of treatment, contrasting methods of research are performed. Currently, the optimal diagnostic method that provides the most complete information about the location, extent, diameter of an aneurysm and its relationship to nearby organs is multislice computed tomography – aortography.

Methods of treatment of aortic aneurysm

The main treatment for an aneurysm in any part of the aorta is surgery. The meaning of the method is to replace the enlarged section of the aorta in order to prevent its further stretching and rupture. Two methods are used to replace the aorta – an endovascular (intravascular) method using a special intravascular prosthesis (stent graft), and an open operation – aortic replacement.

Each method has its own indications, and each of them has its own advantages and disadvantages.

The advantages of the surgical method lie in its versatility, that is, the possibility of correcting all disorders associated with aortic aneurysm, regardless of the department and nature of the lesion. For example, in case of an aneurysm of the ascending aorta and damage to the aortic valve, aortic and aortic valve replacement is performed in combination with coronary bypass grafting.

Surgery on the ascending aorta and its arch requires cardiopulmonary bypass, systemic hypothermia, and often complete circulatory arrest.

Indications for surgical treatment

• transverse dimension of the aneurysm,
• aneurysm growth rate;
• formation of complications of this disease.

For each section of the aorta, there is a borderline limit of the transverse size of the aorta, after reaching which the risk of aortic rupture increases statistically significantly. So, for the ascending and abdominal aorta, the transverse diameter of the aneurysm of 5 cm is dangerous in terms of rupture, for the thoracic aorta – 6 cm. If the aneurysm diameter increases by more than 6 mm in 6 months, then this is also an indication for surgery. Threatening in terms of rupture and dissection of the aorta are also a sac-shaped aneurysm and expansion of the aorta smaller than the diameter that is an indication for surgery, but accompanied by pain at the site of expansion and dysfunction of the presenting organs. Dissections and accomplished ruptures of aneurysms are absolute indications for emergency surgery.

Types of open surgery for aortic aneurysms:

• Supracoronary aortic replacement;

Endovascular interventions

They allow to drastically reduce the volume of surgical trauma, reduce the time of hospitalization and reduce the inevitable suffering of the patient associated with surgical approaches. One of the main disadvantages of the method is the need for repeated interventions.

Types of endovascular operations for aortic aneurysm:

• implantation of a stent graft in the abdominal aorta,
• implantation of a stent graft in the ascending (thoracic) aorta.

The most modern method of treating aortic aneurysm is a hybrid method that allows you to achieve optimal treatment results with the least surgical trauma.

Hybrid operations combine the advantages of open and endovascular interventions.

To prevent the development of aortic aneurysms, the most important is the need to control risk factors, namely arterial hypertension. In addition to arterial hypertension, the most significant risk factors are age (over 55), male sex, smoking, the presence of aneurysms in direct relatives, and elevated cholesterol levels.

Catheterization and expansion of the coronary arteries

The purpose of this leaflet is to provide the patient with information about catheterization of the coronary arteries (coronary angiography) and dilation of the coronary arteries of the heart (coronary angioplasty).

Ischemic heart disease causes damage to the coronary arteries, for a more accurate assessment of which it is necessary to perform catheterization of the coronary arteries (coronary angiography) .

Before your procedure

Unless your doctor tells you otherwise, you must come to the hospital the day before your procedure. In the evening and in the morning you will be given a sedative and aspirin. On the morning of the procedure, you must take a shower. After that, you will shave the area where the catheter is inserted.

On the morning of your procedure, you will receive your morning medication as prescribed by your doctor, except for diuretics (water pills). Patients with diabetes mellitus should not take anti-diabetic drugs and do insulin injections, the procedure is carried out in the first place.

Do not eat before the procedure. It will be possible to eat after the study.

Attention!

If you have had allergic reactions in the past, especially to local anesthetics/anesthetics (such as lidocaine) or iodine (which is contained in the contrast agent), you should always tell your doctor.

Description of the procedure

The procedure takes place in a special x-ray room under sterile conditions. The procedure is performed under local anesthesia. For the introduction of the catheter, the femoral artery or the radial artery on the arm is used. Through a small skin incision, the corresponding artery is punctured with a needle, and a catheter is inserted through a plastic cannula into the blood vessels. It moves, bypassing the aorta, to the coronary arteries of the heart, and then a contrast agent is injected. With the help of an X-ray machine, several pictures are taken in different projections. Thanks to the contrast agent, x-rays allow you to see the gaps of the coronary arteries.

During the administration of the contrast agent, you may notice a sensation of warmth that lasts for a couple of seconds.

After the procedure

After the examination, a weight in the form of a heavy horizontal bag is placed on the puncture site on the femoral artery. It is left there for 6 hours, during which it is necessary to lie on your back with your legs straight. The bed rest will last until the next morning. If the study was carried out through the artery of the arm, then a tight bandage is applied to the arm for 6 hours. In this case, you can get up and walk immediately after the procedure.

If, during catheterization of the coronary arteries, their significant narrowing is detected, then with the help of the expansion of the vessels of the heart, i. e. coronary angioplasty , can improve the blood supply to the heart muscle.

Description of the procedure

Coronary dilatation is a procedure similar to coronary artery catheterization that uses a balloon-tipped catheter. When the balloon is filled, the lumen of the blood vessel expands, and a special metal frame (stent) is installed in the place of narrowing of the coronary artery. After installing a stent, in order to prevent complications (thrombosis), it is necessary to take a special medicine for a period of three months to one year, which prevents platelets from sticking together. The duration of the course of treatment depends on the type of stent, and this is determined by the doctor.

Coronary angioplasty procedure takes about 45 minutes. The procedure is performed by a doctor assisted by nurses.

Possible risks and complications

Both procedures carry certain risks and may cause complications. Most often, a hemorrhage forms at the site of the catheter insertion. To prevent this, at the end of the examination, you must strictly observe the correct position and lying down, which will be explained to you after the procedure. The mode depends on the method that was used during the procedure.

Possible damage to the artery and bleeding from the puncture site. In this case, it may be necessary to resort to surgical treatment.

If a contrast agent is used during the procedure, you may experience short-term nausea.

Severe complications are rare, but myocardial infarction, paralysis, ruptured blood vessels, allergic reactions, and even death can occur. It is also possible the occurrence of cardiac arrhythmias, which require urgent intervention. In this case, in the office where the study is carried out, the necessary equipment and medicines are always at hand. Research personnel are able to act effectively in such situations.

The risk of complications is higher if the patient is in serious condition and has heart failure.