Vascular conditions affect the body’s veins and arteries and can be dangerous in the event of blockages or rupture. Most of us are familiar with heart disease but not as aware of other non-brain vascular diseases, including abdominal aortic aneurysms and thoracic abdominal aneurysms. Aortic aneurysms can be just as deadly as coronary artery disease, and they are tougher to detect. That’s why patients are advised to learn more about these “silent killers” and take action as needed.
What are aortic aneurysms?
An aortic aneurysm is a bulge in a weakened aorta, the body’s largest artery. The aorta carries all of the blood leaving the heart across the chest and the abdomen. Aortic aneurysms can be very difficult to detect through physical examination and may go undetected for years unless specifically tested. Most patients do not notice anything is wrong until or unless the aortic aneurysm begins to dissect (tear) or rupture, which can lead to massive bleeding and is life-threatening.
What are the types of aortic aneurysms?
The most common and deadly aneurysm is aortic. Two-thirds of aortic aneurysms are abdominal (AAA), and one-third is thoracic (occurring in the chest cavity). When the aneurysm occurs in both areas, it is called thoracoabdominal.
How dangerous are these conditions?
According to the Centers for Disease and Prevention, 9,863 Americans died of aortic aneurysms in 2014 (the last year for which data is available). Every year, 200,000 Americans are diagnosed with an AAA. A ruptured AAA is the 10th leading cause of death in men 55 or older. Left untreated, dissections and ruptures can be fatal. With proper treatment and monitoring, however, most patients with these conditions will survive with improved quality of life.
What are symptoms and risks?
In thin patients or those with very large abdominal aneurysms, a pulsing mass may be felt in the middle of the abdomen. Most people, however, feel no pain or other symptoms associated with aortic aneurysms until or unless they rupture or rapidly expand. Most aortic aneurysms are found on imaging studies such as X-rays, CT-scans, MRIs, ultrasound, and echocardiograms. Often the finding of an aortic aneurysm is a surprise from a study done for other reasons.
Several well-known factors increase an individual’s risk of developing an aneurysm. These include: a family history of aneurysms, smoking, arteriosclerosis (hardening of the arteries), high blood pressure, lung disease (COPD), or other known aneurysms. Additionally, several rare genetic disorders affect connective tissue strength and greatly increase the risk of aneurysm formation. The most common of these are Marfans and Elhers Danlos syndrome.
What are the treatments?
Since the risk of complications from aneurysms is related to their size and location, and since growth over time is the norm, a key to aneurysm disease management is early detection. Most small aneurysms have low likelihood of near-term complications and can be monitored with serial ultrasound or CT scans. This imaging will allow for a discussion about the risk of medical management alone (i.e., blood pressure and cholesterol medications) vs. repair of the aneurysm. Options to repair the aneurysm include “relining” procedures in which a graft is threaded inside the aorta.
These minimally invasive procedures are typically achieved though small punctures in the groin through which a graft is inserted and covers the inside of the aorta, thereby preventing the blood flow from touching the weakened aortic wall. These procedures performed from within the aorta are called endovascular repairs and are referred to EVAR (endovascular aneurysm repair) when done to abdominal aneurysms, or TEVR (thoracic endovascular aortic repair) when done in the chest.
Some aneurysms, however, are not suitable for this minimally invasive technique and require open surgical repair, which replaces the diseased aorta with a graft that is sewn into the healthy portions of aorta above and below the aneurysm. Though more traumatic initially, the open approach can be adapted to any anatomy and in selected patients may have better long-term outcomes. Minimally invasive procedures result in less pain and faster recovery, but every patient is different, and customized treatment is critical.
Who should have a “screening” study for AAA?
If you have a known aneurysm or if your doctor feels an aneurysm, you should have a study for cause, not screening. Screening studies are designed to identify problems that have not been previously discovered. As such, screening studies are recommended for diseases that pose a high risk if undiscovered and can be discovered with a low risk and effective test. While the rules vary between commercial insurance companies, Medicare (CMS) currently recommends and pays for a one-time screening ultrasound of the abdominal aorta for 1) anyone with a family history of a AAA or 2) for men 65-75 years old who have smoked over100 cigarettes These screening ultrasound studies, which typically take about 15 minute, are safe and pain-free. If you or someone you know fits in one of these categories and have not been screened, call your primary care physician or vascular specialist to discuss if this is right for you.
What is a vascular surgeon?
Vascular surgeons are specialists who are highly trained to treat diseases of blood vessels and veins. These physicians should be experienced experts who can perform the required procedures—whether traditional or minimally invasive surgery—they also care for patients who may not require surgery and are treated with medication, monitoring, and lifestyle adjustments such as diet and exercise.
What should patients expect following surgery?
This depends on the details of your anatomy and the specific procedure. The less invasive endovascular procedure (EVAR/TVAR) can be done with local anesthesia and sedation or general anesthesia. Most people spend a single night in the hospital and are discharged with mild pain and bruising in the groins. Overall recovery time is minimal baring complications. Open surgical procedures for aortic aneurysms require general and/or spinal anesthesia. Hospital stays are commonly 5-7 days, and recovery sometimes involves rehab stays with return to full activity taking weeks to months. While recovery from open aortic surgery is much tougher than endovascular techniques and the near-term risk of complications is higher than endovascular repair, open surgery is more versatile, allowing for treatment of any aneurysm. Also, in the long term, the endovascular techniques have increased risk of developing “leaks.” Therefore, all patients receiving endovascular AAA repairs should have long-term, follow-up scans to detect and treat these possible leaks and accompanying aneurysm growth.
What is trending in the future?
Device development continues at a brisk pace with several manufacturers that produce the devices used in aortic aneurysm repair. These manufacturers are now several generations into refinements. Today’s endovascular stent grafts are built on smaller and more flexible delivery systems that allow us to offer this treatment to patients with small or tortuous arteries. Devices are now made with branches and custom-made side holes to allow these grafts to extend into branch arteries leading to the arms, intestines, kidneys, and pelvic arteries. These “branched and fenestrated” endografts are increasing the proportion of patients considered anatomically suitable for these minimally invasive, life-saving techniques. The vascular community closely tracks and studies the results on all treatment choices in aneurysm repair and continuously refines recommendations on factors that optimize patient outcomes in the near and long term. Since vascular surgeons perform both open and endovascular repairs, they can provide the most up-to-date recommendations on treatment options.
What should patients do if they are concerned?
Consult with your primary care physician, meet with a specialist, and undergo the recommended tests, as appropriate. Be informed and proactive.
To make an appointment with a vascular specialist, call 844-543-3145.
Posted November 2018 The above content is provided for educational purposes by Tufts Medical Center. It is free for educational use. For information about your own health, contact your physician.